Transfusion Reactions Clinical Presentation: History, Physical Examination

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Presentation

History

A history of previous blood transfusions or pregnancy is often present but is not essential for the diagnosis of a febrile nonhemolytic transfusion. Acute transfusion reactions caused by ABO antibodies, transfusion-related acute lung injury (TRALI; from donor's antibodies), allergy, IgA/anti-IgA anaphylaxis, or sepsis may occur during the first transfusion or subsequent transfusions.

Persons known to have formed red cell alloantibodies as the result of previous transfusions or pregnancy should be informed and provided with a written report listing the antibodies to be presented to the transfusion service if additional transfusions are required at another hospital.

Red cell antibodies may decrease in titer and, although remaining clinically important, may not be detected by routine compatibility testing before future red cell transfusions. Ask patients scheduled for red cell transfusions about any history of previous transfusions and if they are aware of any complications or blood bank antibody problems. Obtain details of any previous transfusions during the medical history or when obtaining the patient's informed consent for a transfusion.

In individuals with sickle cell disease, clinical manifestations of delayed hemolytic transfusion reactions (DHTRs) usually appear 5–15 days after the triggering transfusion, and include hemoglobinuria, jaundice, and pallor due to acute hemolysis. In addition, patients may have signs and symptoms that mimic severe vaso-occlusive crisis (ie, pain, fever, and acute chest syndrome), as well as profound anemia, often with reticulocytopenia. If DHTR is misdiagnosed as vaso-occluisive crisis and the patient is treated with an additional transfusion, this may further exacerbate hemolysis and clinical symptoms and cause life-threatening multiorgan failure.^{[6, 7]}

Physical Examination

Acute hemolytic reactions manifest as follows:

Early signs may include fever, hypotension, flushing, wheezing, anxiety, and/or red-colored urine
Late signs may include a generalized bleeding tendency (DIC) and/or hypotension

Nonhemolytic febrile reactions typically involve only fever. However, some patients also have severe rigors, shaking, chills, hypotension, and vomiting.

Allergic reactions typically comprise maculopapular rash and/or urticaria without fever or hypotension. Anaphylactic reactions manifest as follows:

Dyspnea
Wheezing
Anxiety
Hypotension without fever
Bronchospasm in severe cases

Transfusion-related acute lung injury (TRALI) manifests as rapid onset of shortness of breath, hypoxemia, and rales, without signs of acute cardiogenic pulmonary edema and fever.

Circulatory (volume) overload manifests as follows:

Shortness of breath
Rales
Orthopnea
Tachycardia
Distended jugular veins
Other evidence of cardiac decompensation

Continuous monitoring of vital signs during general anesthesia may prevent acute circulatory (volume) overload, but it may not detect early signs of other reactions (eg, acute hemolytic transfusion reactions). However, the onset of abnormal bleeding/generalized oozing during surgery in a transfused patient should raise the question of a hemolytic transfusion reaction with disseminated intravsacular coagulation (DIC).

Bacterial contamination manifests as high fever, shock, tachycardia, and weak pulse, without a clear focus of infection. Examination of the contents of the container of blood being transfused may reveal clots, discoloration, or a difference in color between the contents of the bag (hemolyzed by contaminating bacteria) and the contents of the segmented tubing attached to the bag (not hemolyzed, no bacteria). In a review of septic transfusion reactions resulting from bacterially contaminated platelets, Hong et al reported that the reactions developed 9 to 24 hours posttransfusion, and occurred only in neutropenic patients.^[59]

Differential Diagnoses

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Media Gallery

Rapid test to distinguish hematuria from hemoglobinuria. The onset of red urine during or shortly after a blood transfusion may represent hemoglobinuria (indicating an acute hemolytic reaction) or hematuria (indicating bleeding in the lower urinary tract). If freshly collected urine from a patient with hematuria is centrifuged, red blood cells settle at the bottom of the tube, leaving a clear yellow urine supernatant. If the red color is due to hemoglobinuria, the urine sample remains clear red after centrifugation.

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Author

S Gerald Sandler, MD, FCAP, FACP Professor Emeritus of Medicine and Pathology, Georgetown University School of Medicine

S Gerald Sandler, MD, FCAP, FACP is a member of the following medical societies: American Association of Blood Banks, College of American Pathologists, International Society of Blood Transfusion

Disclosure: Nothing to disclose.

Coauthor(s)

Viviana V Johnson, MD Medical Director, Blood Bank, Naval Medical Center, Portsmouth

Viviana V Johnson, MD is a member of the following medical societies: American Association of Blood Banks, College of American Pathologists

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Ronald A Sacher, MD, FRCPC, DTM&H Professor Emeritus of Internal Medicine and Hematology/Oncology, Emeritus Director, Hoxworth Blood Center, University of Cincinnati Academic Health Center

Ronald A Sacher, MD, FRCPC, DTM&H is a member of the following medical societies: American Association for the Advancement of Science, American Association of Blood Banks, American Clinical and Climatological Association, American Society for Clinical Pathology, American Society of Hematology, College of American Pathologists, International Society of Blood Transfusion, International Society on Thrombosis and Haemostasis, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Chief Editor

Emmanuel C Besa, MD Professor Emeritus, Department of Medicine, Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University

Emmanuel C Besa, MD is a member of the following medical societies: American Association for Cancer Education, American Society of Clinical Oncology, American College of Clinical Pharmacology, American Federation for Medical Research, American Society of Hematology, New York Academy of Sciences

Disclosure: Nothing to disclose.

Additional Contributors

Pradyumna D Phatak, MBBS, MD Chair, Division of Hematology and Medical Oncology, Rochester General Hospital; Clinical Professor of Oncology, Roswell Park Cancer Institute

Pradyumna D Phatak, MBBS, MD is a member of the following medical societies: American Society of Hematology

Disclosure: Received honoraria from Novartis for speaking and teaching.

Acknowledgements

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government.

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