The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [292]
The prompt management of any adverse transfusion reaction can reduce associated morbidity and can be life saving. Therefore staff caring for patients receiving transfused products must be fully familiar with the immediate management of any suspected reaction. However, specialist advice should always be sought for the diagnosis and ongoing management of transfusion reactions, such as haemolytic, anaphylactic and septic reactions (McClelland 2007, SNBTS 2004).
Minor transfusion reactions
It should always be remembered that the symptoms of a ‘minor’ transfusion reaction may be the prelude to a major, life-threatening reaction. It is essential that staff take any transfusion reaction seriously. Symptomatic patients should have their vital signs monitored closely and they should be clearly observable. Patients with persistent or deteriorating symptoms should always be managed as a major reaction and urgent medical and specialist support should be sought (McClelland 2007, SNBTS 2004).
Allergic and anaphylactic reactions are more common and more severe with transfusion of FFP and platelets than with red blood cells (Domen and Hoeltge 2003).
Symptoms of minor reactions include a temperature rise of up to 1.5°C, rash without systemic disturbance and moderate tachycardia without hypotension (SNBTS 2004). Such reactions may be caused by an immunological reaction to components of the blood product. Whilst it may be possible to manage such symptoms and continue with the transfusion, the following action should always be taken (Contreras and Navarrete 2009).
Stop the transfusion and inform the responsible medical team.
Confirm the patient’s identity and re-check their details against the product compatibility label.
Antihistamines should be considered for skin rashes or urticarial itch.
Antipyretic agents can be considered for mild fever.
It may be possible to continue with the transfusion at a reduced rate once the patient’s symptoms are controlled; however, it may be necessary to increase the frequency of observations until the transfusion is completed. Some patients who have regular transfusions may experience recurrent febrile reactions and may benefit from an antipyretic premedication. Note: aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) are contraindicated in patients with a thrombocytopenia or coagulopathy (BNF 2011).
Major transfusion reactions
Major transfusion reactions include anaphylaxis, haemolysis and sepsis and may present as a fever of >38.5°C, tachycardia ± hypotension. In such circumstances a severe reaction should always be considered and the transfusion should be stopped until a specialist assessment has been conducted (Box 8.5).
Box 8.5 Initial management of a suspected transfusion reaction
Stop the transfusion and seek urgent medical help.
Initiate appropriate emergency procedures, for example call resuscitation team.
Depending on venous access, withdraw the contents of the lumen being used and disconnect the blood product.
Keep venous access patent.
Confirm the patient’s identity and re-check their details against the product compatibility label.
Keep the patient and relative informed of all progress and reassure as indicated.
Initiate close and frequent observations of temperature, pulse, blood pressure, fluid balance.
Inform the transfusion laboratory and seek the urgent advice of the haematologist for further management.
Return the transfused product to the laboratory with new blood samples (10 mL clotted and 5 mL ethylenediamine tetra-acetic acid (EDTA)) from the patient’s opposite arm (SNBTS 2004) with a completed transfusion reaction notification form (if available) or note the patient’s details, the nature and timing of the reaction and details of the component transfused.
Care should be taken when returning