Transfusion reaction

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Shyam Patel [2]; Associate Editor(s)-in-Chief: Khuram Nouman, M.D. [2] Amandeep Singh M.D.[3]


Blood products, when transfused even after cross matching, elicit some reactions. The transfusion reactions are classified into anaphylactic reaction, bacterial infection, acute hemolytic reaction, febrile non-hemolytic reaction, transfusion-related acute lung injuryTRALI, transfusion-associated circulatory overload, transfusion-associated microchimerism (TA-MC), iron overload, and transfusion-associated Graft-versus-Host Disease (GvHD). The symptoms may range from fever to life threatening anaphylaxis. The treatment of each different type of transfusion reaction is different.

Types of Transfusion Reactions

Anaphylactic Reaction

Bacterial Infection

  • Blood products can provide an excellent medium for bacterial growth, and can become contaminated after collection while they are being stored.
  • The risk is highest with platelet transfusion, since platelets must be stored near room temperature and cannot be refrigerated.
  • The risk of severe bacterial infection and sepsis is estimated (as of 2001) at about 1 in 50,000 platelet transfusions, and 1 in 500,000 red blood cell transfusions.

Acute Hemolytic Reaction

Febrile Non-hemolytic Transfusion Reaction

  • This is the most common adverse reaction to a blood transfusion.
  • Symptoms include fever and dyspnea 1 to 6 hours after receiving the transfusion.
  • Such reactions are clinically benign, causing no lasting side effects or problems, but are unpleasant via a blood transfusion is estimated, as of 2006, at 1 per 2 million units transfused. Bacterial infection is a much more common problem.

Transfusion-Related Acute Lung Injury (TRALI)

  • TRALI is a syndrome of acute respiratory distress, often associated with fever, non-cardiogenic pulmonary edema, and hypotension.
  • It may occur as often as 1 in 2000 transfusions.
  • Symptoms can range from mild to life-threatening, but most patients recover fully within 96 hours, and the mortality rate from this condition is less than 10%.

Transfusion-associated Microchimerism (TA-MC)

Transfusion-associated Graft-vs-Host Disease (GvHD)

  • GVHD refers to an immune attack by transfused cells against the recipient. This is a common complication of stem cell transplantation, but an exceedingly rare complication of blood transfusion.
  • It occurs only in severely immunosuppressed patients, primarily those with congenital immune deficiencies or hematologic malignancies who are receiving intensive chemotherapy.
  • When GVHD occurs in association with blood transfusion, it is almost uniformly fatal. Transfusion-associated GVHD can be prevented by irradiating the blood products prior to transfusion.

Volume Overload

  • Patients with impaired cardiac function (e.g. congestive heart failure) can become volume-overloaded as a result of blood transfusion, leading to edema, dyspnea (shortness of breath), and orthopnea (shortness of breath while lying flat).
  • This is sometimes called TACO, or Transfusion Associated Circulatory Overload.[1]

Iron Overload

  • Each transfused unit of red blood cells contains approximately 250 mg of elemental iron.
  • Since elimination pathways for iron are limited, a person receiving numerous red blood cell transfusions can develop iron overload, which can in turn damage the liver, heart, kidneys, and pancreas. The threshold at which iron overload becomes significant is somewhat unclear, but is likely around 12-20 units of red blood cells transfused.

Following table summarizes the difference between transfusion-related acute lung injury (TRALI) and transfusion associated circulatory overload (TACO):

Parameters Transfusion-related acute lung injury (TRALI) Transfusion-associated circulatory overload (TACO)
Fever ±
Blood pressure Hypotension Hypertension
Respiratory distress + +
JVP Non-distended Distended
Respiratory auscultation Rales Rales + S3 heart sounds may be present
CXR Bilateral pulmonary infiltrates Bilateral pulmonary infiltrates
Fluid balance Neutral Positive
Diuretics Responsive only when there is fluid overload Improvement with diuretics
Ejection fraction Normal Decreased
BNP <250 pg/mL >1200 pg/mL
PCWP <18 mm Hg >18 mm Hg
WBC Unchanged Transient decreased

Treatment of Transfusion Reactions

  • The most important step in treating a presumed transfusion reaction is to stop the transfusion immediately (saving the remaining blood and IV tubing for testing) and to provide supportive care to the patient.
  • More specific treatments depend on the nature and presumed cause of the transfusion reaction.
  • Most hospitals and medical centers have transfusion reaction protocols, which specify testing of the blood product and patient for hemolysis, bacterial contamination, etc.

The following table shows different types of transfusion reactions along with their treatment:

Transfusion Reaction Time of onset Fever Rigors Rash Blood Pressure Additional Features Labs Treatment Prevention Mechanism/


Anaphylactic reaction
  • Rapid onset
  • Stop the transfusion immediately
  • S/C epinephrine
  • IV epinephrine(in case of severe hypotension)
  • Avoid clerical errors
  • Proper storage record
  • Repeat type and screen before transfusion
  • Proper blood storage conditions
IgA deficiency
Bacterial Infection
  • Rapid onset
++ + ±
  • Hypotension is common
  • Occasionally hypertension
  • Fever > 2
  • Tachycardia
  • CBC
  • Urine complete examination
  • Blood and urine culture
  • Transfusion set culture
  • Clotting profile
  • Stop the transfusion
  • Check identity on blood unit
  • Look for clerical errors
  • Supportive management(O2 inhalation,normal saline)
  • Broad spectrum antibiotics for bacterial infections
  • Inform blood bank
  • Extensive screening of blood
  • Decrease storage time
  • Leukodepletion
  • Bactericidal treatment
Acute hemolytic reaction
  • Rapid onet
+ + ±
  • Hypotension
  • Stop the transfusion immediately
  • Look for clerical errors
  • Alert blood bank
  • Maintain IV access
  • Supportive management
  • To prevent renal failure-give low dose dopamine,normal saline,mannitol for diuresis
  • Treat DIC(if happens)
  • Avoid clerical errors
  • Proper storage record
  • Repeat type and screen before transfusion
  • Proper blood storage conditions
ABO incompatibility
Transfusion Reaction Time of onset Fever Rigors Rash Blood Pressure Additional Features Labs Treatment Prevention Mechanism/


Febrile non-hemolytic transfusion reaction
  • 1/2 to 1 hour
+, with chills +
  • No Effect
  • Can occur in first few hours
  • Fever rise of 1-2
  • No labs usually required
  • Slow or Stop the transfusion
  • Give Acetaminophen for fever
  • Leukoreduction
Cytokine in storage
Transfusion-related acute lung injury (TRALI) within 6 hours ± ±
  • Hypotension
  • ABGs
  • CBC
  • SpO2 monitoring
  • CXR-pulmonary infiltrates
  • HLA typing(remove donor from the list)
  • Stop the transfusion immediately
  • O2 inhalation
  • Ventilatory support
  • Supportive treatment
  • Diuretics for volume overload
  • Inform the blood bank
  • Consult hematologist
  • Donor whose blood cause TRALI must be put on non-donor list
Donor anti-leukocyte antibodies
Transfusion-associated circulatory overload (TACO) usually over hours
  • Hypertension
  • Dyspnea
  • Orthopnea
  • Cough
  • Headache
  • Tachycardia
  • Decrease spO2
  • Increase JVP
  • Increase CVP
  • SpO2 monitoring
  • CXR
  • Serum BNP
  • ABGs
  • Stop transfusion
  • Supportive therapy
  • O2 supplementation
  • Ventilatory support
  • Diuretics
  • Exchange transfusion(if transfusion is unavoidable)
  • Controlled phelbotomy
  • Slow rate of transfusion
  • Avoid unnecessary transfusion
  • Cardiac evaluation


  1. Suddock JT, Crookston KP. Transfusion Reactions. [Updated 2018 Sep 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: