Blood Disorders
Blood Products
Bone Marrow



The following is a rapid reference guide to transfusion reactions and complications, with the appropriate steps to take to investigate and treat.




Acute intravascular haemolytic transfusion reactions are the most serious and potentially life-threatening complication of transfusion. These are due to transfusion of incompatible blood product with subsequent break-down of the red cells by antibody. ABO incompatibility is by far the most severe. The most common reason for this type of reaction is clerical error in identifying the patient (either at the time the crossmatch sample is taken or in hanging the unit of blood). For this reason extremely strict guidelines are enforced for the samples and identification of the patient.


ABO incompatibility causes massive immediate intravascular haemolysis with urticaria, lumbar pain, flushing, headache, chest pain, dyspnoea, vomiting, rigors, fever, hypotension and shock. The haemolysis causes jaundice, haemoglobinuria and DIC, followed by renal failure and often death. The reaction occurs early into the transfusion, and only requires a small volume to have been transfused.


Frequency: 1 in 12,000 to 1 in 77,000 units.



       Stop transfusion immediately if any of the above symptoms occur.

       Call medical staff immediately

       Resuscitative measures may be required to maintain BP and renal perfusion

       IV fluid (saline, plasma, colloid)

       Hydrocortisone 100mg iv and antihistamine (eg Phenergan 12.5 - 25mg)

       If shock:  IV adrenaline

       Treat renal failure as with any other cause. Dialysis may be needed.



       Complete a Transfusion Reaction form and send to blood bank with:

       Return all the unit(s) of blood for regrouping and further testing

       Take samples from the patient:

       10ml EDTA: for repeat blood group, crossmatch, Direct Coombs Test and plasma Hb

       5ml Lithium heparin: haptoglobin, bilirubin, LDH

       10ml citrate: coagulation profile & D-dimer

       First urine sample voided: for urinary Hb




This is the most common reaction to occur during blood transfusion (up to 1% of transfusions). It has many causes. Co-incidental fever unrelated to blood transfusion may occur, due to sepsis, inflammation, etc. The most common transfusion related cause is white cell associated fever*, which is generally mild (<38.5C) and settles with cessation of that unit of blood, or slowing the transfusion. Once the fever has settled (with paracetamol) transfusion of a new unit can occur. A transfusion reaction form and investigation should not routinely be carried out for simple fever that settles promptly.


Consider transfusing leucocyte depleted (filtered) blood in future.


* Usually due to alloimmunisation to HLA antigens or cytokine accumulation in storage.












Infected blood (bacterial)
? 1:100,000.

Fever, shock.
More common with platelets.


Antibiotics. Do not use cloudy or expired blood or blood left out of fridge for >30mins

Microbiological culture of unit and patients blood


Febrile reaction to white cells.

Due to sensitisation by previous pregnancy or blood transfusion. Fever rigors. Due to HLA- or neutrophil Ab or cytokines

Leucocyte reduced products (filtered)

None usually


Allergic reactions
Anaphylaxis (1:100,000)

Hypersensitivity to donor plasma proteins.

Urticaria, fever, (dyspnoea, oedema, rigor)

Slow/stop transfusion. Antihistamine, Hydrocortisone.

Washed cells if severe.

Check IgA levels


Circulatory overload

This is rare with packed cells

as for cardiac failure



Citrate toxicity

Due to massive transfusion (>10 units) with citrate anticoagulant in blood unit. Hypocalcaemia occurs

Calcium replacement.


Serum calcium



Post-transfusion hepatitis

Transmission of viral infection - usually non-A,B,C now due to screening for A,B,C viruses.

CMV also

Standard hepatitis management.

CMV can be prevented by CMV negative products

Viral serology, both donor and recipient.

CMV serology.


Local complications






Iron overload

With repeated transfusion. Each unit of blood contains 300mg iron

Transfuse only if required. Chelation with desferrioxamine

Iron studies



eg to Rh(D), or other red cell antigens.

If allo-antibody detected then blood bank will issue blood negative for that antigen if the antibody is clinically relevant (ie implicated in haemolytic transfusion reactions)

Use antigen negative product. Immunise with anti-D.
See 12.1: Prevention of sensitisation to Rh(D) below.

Group and screen (screen for antibodies)


Delayed Haemolysis (1:5000)

Occurs in pts previously alloimmunised in whom Ags on transfused red cells provoke amamnestic red cell Ab. 2-14 days post-transfusion.

Usually none required. Identify Ab and provide antigen negative blood for future transfusions.

Hb, Direct Coombs Test, LFT (bili, LDH), retics, haptoglobin.


Transfusion related Acute lung Injury (TRALI)

Alloimmunisation to donor HLA or granulocyte Ags. Fever, tachycardia, hypotension, hypoxia and pulmonary oedema within 6hrs of Tx

Stop Transfusion. Supportive.

Demonstrate HLA or granulocyte Ab in donor / recipient serum


Immune modulation  (TRIM)(unknown)

Cause unknown. ? increase in infection and cancer recurrence

Unknown. ? leucocyte depletion



Problems of massive transfusion

> 10 units.  Hypothermia

Citrate toxicity

Coagulation factor depletion

Platelet depletion






Use fresh blood

Coagulation profile, FBP, serum calcium and potassium.