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Distinguishing findings in the evaluation of suspected transfusion reactions

Distinguishing findings in the evaluation of suspected transfusion reactions
Reaction Typical time course* Clinical findings Laboratory findings Implicated products
Acute hemolytic transfusion reaction During transfusion or within 24 hours of transfusion completion Fever, chills, hypotension, back pain, DIC Hemoglobinemia, hemoglobinuria, positive direct antiglobulin (Coombs) test (may be negative if all cells have hemolyzed), findings of DIC (prolonged PT, prolonged aPTT, low fibrinogen, thrombocytopenia)

RBCs, plasma (much less common), rarely platelets

Incompatible blood product (typically ABO incompatible due to clerical error)
Anaphylactic transfusion reaction During transfusion or within 4 hours of transfusion completion Hypotension, angioedema, wheezing, respiratory distress Hypoxemia, IgA deficiency, anti-IgA RBCs, platelets, plasma products
Transfusion-related acute lung injury (TRALI) During transfusion or within 6 hours of transfusion completion Respiratory distress, hypotension Abnormal chest radiography, hypoxemia, transient leukopenia, anti-neutrophil or anti-HLA antibodies (if tested) RBCs, platelets, plasma products
Transfusion-associated circulatory overload (TACO) During transfusion or within 12 hours of transfusion completion Respiratory distress, rales Abnormal chest radiography, hypoxemia, increased BNP or NT-proBNP RBCs, platelets, plasma products, and other fluids
Sepsis/bacterial infection During transfusion or within 72 hours of transfusion completion Fever, chills, hypotension, DIC Bacteremia, leukocytosis, findings of DIC

Platelets most commonly implicated, but can be any product

Product may show bacterial contamination
Febrile non-hemolytic transfusion reaction During transfusion or within 4 hours of transfusion completion Fever None All blood products, but plasma is much rarer
Allergic transfusion reaction During transfusion or within 4 hours of transfusion completion Hives, urticaria None unless specific investigation is made All blood products
The table includes some common findings but is not comprehensive and does not substitute for clinical judgment in the patient evaluation. Not all of the findings listed under each reaction will be present in every case. Refer to UpToDate topics on transfusion reactions for details of evaluation, diagnosis, and management.

aPTT: activated partial thromboplastin time; BNP: brain natriuretic peptide; DIC: disseminated intravascular coagulation; HLA: human leukocyte antigens; Ig: immunoglobulin; NT-proBNP: N-terminal BNP; PT: prothrombin time; RBCs: red blood cells.

* Except for sepsis/bacterial infection, all typical time course criteria are from the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network Biovigilance Component. Septic transfusion reactions generally occur immediately after initiating the transfusion but may take time to develop depending on the size of the bacterial inoculum.
Adapted from: Sazama K, DeChristopher PJ, Dodd R, et al. Practice parameter for the recognition, management, and prevention of adverse consequences of blood transfusion. College of American Pathologists. Arch Pathol Lab Med 2000; 124:61.
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