PA21.1-6 | Transfusion Reactions & Investigation — Summary & Reflection

REFLECT

Think back to the opening scenario — the woman 15 minutes into an ABO-incompatible transfusion.

1. Walk through the investigation algorithm step-by-step in your mind (or on paper). Which step would have prevented this if it had been correctly performed before the transfusion started?

1. A patient on your ward has thalassaemia major and has received 150 units of blood over 10 years. She develops diabetes and elevated liver enzymes. Which delayed complication explains this? What treatment would you recommend?

1. You are called to see a patient who is febrile 45 minutes into a transfusion. You suspect FNHTR. What clinical and laboratory findings would reassure you that this is not an AHTR?

KEY TAKEAWAYS

Core principles to carry forward:

• Transfusion reactions classify as acute (<24 h) vs delayed AND immune vs non-immune — a 2×2 framework.

• AHTR (ABO incompatibility, clerical error) is the most feared — IgM + classical complement → intravascular haemolysis → DIC + renal failure. Preventable by bedside check.

• FNHTR (anti-leukocyte antibodies/cytokines) is the commonest — fever without haemolysis; must be distinguished from early AHTR.

• Allergic/anaphylactic — IgE-mediated; anaphylaxis classically in IgA-deficient recipients.

• TRALI — donor anti-leukocyte antibodies → non-cardiogenic pulmonary oedema; normal JVP distinguishes from TACO.

• TACO — cardiogenic overload; slow transfusion and diuresis prevent it.

• Delayed haemolytic — anamnestic IgG response, extravascular, mild; TA-GVHD — T-cell engraftment in immunocompromised, fatal without gamma-irradiation.

• Investigation algorithm (ordered): STOP → stabilise → clerical recheck → return unit → fresh samples (DAT, grouping, crossmatch) → haemolysis screen (plasma, urine, LDH) → blood cultures → monitor renal + coagulation.

• The bedside check is non-negotiable: right patient + right unit + right time eliminates the commonest cause of transfusion death.