Transfusion Reaction

Transfusion Reaction

Clinical Findings

Neuro: Anxiety, restlessness. Resp: Shortness of breath, dyspnea, tachypnea, bronchospasm. CV: Chest pain, tachycardia, hypotension. Skin: Urticaria, pruritus, erythema, burning at infusion site. GI/GU: Nausea, vomiting, diarrhea, hematuria, oliguria, anuria. MS: Flank, back, or joint pain. Metabolic: Fever, chills.

Nursing Interventions

■ Stop transfusion and run normal saline to maintain IV access. Note: LR contains calcium and will clot blood in the tubing. ■ Palpate radial pulse for rate and rhythm. If Pt is monitored, assess ECG and manage dysrhythmias per ACLS protocol. ■ Administer supplemental oxygen titrated to SpO2 >90%. ■ Obtain and document baseline VS (HR, RR, BP, temp, SpO2). ■ Assess and document LOC. ■ Notify physician and blood bank of reaction STAT. ■ Recheck Pt ID and blood labels for possible errors. ■ Return unused blood product to blood bank for analysis. ■ Administer ordered medications (see specific reaction). ■ Assess indwelling urinary catheter and record amount, color, and clarity of urine. If Pt does not have urinary catheter in place, prepare to insert one for monitoring UO. ■ Continue IV fluids to maintain minimum UO of 30 mL/hour. ■ Monitor for early detection of any hemodynamic instability (e.g., dysrhythmias, abnormal lab values, CHF). ■ Consult physician about continued treatment, including ordering 12-lead ECG, labs (CBC, electrolytes, and coagulation studies), chest x-ray, and/or transfer to ICU. ■ Document assessments, any interventions, and outcome.

Reaction-Specific Treatments

Anaphylactic Reaction ■ Support airway, breathing, and circulation as indicated. ■ Administer epinephrine, antihistamines, and corticosteroids. ■ Maintain intravascular volume. Hemolytic Reaction ■ Maintain renal perfusion with aggressive fluid resuscitation. ■ Consider furosemide to increase renal blood flow. ■ Consider low-dose dopamine to improve renal blood flow. ■ Maintain urine output at 30–100 mL/hour. Febrile, Nonhemolytic Reaction ■ Treat fever with acetaminophen. ■ If Pt develops chills, cover with blanket unless temp is >102 F.