Blood Transfusion and Transfusion Reactions

Use these numbers at the bedside. Volumes are weight-based where the blood bank or protocol says so. Follow local protocols and medical direction.

Blood components (red cells, plasma, platelets, and whole blood where a program uses it) replace one of two things: oxygen-carrying capacity or clotting factors. Transfusion acts like a drug, and it carries real risk. Get the indication right, check the unit, and know your reaction response. Those matter as much as the connection itself.

How It Works

• Red cells: the cells restore oxygen-carrying capacity. Low hemoglobin and a patient who shows need are the reasons to give them.
• Plasma and platelets: they replace clotting factors or platelets in a bleeding patient. In hemorrhage, the massive transfusion protocol is the tool.
• Unit handling: keep it cold until it is spiked. Don't leave it at room temperature.
• Line: one fluid, the right set. Use a compatible set and 0.9% saline only. Dextrose and calcium-containing solutions are not used with red cells.
• Reactions: most show up within the first minutes to hours. Watch the patient from start to finish.

Where It Fits

• Stable anemia: the AABB 2023 restrictive strategy runs on a hemoglobin trigger.
• Active hemorrhage: the hemoglobin number does not guide transfusion. Run the massive transfusion protocol and follow the clinical response.
• Prehospital or in-flight: transport teams may carry blood under local protocol. The JTS 2020 guideline names cold-stored low-titer O whole blood, calcium replacement and minimal crystalloid as key points (see Indications).

Indications

• Stable hospitalized adults: transfuse red cells when Hgb is below 7 g/dL per the AABB 2023 guideline.
• Orthopedic surgery or preexisting cardiovascular disease: a threshold of 8 g/dL is an accepted choice per the AABB 2023 guideline.
• Hematologic or oncologic disorders: a restrictive 7 g/dL threshold per the AABB 2023 guideline (conditional, low certainty evidence).
• Cardiac surgery: a threshold of 7.5 g/dL is an accepted choice per the AABB 2023 guideline.
• Hemorrhage with shock: transfuse under the massive transfusion protocol, guided by response, not a single hemoglobin value.
• Children: critically ill, hemodynamically stable children without hemoglobinopathy, cyanotic cardiac condition or severe hypoxemia use a restrictive 7 g/dL threshold per the AABB 2023 guideline (strong recommendation). Congenital heart disease thresholds: see Special Populations.

Prehospital and In-Flight Hemorrhage

• No hemoglobin trigger: the 7 g/dL number does not apply to hemorrhage. Judge by blood loss, shock and response.
• Product: if the program carries cold-stored low-titer O whole blood, the JTS 2020 guideline names it as a key option. Otherwise, follow the program’s component plan. Ratios are set by protocol, and this page does not state them.
• Calcium: calcium replacement goes with blood products, per protocol (see Medications).
• Crystalloid: keep it to a minimum. Crystalloid dilutes clotting factors and red cells.
• Warming: rapid infusion calls for a warmer. Hypothermia worsens coagulopathy.
• Evidence: a randomized trial of air-transported trauma patients at risk of hemorrhagic shock found that prehospital plasma lowered 30-day mortality (PAMPer). Hemorrhage control and tranexamic acid follow the program protocol. Their doses are not on this page.

Absolute Contraindications

• Wrong unit or wrong patient: the unit label does not match the order or the patient.
• Incompatible unit: a crossmatch or ABO mismatch is found.

Relative Contraindications & Cautions

• Volume overload: heart failure or renal failure raises the TACO risk. Give slowly. Reassess the lung exam and oxygenation.
• Unexplained fever or hypotension: assume a possible reaction until the blood bank says otherwise.
• Known antibodies: units need extended matching. The blood bank decides.

Consider an Alternative

• Volume loss without anemia: crystalloid or albumin per protocol; see Albumin.
• Vascular access problems: see IO Access when IV access fails.

Team Roles During the Transfusion

• Verifier: checks the unit, order and patient with a second clinician or a bar-code check.
• Operator: starts the unit, sets the rate and watches the line.
• Monitor: records vital signs and calls for reaction signs.
• Blood bank contact: receives the call for any reaction and returns the unit if needed.

Patient Check

• Identifiers: two patient identifiers (name plus date of birth or ID number) per facility policy. A room number is not one.
• Baseline: temperature, heart rate, blood pressure, respiratory rate and SpO₂ before the first mL.
• Indication: the Hgb or bleeding status that led to the order.
• Allergy and prior reactions: note any past reaction and the blood bank history.

Unit Check

• Label: component type, ABO/Rh, donor number and unit number match the order and the patient.
• Storage: track the time out of refrigeration. If the 4-hour limit cannot be met, return the unit.

Equipment

• Blood administration set: standard set with a 170–200 µm filter (not a dextrose-compatible set).
• 0.9% sodium chloride: the only line fluid; no dextrose and no Lactated Ringer's with the unit.
• Warmer: use a blood warmer per device labeling for rapid or large-volume transfusion.
• Pump or rapid infuser: set the rate per protocol; use a pressure device only where the device is labeled for blood.
• Monitoring: cardiac monitor, pulse oximetry, blood pressure and temperature.
• Emergency drugs: epinephrine (IM and IV), diphenhydramine, calcium chloride and hydrocortisone available.

Patient Positioning & Preparation

• Place the patient in a stable position with the IV site visible and checked.
• Give the team a clear plan for reactions and the blood bank phone number.

Read these as typical adult and pediatric references for reaction response. Before use, check them against local protocol and current drug labeling. Doses vary by protocol; follow local protocols and medical direction.

Settings

• Completion time: finish within 4 h of leaving refrigerated storage.
• Rate: set per protocol and per patient response; slow rate for TACO risk.
• Pediatric rate and volume: set by weight per blood bank protocol.

Phase 1: Prepare

1. Confirm the order: product, indication and the patient. Check two patient identifiers.
2. Check the unit: label matches the order and the patient. A second person or bar-code check confirms the match.
3. Check the time: note the time the unit left controlled storage. Start promptly; many policies require the start within 30 minutes. If it cannot start, return it to the blood bank per policy.
4. Set the line: use a standard blood set with a 170–200 µm filter, primed with 0.9% saline.

Phase 2: Perform

5. Start slowly: begin at the slow rate set by protocol and check vital signs at about 15 minutes; a reaction most often shows early.
6. Keep the line saline-only: no dextrose, no Lactated Ringer's and no drug through the unit line.
7. Increase the rate: per protocol and per patient response, watching for volume overload.

Phase 3: Confirm & Finish

8. Finish within 4 hours: complete the unit within 4 h of leaving controlled storage; this is the hard limit.
9. Record: unit number, start and stop times, rate, vital signs and any reaction.
10. Return the bag: per blood bank policy when the unit is not used.

Primary Confirmation

The primary check happens at the bedside. Match the unit label against the order and the patient, by two people or by bar code. No lab or waveform confirms a transfusion. Vital signs and the patient's clinical course do.

Secondary Confirmation

• Flow is steady through the filter, with no clotting or swelling at the site.
• Vital signs are stable before, during and after the first 15 minutes.
• The patient has no new rash, dyspnea or fever.

Ongoing Monitoring

• Baseline: vital signs before the first mL.
• At start: vital signs when the unit starts.
• About 15 minutes after start: vital signs and a symptom check.
• During: vital signs and symptoms at the frequency set by facility policy.
• After completion: vital signs at completion and with any new symptom.

Blood Bank Workup

• Direct antiglobulin test (DAT), repeat ABO/Rh typing and crossmatch on a new sample.
• Hemolysis tests: plasma free hemoglobin, LDH, bilirubin, haptoglobin and urine for hemoglobin.
• Blood cultures from the patient and the bag when sepsis is possible.
• Return the bag and paperwork to the blood bank.

Pediatrics

• Volume: weight sets it, in mL/kg, per blood bank and hospital protocol. Never give a fixed adult unit.
• Rate: go slow and reassess. Children have less reserve for volume overload.
• Thresholds: critically ill, hemodynamically stable children without hemoglobinopathy, cyanotic cardiac condition or severe hypoxemia use 7 g/dL (AABB 2023, strong recommendation). Stable children with congenital heart disease (AABB 2023, conditional, low certainty): 7 g/dL after biventricular repair, 9 g/dL after single-ventricle palliation, and 7 to 9 g/dL when uncorrected.
• Drugs: epinephrine IM 0.01 mg/kg (max 0.3 mg) and diphenhydramine 1 mg/kg (max 50 mg) per the medication pages.
• See Weight-Based Dosing and Pediatric Vascular Access.

Pregnancy

• The blood bank selects the product. Rh-negative patients who may bear children get Rh-negative red cells per blood bank policy.
• Emergency release for females of childbearing potential: until the patient’s type is known, the blood bank may issue group O red cells, Rh-negative when available (blood bank policy).

Older Adults and Heart Failure

• TACO risk runs higher here. Slow the rate and reassess lungs and oxygenation at each step.

Immediate Aftercare

• Recheck vital signs at completion and at the interval set by policy.
• Watch for delayed reactions for hours after the last unit.

Ongoing Maintenance

• Keep the IV patent with saline and check the site.
• Repeat labs per protocol after large-volume transfusion (hemoglobin, potassium, calcium).

Transport Considerations

• Secure the line and the unit; check the rate after every move.
• Keep the unit cold until spiked; do not let it sit at room temperature in the transport vehicle.
• Rely on monitors and vital signs in noise and vibration; a reaction can start after departure.

Pearls

• Stable threshold: Hgb <7 g/dL in stable hospitalized adults per the AABB 2023 guideline.
• Saline only: one line, one fluid, no dextrose.
• Reaction response: stop, keep the line, notify the blood bank.
• Time limit: 4 h from leaving storage.

Common Pitfalls

• Skipped check → wrong unit: confirm two identifiers and the unit label at the bedside.
• Slow reaction call → delayed response: stop the unit at the first sign and call the blood bank.
• Drugs in the unit line → clotting or hemolysis risk: use a separate line for drugs.
• Threshold used in hemorrhage → delayed blood: judge by blood loss and shock.

Skill Maintenance

• Run a simulated reaction drill with the blood bank call included.
• Practice the two-person bedside check on every unit.
• Review the facility transfusion policy each year.