Lippincott Certification Review Medical-Surgical Nursing


Multiple Myeloma

Box 8-5: Guide to Immediate Transfusion Reactions

Any patient receiving a transfusion of blood or blood products is at risk for a transfusion reaction. An immediate reaction may occur during the transfusion itself or several hours after the transfusion. The chart below describes immediate reactions. Reaction Cause Signs and Symptoms Nursing Interventions Acute hemolytic

• Administration of incompatible blood • Antibodies in the blood targeting donor antigens

• Chest pain • Dyspnea • Facial flushing

• Monitor the patient carefully, especially during the first 15 minutes of any transfusion. If the patient exhibits signs of a reaction, stop the transfusion immediately. • Administer IV fluids, oxygen, epinephrine, and vasopressors, as ordered. • Observe the patient for signs of coagulopathy. • Provide antibiotics as ordered. • Monitor the patient for fever for several hours after completion of the transfusion. • Obtain blood cultures from a site other than IV infusion site. • Keep all blood bags and tubing and send them to the blood bank. • Relieve signs and symptoms with an antipyretic. • If the patient requires further transfusions, consider using a leukocyte removal filter.

• Fever • Chills • Hypotension • Flank pain • Bloody oozing at the infusion or surgical incision site • Nausea • Tachycardia

Bacterial contamination

• Contamination of blood product

• Chills • Fever • Vomiting • Abdominal cramping • Diarrhea • Shock

Febrile nonhemolytic

• Cytokines from leukocytes in transfused red cell or other blood components cause a reaction in the recipient

• Fever within 2 hours of transfusion

• Chills • Rigor

• Headache • Palpitation • Cough • Tachycardia

Transfusion-related acute lung injury (TRALI)

• Granulocyte antibodies in the donor or recipient react with one another and subsequently cause pulmonary edema in the recipient

• Severe respiratory distress within 6 hours of transfusion

• Stop the transfusion immediately.

• Fever • Chills • Cyanosis • Hypotension

• Provide oxygen as needed. • Monitor pulse oximetry. • Prepare for intubation and ventilatory support and hemodynamic monitoring.

Allergic reaction • Allergic reaction to the allogenic proteins in the donor’s plasma

• Urticaria • Fever • Nausea and vomiting

• Stop the transfusion and administer antihistamine, corticosteroid, or epinephrine, as ordered. • Prepare for intubation and respiratory support if the patient develops anaphylaxis. • Monitor intake and output, breath sounds, and blood pressure. • Administer diuretics as ordered. • Closely monitor older adult patients and those with a history of cardiac disease carefully because they are at higher risk.

• Anaphylaxis (facial swelling, laryngeal edema, respiratory distress) in extreme cases

Transfusion associated circulatory overload (TACO)

• Rapid infusion of blood or excessive volume of transfusion causes hypervolemia

• Chest tightness • Chills • Dyspnea

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• Tachypnea • Hypoxemia

• Hypertension and jugular vein distention that occurs 2–6 hours after transfusion

From Suddock, J. T., & Crookston, K. P. (2022). Transfusion reactions. StatPearls . StatPearls Publishing. https://www.ncbi.nlm.nih. gov/books/NBK482202/

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