Transfusion Reaction Comparison: Hemolytic vs Febrile vs Allergic vs TACO vs TRALI
Five transfusion reactions all start with "stop the transfusion" — but the next intervention is completely different for each. Giving furosemide saves the TACO patient and worsens the TRALI patient. Mixing up hemolytic and febrile reactions delays life-saving treatment for ABO mismatch. The NCLEX expects you to discriminate by symptom cluster, not just react generically.
Comparison
- ABO incompatibility → RBC destruction
- Recipient antibodies vs donor WBCs
- Most common reaction
- Hypersensitivity to donor plasma proteins
- Volume overload — too much, too fast
- Donor anti-leukocyte Ab → non-cardiac edema
- ★Flank/back pain, dark urine (ABO mismatch)
- Onset <15 mL; fever, chills
- Fever ≥ 1°C rise + chills
- During or within 1–4 hr; no rash
- Urticaria, hives, pruritus, flushing
- Anaphylaxis → wheeze, hypotension
- Dyspnea, crackles, JVD, hypertension
- Within 1–2 hr; peripheral edema
- Acute dyspnea, hypoxemia within 6 hr
- + Coombs, ↓ haptoglobin, hemoglobinuria
- Diagnosis of exclusion; cultures negative
- Clinical; vitals normal except skin
- ★↑ BNP, ↑ PCWP; CXR edema + cardiomegaly
- ★Normal BNP/PCWP; CXR bilateral infiltrates
- Stop the transfusion immediately
- Send bag + sample to blood bank; NS, UOP ≥30
- Stop the transfusion immediately
- Rule out hemolytic first; keep NS open
- Stop the transfusion immediately
- Assess airway
- Stop the transfusion immediately
- Sit upright; O₂; strict I&O
- Stop the transfusion immediately
- Respiratory support
- Supportive; treat DIC if it develops
- Antipyretic (acetaminophen)
- Diphenhydramine; epinephrine if anaphylaxis
- ★Furosemide IV
- ★NO diuretics; O₂, possible intubation
- 2-RN ID check prevents ABO error
- Leukoreduced units; premedicate next time
- Premedicate antihistamine; wash RBCs if recurrent
- Transfuse slowly; diuretic between units
- Report for donor workup/deferral
- Progresses to shock + DIC
- Must exclude hemolytic before resuming
- ★Anaphylaxis → airway compromise, shock
- Respiratory failure from overload
- Severe hypoxemia → ARDS
- Acute kidney injury, DIC, death
- Benign, self-limited
- Anaphylactic shock
- Pulmonary edema, cardiac failure
- ARDS; leading cause of transfusion death
Acute Hemolytic
- ABO incompatibility → RBC destruction
Febrile Non-Hemolytic
- Recipient antibodies vs donor WBCs
- Most common reaction
Acute Hemolytic
- ★Flank/back pain, dark urine (ABO mismatch)
- Onset <15 mL; fever, chills
Febrile Non-Hemolytic
- Fever ≥ 1°C rise + chills
- During or within 1–4 hr; no rash
Acute Hemolytic
- + Coombs, ↓ haptoglobin, hemoglobinuria
Febrile Non-Hemolytic
- Diagnosis of exclusion; cultures negative
Acute Hemolytic
- Stop the transfusion immediately
- Send bag + sample to blood bank; NS, UOP ≥30
Febrile Non-Hemolytic
- Stop the transfusion immediately
- Rule out hemolytic first; keep NS open
Acute Hemolytic
- Supportive; treat DIC if it develops
Febrile Non-Hemolytic
- Antipyretic (acetaminophen)
Acute Hemolytic
- 2-RN ID check prevents ABO error
Febrile Non-Hemolytic
- Leukoreduced units; premedicate next time
Acute Hemolytic
- Progresses to shock + DIC
Febrile Non-Hemolytic
- Must exclude hemolytic before resuming
Acute Hemolytic
- Acute kidney injury, DIC, death
Febrile Non-Hemolytic
- Benign, self-limited
★ marks the fact that sets a column apart.
Clinical Pearl
Flank pain + dark urine = hemolytic. TACO has high BP and high BNP; TRALI has low BP and normal BNP.
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