Managing a Blood Transfusion Reaction

Scenario

Ten minutes after starting a unit of packed red blood cells (PRBCs), your patient reports chills, flank pain, and shortness of breath.
You note flushed skin, fever 38.8°C, HR 122, and BP 86/48.

Question: What are your immediate interventions, and how do you manage this transfusion reaction safely?

Best Practice Answer

1. Recognize and Stop the Reaction Immediately:

   • Stop the transfusion right away.
   • Keep the IV line open with normal saline (NS) using new tubing — do not flush blood.
   • Remain with the patient and monitor airway, breathing, circulation (ABCs).
   • Check vital signs every 5 minutes or more frequently if unstable.

2. Differentiate Possible Reaction Types:

   • Acute hemolytic: Flank pain, fever, hypotension, dark urine — most dangerous.
   • Febrile non-hemolytic: Fever/chills, usually benign.
   • Allergic (mild): Itching, rash, no fever.
   • Anaphylactic: Dyspnea, hypotension, angioedema.
   • TRALI (Transfusion-Related Acute Lung Injury): Acute respiratory distress, SpO₂ drop, frothy sputum.
     Treat as hemolytic until proven otherwise.

3. Immediate Nursing Actions:

   • Stop transfusion, maintain IV access with NS.
   • Notify provider and blood bank immediately.
   • Recheck patient identifiers and blood unit label against transfusion record to confirm correct match.
   • Send the blood bag and tubing to the blood bank for analysis.
   • Collect samples: new blood specimen, urine for hemoglobin, and labs (CBC, bilirubin, BUN, creatinine).
   • Monitor urine output — insert Foley if ordered to assess renal perfusion.

4. Supportive Care:

   • Administer oxygen if SpO₂ < 94%.
   • Anticipate orders for antihistamines (diphenhydramine), corticosteroids, vasopressors, or diuretics (e.g., furosemide).
   • Monitor for shock: hypotension, tachycardia, cyanosis, reduced urine output.
   • Maintain IV fluids to support renal clearance of free hemoglobin and prevent AKI.

5. Documentation and Follow-Up:

   • Record onset time, symptoms, interventions, and patient response.
   • Document provider and blood bank notification times.
   • Complete transfusion reaction report per hospital policy.
   • Educate patient and family — future transfusions will require crossmatch review and premedication if indicated.

Real-World Application

Transfusion reactions are high-stakes, time-critical events.
This question evaluates your ability to:

• Recognize symptoms early (within minutes)
• Stop the transfusion immediately
• Follow institutional protocol precisely
• Maintain patient stability and documentation accuracy

Interviewers look for structured, confident responses showing mastery of safety-first reasoning and interdisciplinary coordination.

Tip: In interviews, say —
“At the first sign of reaction, I’d stop the transfusion, maintain NS with new tubing, monitor vitals, notify the provider and blood bank, and send all samples per protocol.”
That shows precision, composure, and accountability — exactly what clinical teams expect.