Suspected acute transfusion reaction
New symptoms or signs during or within 24 h of a transfusion of any blood component
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Hematology & OncologyEmergency
Acute Transfusion Reaction Management
Acute Transfusion Reaction Management: Suspected acute transfusion reaction → STOP the transfusion now → Assess and classify the reaction → Any severe f...
Pathway Overview
17 steps
Algorithm Steps
17 total
01Start 02Warning STOP the transfusion now
Assess airway, breathing and circulation (ABC) and vital signs. Call for help if unwell.
- Keep IV access. Do not flush the line; use a new line or giving set
- Re-check patient ID against the pack label and compatibility report. Look at the pack for clots, haemolysis, discolouration or cloudiness
- Keep the pack and giving set; tell the medical officer and transfusion lab now
03Action Assess and classify the reaction
Check temperature, BP, heart rate, RR, SpO2 and urine colour. Look for skin, airway and chest signs.
- Severe features: temp 39 °C or more, or rise 1.5 °C or more; chills or rigors; hypotension or hypertension; tachycardia; dyspnoea or low SpO2; stridor or wheeze
- Also severe: chest, flank, back or IV-site pain; anxiety or sense of doom; nausea or vomiting; dark or red urine; abnormal bleeding
- Mild: temp over 38 °C with rise 1 to under 1.5 °C, or skin signs only (rash, itch, hives), and no other features
- Under anaesthesia: hypotension, haemoglobinuria or oozing (DIC) may be the first sign
04Decision Any severe feature or ABC problem?
Severe = fever 39 °C or more or rise 1.5 °C or more, chills or rigors, BP change, tachycardia, breathing problem, pain, sense of doom, nausea or vomiting, dark urine or bleeding. Skin signs alone are not severe.
- If Yes
05Warning Severe reaction: do not restart the transfusion
Could be haemolysis (AHTR), bacterial contamination, anaphylaxis, TACO or TRALI. Call rapid response.
- Give oxygen; monitor ECG, BP and SpO2
- Hypertension or fluid overload signs (possible TACO): no fluid bolus
- Call the haematologist or transfusion service now
06Decision Anaphylaxis features?
Stridor, airway swelling, wheeze or hypotension; or skin or mucosal signs (hives, flushing, lip or tongue swelling) with breathlessness, low SpO2, or persistent severe vomiting or abdominal pain. Usually within 45 min of starting; skin signs may be absent. If in doubt, give adrenaline.
- If Yes
07Action Anaphylaxis: give IM adrenaline now
Adrenaline 1 mg/mL (1:1,000) IM, outer mid-thigh. Adult: 0.5 mg (0.5 mL). Child: 0.01 mg/kg (0.01 mL/kg), max 0.5 mg. Repeat after 5 min if needed.
- Lay flat (sit with legs out if breathing is hard; pregnant or vomiting: lie on the left side); oxygen; IV 0.9% sodium chloride bolus for hypotension
- No response after 2 doses: refractory anaphylaxis protocol; call ICU or anaesthetics
- Stop other possible allergens
- Tests: serial tryptase, IgA level (IgA antibodies if deficient), haptoglobin
08Action Possible AHTR, sepsis or TRALI: treat until excluded
Fever 39 °C or more, rigors, hypotension, hypoxia without overload, pain or dark urine. Also after anaphylaxis if shock or fever persists.
- Blood cultures from patient (and central line), then broad-spectrum IV antibiotics
- Maintain BP and urine output: IV fluids; inotropes or vasopressors as needed. Heart or kidney failure: give fluids in small steps and reassess; do not withhold in shock
- Hypoxia with hypotension and no overload (possible TRALI): oxygen, ventilatory support; diuretics may worsen TRALI
- Suspected contamination or TRALI: lab must notify Lifeblood urgently (co-components)
09Action Severe reaction: investigations
Send the pack and giving set (sealed) to the lab. Tell the lab at once if a wrong pack was given.
- Group and screen, DAT and crossmatch on pre- and post-transfusion samples
- Haemolysis: FBC and film, LDH, bilirubin, haptoglobin, electrolytes, creatinine, urinalysis
- DIC: aPTT, PT, fibrinogen, D-dimer
- Sepsis: blood cultures (patient); culture and Gram stain of the pack
- Dyspnoea: chest X-ray; consider NT-proBNP and echo
- Anaphylaxis: serial tryptase, IgA level
10Decision Haemolysis or ABO incompatibility?
Wrong pack given, positive DAT, or lab signs of haemolysis
- If Yes
11Warning AHTR: support BP and urine output
Haematologist and transfusion service lead care. No more blood components until they clear it.
- IV fluids to restore BP first (inotropes if needed), then a diuretic if needed to keep a good urine output; heart or kidney failure: watch for overload
- Wrong blood: check that no other patient received a wrong pack
- Monitor for DIC and kidney injury; ICU if unstable
12Action Document, report and plan future transfusions
Record the reaction in the medical record. Complete an incident report as per local policy.
- Report through the hospital transfusion service; it informs Lifeblood and haemovigilance as required
- Recurrent allergic reactions: consider antihistamine premedication; ask a haematologist
- IgA deficiency with IgA antibodies: washed or IgA-deficient components (contact Lifeblood)
- TACO risk (older age, child, heart or kidney disease, severe anaemia): transfuse slowly; consider a diuretic
- Tell the patient what happened and what it means for future transfusions
13Outcome Reaction managed and reported
Patient stable; investigation complete; plan for future transfusions recorded
If No14Action Not haemolytic: manage by reaction type
Febrile non-haemolytic reaction (FNHTR) is a diagnosis of exclusion.
- Bacterial contamination: continue antibiotics; guide by patient and pack cultures
- TRALI: oxygen and ventilatory support; avoid diuretics; Lifeblood tests the donor
- TACO: diuretic; future transfusions slowly
- Anaphylaxis: check IgA; future components by haematologist (contact Lifeblood)
- FNHTR: antipyretic and supportive care
- Path rejoins step 12Shared downstream outcome
If No15Decision Dyspnoea with hypertension or fluid overload?
Not anaphylaxis. Look for raised JVP, orthopnoea, basal crackles, positive fluid balance.
- If Yes
16Action Fluid overload (TACO) suspected: no fluid bolus
Sit upright. Oxygen. IV diuretic (e.g. furosemide). Pause other IV fluids. If hypotensive, think TRALI instead: no diuretic.
- Fever 39 °C or more or rigors too: blood cultures, then broad-spectrum IV antibiotics; treat as possible sepsis or AHTR
- Chest X-ray for pulmonary oedema
- Consider NT-proBNP and echocardiogram
- Look for other causes of pulmonary oedema
- Path rejoins step 09Shared downstream outcome
If No- Path rejoins step 08Shared downstream outcome
If No17Action Mild fever alone, or skin signs alone
Stable, with no other features. Stay with the patient and observe closely. Not settling or worse: stop and do not restart; treat as severe.
- Mild fever: paracetamol; send a reaction form; think of other causes of fever
- Isolated hives or itch (not generalised): antihistamine; stop other possible allergens
- Generalised hives or redness, or localised angioedema, with no airway, breathing or BP problem: do not restart; antihistamine, corticosteroid if needed
- Mild fever or isolated hives: restart slowly only if symptoms settle and the pack is still usable
- Path rejoins step 12Shared downstream outcome
Guideline Source
Australian Red Cross Lifeblood - Management of suspected transfusion reactions (updated Oct 2025) and Acute Transfusion Reactions card V14 (May 2026)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Guide for the first hours only; follow local transfusion reaction policy and the haematologist or transfusion service
- Signs of AHTR, sepsis, anaphylaxis, TACO and TRALI overlap; more than one can occur together
- Delayed haemolytic and other delayed reactions are not covered
- Anaphylaxis doses follow ASCIA 2026; no fluid, diuretic or antibiotic doses are given
Applicable Regions
AUUSEUGlobal
AU: Lifeblood supplies leucodepleted red cells and platelets. Report reactions through the hospital transfusion service to Lifeblood and the state haemovigilance program as required.
Global: Blood bank procedures and reporting routes vary by institution and country.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Acute Transfusion Reaction Management?
The Acute Transfusion Reaction Management is a emergency clinical algorithm for Hematology & Oncology. It provides a structured decision tree to guide clinical decision-making, based on Australian Red Cross Lifeblood - Management of suspected transfusion reactions (updated Oct 2025) and Acute Transfusion Reactions card V14 (May 2026).
What guideline is the Acute Transfusion Reaction Management based on?
This algorithm is based on Australian Red Cross Lifeblood - Management of suspected transfusion reactions (updated Oct 2025) and Acute Transfusion Reactions card V14 (May 2026).
What are the limitations of the Acute Transfusion Reaction Management?
Known limitations include: Guide for the first hours only; follow local transfusion reaction policy and the haematologist or transfusion service; Signs of AHTR, sepsis, anaphylaxis, TACO and TRALI overlap; more than one can occur together; Delayed haemolytic and other delayed reactions are not covered; Anaphylaxis doses follow ASCIA 2026; no fluid, diuretic or antibiotic doses are given. Individual patient factors may require deviation from these recommendations.
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