A transfusion reaction is any harmful response to blood products, ranging from mild hives or fever to life-threatening hemolysis, anaphylaxis, lung injury or fluid overload. Most severe reactions start in the first 15 minutes, which is why close monitoring at the start of every unit matters.
Key symptoms
- Fever, chills or rigors during or soon after the transfusion
- Itching, hives or flushing
- Shortness of breath, chest tightness or cough
- Back or flank pain, a sense of dread, dark or red urine
- Headache, nausea or feeling faint
What you find on exam
- Compare vital signs with the pre-transfusion baseline
- Temperature rise of 1 degree C or more, fast heart rate, low blood pressure
- Wheeze, stridor, lip or tongue swelling suggest anaphylaxis
- Crackles, raised jugular venous pressure and high blood pressure suggest fluid overload
- Oozing from IV sites, urine color and urine output
Tests
- Recheck patient identity, wristband and blood bag labels at the bedside
- Send the bag and tubing with new blood samples to the blood bank: repeat type and crossmatch, direct antiglobulin test
- Hemolysis labs: bilirubin, LDH, haptoglobin, blood count, urinalysis for hemoglobin
- Chest X-ray and oxygen saturation if breathless; blood cultures if high fever
Treatment basics
- Stop the transfusion at once and keep the IV open with normal saline through new tubing
- Call the provider and blood bank and follow the reaction protocol
- Anaphylaxis: intramuscular epinephrine, oxygen, IV fluids
- Fluid overload: sit the patient up, oxygen, IV furosemide
- Mild hives only: diphenhydramine, and restart only if the provider approves
Red flags
- Low blood pressure, fever and back pain early in the unit (acute hemolysis)
- Stridor, wheeze or facial swelling (anaphylaxis)
- Sudden low oxygen with bilateral infiltrates within 6 hours (lung injury)
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Sources: NCSBN 2026 NCLEX-RN Test Plan; Open RN, Nursing Skills 2e (Chippewa Valley Technical College); NCCPA PANCE Content Blueprint. Written by Making Synapses. Making Synapses is not affiliated with these organizations.