Practice Information

Guidelines For Monitoring Transfusion Recipients and
Transfusion Reaction Response Guide

by the New York State Council on Human Blood and Transfusion Services and New York State Board for Nursing


The following guideline and Transfusion Reaction Response Guide reflect the thinking of New York State experts in transfusion medicine and nursing. The documents may be helpful during preparation of institutional standard operating procedures and can be modified for incorporation into institution documents, as indicated. References that provide additional information on this topic are listed at the end of the guideline.

  1. The patient's vital signs (temperature, pulse, respirations, and blood pressure) should be recorded shortly before transfusion and after the first 15 minutes, and compared to baseline values. Some patients' history or clinical conditions may indicate a need for more frequent monitoring.
  2. After the transfusion is initiated, the rate of flow should be observed and regulated, according to the physician's orders.
  3. If a particular patient is determined to be at increased risk for a mild reaction, a "PRN" (if needed) order, for that patient, for medications such as acetaminophen and/or diphenhydramine, may be useful in order to facilitate immediate availability in the patient care area.
  4. During the transfusion, the patient should be observed periodically, especially during the first 10 to 15 minutes, for signs and symptoms of transfusion reaction.
    The Transfusion Reaction Response Guide lists signs and symptoms suggestive of a transfusion reaction and lists actions that should be taken in the event that such signs and symptoms occur during the administration of the transfusion or shortly thereafter.
  5. If transfused at a medical facility, the patient should be instructed, prior to transfusion, to alert a health care provider of any discomfort or unusual sensations.
  6. Upon completion of the transfusion, the patient's vital signs (temperature, pulse, respirations, and blood pressure) should be recorded, and compared with the previous values.
  7. The ordering physician or designee who is familiar with the patient should be available by telephone to handle any complications.
  8. In an ambulatory setting, it is important that the patient be given instructions on potential problems following transfusion and the telephone number to call in the event of a reaction.
  9. Assessment of the effect of the transfusion (increment in hemoglobin/hematocrit, platelet count or fibrinogen, or correction of PT/INR or PTT, as applicable) is important post-transfusion. Blood specimens (EDTA tube for hemoglobin/hematocrit or platelet count; citrated tube for coagulation parameters) should be collected as ordered by the physician. However, the timing of such a phlebotomy may vary depending on the clinical condition of the patient.

Pertinent Literature

  • Popovsky MA, ed. Transfusion reactions. 3rd ed. Bethesda, MD: AABB Press, 2007.
  • Triulzi DJ, ed. Blood transfusion therapy: a physician's handbook. 8th ed. Bethesda, MD: AABB, 2005.
  • Brecher M, ed. Technical manual. 15th ed. Bethesda, MD: AABB, 2005 Chapter 27: Noninfectious complications of blood transfusion, pp. 633-65. Chapter 28: Transfusion-transmitted diseases, pp. 667-711.
  • Cherry T, Steciuk M, Reddy V, Marques, M. Transfusion-related acute lung injury; past, present and future. Am J Clin Pathol 2008;129:287-97.
  • New York State Council on Human Blood and Transfusion Services. Transfusion Reactions Fact Sheets, 2008.

Transfusion Reaction Response Guide
Acute Reactions
Symptoms/Signs Possible Etiology Actions
  • Local erythema
  • Hives
  • Itching
  • Flushing

These symptoms/signs are related to a mild allergic reaction to plasma proteins

  • Stop infusion
  • Maintain IV line with Normal saline at a "keep vein open" rate
  • Notify physician or other provider
  • Reconfirm patient and unit identification to verify that the correct unit is being given to the intended recipient
  • Administer diphenhydramine (Benadryl), if ordered
  • Notify the Blood Bank; no specimen need be sent
  • If symptoms resolve, the physician or other provider may decide to restart the transfusion after treatment
  • Monitor closely for any further signs or symptoms
  • Document the reaction in the patient's chart as per institution policy
  • Chills
  • Fever - 1°C (2°F) or more increase in temperature up to 4 hours after the transfusion
  • Flushing
  • Restlessness
* * * * * * * * *
  • Chest pain or pressure
  • Lower back pain
  • Dyspnea
  • Tachycardia
  • Nausea/Vomiting
  • Diarrhea
  • Hypotension
  • Shock
  • Wheezing
  • Complaints of throat tightness
  • Rigors
  • Wine- or cola-colored urine
  • Pain at the infusion site
  • Unexplained bleeding from mucous membranes or infusion site
These symptoms/signs may be due to a febrile, nonhemolytic reaction related to infused white blood cells or cytokines, or may be the initial presentation of a more serious acute hemolytic reaction or sepsis

* * * * * * * * *

These may be symptoms/signs related to fluid overload, acute hemolysis, sepsis, anaphylaxis, or transfusion-related acute lung injury (TRALI)
  • Stop infusion
  • Maintain IV line with Normal saline at a "keep vein open" rate
  • Notify physician or other provider
  • Reconfirm patient and unit identification to verify that the correct unit is being given to the intended recipient
  • Notify the Blood Bank; collect a type and screen specimen and a first post-transfusion urine specimen. Send these along with the remaining blood unit, and administration set with attached solutions to the laboratory unless otherwise instructed
  • Do not initiate another transfusion without Blood Bank consultation
  • Document the reaction in the patient's chart as per institution policy

Delayed Reactions

Observation of these symptoms/signs in the days following a transfusion, if not explained by the patient's medical condition, may merit being brought to the attention of a physician or other provider.

Clinical Presentation Possible Etiology
  • Fever
  • Rash
  • Elevated liver function tests
  • Watery diarrhea
  • Rapid progression to death with virtually 100% mortality
  • Symptoms/signs may occur from several days to a month after transfusion
These symptoms/signs may be caused by graft-vs-host disease, which can occur if HLA-incompatible donor T-lymphocytes attack recipient tissues.
  • Fall in hemoglobin and hematocrit
  • Fever
  • Jaundice
  • ↑ Lactate dehydrogenase (LDH)
  • Typically occurs 3-7 days after transfusion, but may occur 14 days after transfusion or later
  • Often, patient is asymptomatic
  • Direct antiglobulin test (DAT) may be positive and an antibody not detected prior to the transfusion may be identified
These symptoms/signs may be caused by a delayed hemolytic reaction, which is due to an antibody, developed as a result of pregnancy or a transfusion in the past, when the antibody is of low enough titer so as to be undetectable at the time of a recent transfusion, but has intensified as a result of a recent transfusion (an anamnestic response).
  • Thrombocytopenia, often severe, occurring with an abrupt onset, generally 1-2 weeks after a transfusion
  • Melena
  • Hematuria
  • Vaginal bleeding
  • Occurs most commonly in multiparous women
  • Usually self-limited, but severe bleeding may occur and can be fatal (e.g., intracranial bleeding).
These symptoms/signs may be caused by posttransfusion purpura, in which antibodies stimulated by a recent transfusion (usually of red blood cells or platelets) destroy platelets in a patient who has made an antibody against a foreign platelet antigen as a result of pregnancy or a previous transfusion.
Last Updated: January 31, 2013