What each product is for, when not to give it, what can go wrong, and exactly what you do about it.
Two RNs verify client ID, blood type and unit number at the bedside.
Normal saline is the ONLY compatible fluid. Lactated Ringer's clots the line; dextrose lyses the cells.
Stay with the client for the first 15 minutes and run slowly — that is when reactions show.
Vitals before, at 15 minutes, then per policy. Finish within 4 hours.
New tubing matters — if you keep the old line open you keep infusing the product.
• Symptomatic anemia, usually Hgb below 7 g/dL (below 8 with cardiac disease)
• Acute blood loss with signs of poor oxygen delivery
• Chronic anemia that is not correctable another way
• Anemia correctable with iron, B12 or folate — treat the cause instead
• Client refusal, including documented religious objection
• Volume overload risk means transfuse slowly, not never
• Fever, chills, urticaria
• Hemolytic reaction
• Circulatory overload (TACO)
• Iron overload with repeated transfusion
• Hyperkalemia from older units
• Two RNs verify client ID, blood type and unit number at the bedside
• Normal saline ONLY — LR clots the line, dextrose lyses the cells
• Start slow and stay with the client the first 15 minutes, when reactions usually appear
• Complete within 4 hours; use a filtered Y-set and an 18-20 gauge line
STOP the transfusion, keep the line open with normal saline using new tubing, take vitals, notify the provider and the blood bank, and send the bag and tubing back.
• Platelet count below 10,000, or below 50,000 with active bleeding or before a procedure
• Functional platelet defect with bleeding
• Massive transfusion protocol
• Thrombotic thrombocytopenic purpura (TTP) and heparin-induced thrombocytopenia (HIT) — platelets can worsen clotting
• Immune thrombocytopenia without bleeding
• Fever and chills (most common of any product)
• Allergic and urticarial reactions
• Bacterial contamination — highest risk of any product because platelets are stored at room temperature
• Alloimmunization with repeat transfusions
• Do not refrigerate
• Infuse fast, usually over 15-30 minutes
• ABO compatibility is preferred but not always required
• Expect a post-transfusion count 1 hour after
Same stop-and-notify sequence. For a febrile reaction, an antipyretic and a leukocyte-reduced product next time.
• Active bleeding with multiple factor deficiencies
• Urgent warfarin reversal when bleeding — give with vitamin K
• Massive transfusion, DIC, liver failure with bleeding
• Volume expansion — use crystalloid or albumin instead
• Correcting a mildly high INR when there is no bleeding
• Nutritional supplementation
• Circulatory overload (large volume)
• Allergic and anaphylactic reactions
• TRALI — plasma products carry the highest risk
• Citrate toxicity causing low calcium
• Must be ABO compatible
• Infuse as soon as it is thawed
• Watch for tingling around the mouth, tetany, tremors — that is citrate binding calcium
For citrate toxicity, IV calcium gluconate. For TRALI, respiratory support — do not diurese, it is not volume overload.
• Fibrinogen below 100 mg/dL, especially in DIC
• Massive transfusion with ongoing bleeding
• Hemophilia A or von Willebrand disease when factor concentrate is unavailable
• Bleeding from uremic platelet dysfunction
• Routine volume replacement
• Factor deficiencies where a specific concentrate exists — use the concentrate
• Allergic reactions
• Rarely, thrombosis with large repeat doses
• Same infectious risk profile as other pooled products
• Small volume, infuse fast
• Usually given as a pool of several units
• Recheck fibrinogen after
Standard stop-and-notify. Recheck fibrinogen and give more if bleeding continues.
• 5%: hypovolemia, burns, plasmapheresis replacement
• 25%: hypoalbuminemia with edema, ascites, nephrotic syndrome
• Large-volume paracentesis to prevent circulatory dysfunction
• Heart failure and pulmonary edema — it pulls fluid into an already overloaded circulation
• Severe anemia
• Known albumin hypersensitivity
• Fluid overload and pulmonary edema
• Hypertension from a fast rise in volume
• Fever, chills, urticaria
• Dilutional anemia and coagulopathy
• 25% albumin pulls roughly 3-4 times its volume into the vasculature
• Monitor lung sounds, JVD and blood pressure closely
• No ABO matching and no crossmatch needed
• Normal saline is the only compatible line fluid
There is no reversal agent. Stop the infusion, sit the client upright, give oxygen, and expect an order for a loop diuretic.
• Life-threatening bleeding on warfarin — works faster and in less volume than FFP
• Urgent surgery on a client who is anticoagulated
• Some formulations are used for factor IX deficiency
• Active thrombosis, recent MI or stroke, DIC
• Heparin-induced thrombocytopenia if the product contains heparin
• Thromboembolism — the main risk
• Headache, nausea
• Allergic reactions
• Rarely DIC
• Always give vitamin K with it — PCC wears off long before the warfarin does
• Recheck INR after the dose
• Watch for signs of clotting: chest pain, dyspnea, leg swelling
There is no antidote for over-correction. Watch for thrombosis and treat it if it occurs.
• Primary immunodeficiency
• Immune thrombocytopenia (ITP)
• Guillain-Barré syndrome, myasthenic crisis, Kawasaki disease
• IgA deficiency — risk of anaphylaxis
• Severe renal impairment, especially sucrose-containing products
• History of thrombosis
• Headache, and aseptic meningitis especially with fast infusion
• Renal failure
• Thrombosis
• Flu-like symptoms, flushing, chest tightness
• Infuse slowly and hydrate well — most reactions are rate-related
• Premedicate with acetaminophen and diphenhydramine when ordered
• Baseline renal function before starting
Slow or stop the infusion for reactions. Anaphylaxis is treated with epinephrine; supportive care for the rest.
• Massive hemorrhage where both volume and oxygen-carrying capacity are lost
• Some trauma and military protocols
• Exchange transfusion in neonates
• Chronic anemia — PRBCs are the right product
• Any client at risk of circulatory overload
• Circulatory overload
• All the same reactions as PRBCs
• Electrolyte shifts with large volumes
• Same two-RN verification and normal saline rule
• Warm large volumes to prevent hypothermia
• Monitor calcium and potassium in massive transfusion
Same stop-and-notify sequence as PRBCs.
ABO incompatibility — the wrong unit, usually a clerical error
Fever, chills, low back or flank pain, dark or red urine, hypotension, a feeling of impending doom, DIC
STOP immediately. New tubing with normal saline. Notify provider and blood bank. Send the bag, tubing and blood and urine samples. Support blood pressure, maintain urine output, watch for renal failure and DIC.
Recipient antibodies reacting to donor white cells — the most common reaction
Temperature rise of 1°C or more, chills, headache; no hemolysis
Stop the transfusion and rule out a hemolytic reaction first. Give an antipyretic. Use leukocyte-reduced products in future.
Reaction to donor plasma proteins
Hives, itching, flushing — no fever, no hypotension
Pause the transfusion, give an antihistamine. This is the only reaction that may be restarted if symptoms fully resolve and the provider agrees.
Often IgA deficiency in the recipient
Wheezing, stridor, angioedema, hypotension, shock — usually without fever
STOP. Epinephrine. Airway support, oxygen, IV fluids, antihistamines and steroids. Future products must be IgA-deficient or washed.
Volume given faster than the heart can handle; older adults, cardiac and renal clients
Dyspnea, crackles, JVD, hypertension, cough, rising oxygen requirement
Slow or stop. Sit the client upright with legs dependent. Oxygen. Expect a loop diuretic. Transfuse slowly next time.
Donor antibodies triggering pulmonary capillary leak; plasma-rich products
Sudden hypoxia, bilateral infiltrates, fever, hypotension — jugular veins are flat
STOP. Aggressive respiratory support, often intubation. Do NOT give a diuretic — this is not fluid overload. That is the difference from TACO.
Contaminated unit — highest risk with platelets (room-temperature storage)
High fever, rigors, hypotension, shock, GI symptoms
STOP. Blood cultures from the client and the bag. Broad-spectrum antibiotics. Vasopressors as needed.
Anamnestic antibody response in a previously sensitized client
Unexplained falling H&H, mild jaundice, low-grade fever
Usually supportive. Recheck H&H, direct Coombs, bilirubin. Flag the antibody for future crossmatching.
Citrate preservative binds the client's calcium
Tingling around the mouth, tremors, muscle twitching, tetany, prolonged QT, dysrhythmias
Slow the transfusion. IV calcium gluconate is the treatment. Monitor ionized calcium and the ECG.
Potassium leaks out of stored red cells over time
Peaked T waves, widening QRS, bradycardia, muscle weakness
Use fresher units. Treat as any hyperkalemia: calcium gluconate first, then insulin with dextrose, albuterol, Kayexalate, dialysis.
| TACO (overload) | TRALI (lung injury) | |
|---|---|---|
| Blood pressure | HIGH | LOW |
| Neck veins | Distended | Flat |
| Cause | Too much volume, too fast | Donor antibodies, capillary leak |
| Treatment | Upright, oxygen, diuretic | Respiratory support, NO diuretic |