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For further information, see CMDT Part 13-39: Red Blood Cell Transfusions

Key Features

  • Severe reactions usually involve incompatible mismatches in ABO system that are isoagglutinin-mediated

  • Most cases are due to clerical errors and mislabeled specimens

  • When hemolysis occurs, it is rapid and intravascular; most reactions occur in surgical patients under anesthesia

  • Severity depends on RBC dose

  • Less severe reactions caused by minor antigen systems

  • Hemolysis is slower and is mediated by IgG antibodies causing extravascular red blood cell destruction; reactions may be delayed for 5–10 days after transfusion

  • Duffy, Kidd, Kell, and C and E loci of Rh system are antigens most commonly involved

  • Most transfusion reactions are not hemolytic but related to antigens present on WBCs

Clinical Findings

  • Fever, chills, backache, headache

  • Apprehension, dyspnea, hypotension, vascular collapse

  • Disseminated intravascular coagulation (DIC)

  • Acute kidney injury from acute tubular necrosis

  • Tachycardia, generalized bleeding, and oliguria in patients under general anesthesia


  • Hemoglobin fails to rise as expected

  • Acute kidney injury

  • Acute DIC (low fibrinogen, elevated fibrin degradation products, thrombocytopenia, prolonged prothrombin time)

  • Hemoglobinemia (plasma pink and hemoglobinuria)

  • In delayed cases, there is an unexpected drop in hemoglobin and an increase in the total and indirect bilirubins

  • Offending alloantibody detectable in patient's serum


  • Stop transfusion immediately

  • Check identification of recipient and blood

  • Return transfusion product bag with pilot tube to blood bank with fresh sample of recipient's blood for retyping and repeat of cross-match

  • Hydrate patient vigorously to prevent acute tubular necrosis. Forced diuresis with mannitol may help prevent or minimize acute kidney injury

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