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Complications of Transfusion - Types, Causes, Symptoms, and Treatment

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Blood transfusions can be associated with adverse reactions. Read the article to learn more about the complications of transfusion.

Medically reviewed by

Dr. Mohammad Rajja

Published At December 29, 2022
Reviewed AtAugust 31, 2023


Blood transfusion is a routine medical procedure in which blood is provided to a patient post-surgery or to recover from illness. Patients with blood transfusions generally do not have any problems. However, a range of problems is associated with blood transfusion. Therefore, recognizing the symptoms of transfusion reaction is essential.

What Is Massive Blood Transfusion?

When a patient's total blood volume is replaced within 24 hours, it might give rise to the following reactions. It can lead to the following complications:

  • Coagulation:

Transfusion of red blood cells and RBCs can lead to coagulation because RBCs are devoid of coagulation factors and platelets. It can cause hemorrhage followed by intravascular coagulation. The line of treatment includes replacement therapy with clotting factors, plasma, cryoprecipitate, and platelets.

  • Hypokalemia:

Plasma and platelets contain higher citrate levels. This citrate binds calcium and decreases plasma calcium levels. It causes decreased blood pressure, reduced pulse rate, and electrocardiogram (ECG) changes. It can be treated with intravenous administration of ten percent of calcium gluconate.

  • Hyperkalemia:

The storage of blood increases its potassium concentration. After the transfusion, sodium-potassium channels regulate, causing potassium to reuptake. Hyperkalemia occurs only if the patient is in hypothermia and in a state of metabolic acidosis.

  • Acid-base Balance:

RBC has increased acid production due to citric acid from anticoagulants and lactic acid from storage. Citrate forms bicarbonate. This can lead to metabolic alkalosis. Fluid resuscitation can help maintain the acid-base balance.

  • Hypothermia:

RBCs are generally stored at 4℃. Rapid transfusions decrease body temperature. This disturbs the hemostasis. This decreases the oxygen delivered to the tissues. This can be prevented by using air convection warming blankets and warming all the fluids.

What Is Febrile Nonhemolytic Transfusion Reaction?

These reactions are very common. These reactions occur due to reactions between the recipient's antibodies and the donor's leukocyte antigens. It forms a leucocyte antigen-antibody complex. This complex binds, complements, and releases pyrogens. This reaction can also occur due to contaminated leukocytes in the storage bag, which form cytokines. The onset of the reaction is during transfusion or hours later. The severity depends on the rate of transfusion and leucocyte load. Symptoms of febrile nonhemolytic transfusion reaction are mentioned below.

  • Fever.
  • Chills.
  • Malaise.
  • Muscle pain.
  • Decreased blood pressure.
  • Breathing problems.
  • Vomiting.

Air Embolism:

Air can enter a catheter during a change of blood bags or when blood is infused under pressure. This is controlled with the use of plastic bags.

Hemolytic Transfusion Reaction:

This is one of the severe complications of blood transfusion. It arises from the interaction between antibodies in the recipient's plasma and antigens in the donor RBC. The ABO and Rhesus D blood groups cause the majority of reactions. Naturally occurring antibodies like anti-A and anti-B, which belong to the IgM class, are responsible for this reaction. These develop due to previous exposure to RBC antigen, which is absent in the recipient. These reactions can occur immediately or can have a delayed onset. Hemolytic transfusion reactions are seen with past history of blood transfusions or transplacental transfusions during pregnancy.

Immediate Reaction:

Incompatible RBC antigen and recipient antibodies can cause complement fixation and intravascular destruction of red blood cells. The symptoms include:

  • Head, chest, and flank pain.
  • Fever and chills.
  • Flushing.
  • Rigors (shivering and rise in temperature).
  • Nausea and vomiting.
  • Dyspnea (difficulty breathing).
  • Hypotension.

The line of treatment includes,

  • Cardiac and respiratory support.
  • Maintenance of renal perfusion.
  • Intravenous fluid administration.
  • Use of Vasopressors and Diuretics group of drugs.

Delayed Reaction:

Incompatibility in minor blood groups can cause a delayed reaction. This can cause the extravascular breakdown of red blood cells. Delayed reactions can be detected due to low hematocrit values and jaundice.

These occur due to immunoglobulin E. presence of foreign protein in the donor's blood leads to allergic reactions. In such cases, transfusion should be discontinued, and Antihistamines should be administered. Allergy presents itching of skin and rashes, with or without fever. In recipients with hereditary IgA deficiency and IgA antibodies are already present, it leads to antigen-antibody reaction and anaphylaxis. If anaphylaxis presents as follows:

  • Urticaria which means itching of the skin.
  • Dyspnea is difficulty breathing.
  • Bronchospasm means severe constriction in the airways and difficulty breathing.
  • Laryngeal edema.
  • Cardiovascular collapse is acute dysfunction of the cardiac system.

Treatment options for anaphylaxis include fluid resuscitation, administration of Epinephrine, Antihistamines, Corticosteroids, and ventilation support.

Transfusion-Related Acute Lung Injury:

This presents with the acute respiratory syndrome. This reaction takes place immediately or six hours after transfusion. It occurs either as an antibody-mediated response due to donor leukocyte antigens or recipient leukocyte antibodies. In some cases, lipid products from donor blood cells act as a trigger for this reaction. The neutrophils are the cells causing this reaction. In the acute phase of the cycle, they move toward the lungs and are trapped in lung vessels. This releases oxygen-free radicals and proteolytic enzymes. This destroys the cells of lung capillaries. Air sacs in the lung fill up with fluid and proteins, causing lung edema. Clinical features of transfusion-related acute lung injury are as follows:

  • Hypoxemia - Decreased oxygen levels.
  • Dyspnea - Difficulty breathing.
  • Cyanosis - Bluish or grayish discoloration of nails, lips, and around eyes.
  • Fever - Increased body temperature.
  • Tachycardia - Increased heart rate.

Transfusion-Related Infections:

Contamination of blood during veinpuncture or blood of an asymptomatic donor with bacteremia. Red blood cells are stored at 4°C. This increases the proliferation of certain gram-negative bacteria. Platelet contamination can occur at room temperature due to the proliferation of gram-positive bacteria. Careful examination of bags before transfusion to look for dark coloration or the presence of bubbles for the presence of infection. Bacterial infections present with the following symptoms.

  • Fever.
  • Rigors (sudden feeling of cold and shivering).
  • Erythema (redness over the skin).
  • Cardiovascular collapse.

Testing of donor blood is done to rule out diseases that spread through blood, like Hepatitis B and C, HIV, Syphilis, or Cytomegalovirus. However, if the transfusion occurs in the window period of the disease, it becomes difficult to detect in screening tests.

What Is Transfusion-associated Graft Versus Host Disease?

This is a rare complication that presents with the following symptoms:

  • Rash involving the face, palm, and soles.
  • Stomach ache.
  • Diarrhea.
  • Abnormal liver function test.
  • Donor T cells destroy bone marrow stem cells.


Blood transfusion is an essential and life-saving procedure. However, it has certain potential hazards. Blood transfusions should be done only when necessary. Blood groups should be cross-matched before transfusions. Transfusion reactions should be identified and treated immediately.

Frequently Asked Questions


When Do Some Blood Transfusions Not Work?

When red blood cells are transfused into patients, they frequently form antibodies against them, making it more challenging to match donors for subsequent transfusions. Transfused blood also suppresses the immune system, increasing the risk of diseases such as pneumonia and sepsis.


When Do Blood Transfusion Reactions Usually Occur?

Reactions might occur anywhere from one day to four weeks after the transfusion. These antibodies might be acquired through previous pregnancies or blood transfusions. These antibodies gradually deteriorate to undetectable levels. Those who have the antibodies are more likely to suffer these transfusion reactions.


What Are the Delayed Complications of Blood Transfusion?

The delayed complications of the blood transfusion occur when an antibody that the receiver already possesses reforms and reacts to red cell antigens; this is known as a delayed hemolytic or delayed serologic transfusion reaction. Reactions might occur between one day and four weeks after the transfusion.
Another delayed complication is transfusion-associated graft versus host disease. It occurs when T-lymphocytes, a kind of white blood cell, from the donor blood multiply fast in the recipient. They then attack the cells of the recipient.
Posttransfusion purpura is also a rare complication that can occur when the receiver develops antibodies against the platelets. This leads to platelet breakdown and a decrease in platelet counts.


What Are the Disadvantages of Blood Transfusion?

Blood transfusion has some disadvantages. It can lead to some serious complications like renal failure, lung injury, or the formation of blood clots. These complications pose a risk to life.


Can Transfusion Reactions Cause Death?

Yes, although it is very rare, unfortunately, it is the most serious complication of blood transfusion. A hemolytic transfusion reaction is a potentially fatal complication that can occur following a blood transfusion. The reaction occurs when the person's immune system destroys the red blood cells donated during the transfusion. Hemolysis is the process by which red blood cells are destroyed.


What Risks Are Associated With Blood Transfusions?

The risks associated with blood transfusion include.
- A hypersensitive reaction. This might range from minor to severe.
- Fever.
- The body's destruction of red blood cells (hemolytic response).
- An overabundance of blood in the body (transfusion excess).
- An overabundance of iron in the body (iron overload).
- Viruses can be transmitted through blood.
- Risk of developing graft versus host disease.


Under Which Conditions Will a Transfusion Reaction Occur?

The recipient’s body will generate antibodies to kill the blood cells from the donor if they get blood that is incompatible with their own blood. This procedure causes the transfusion response.  Therefore, it is crucial that the transfused blood must be compatible with the recipient’s own blood.
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Dr. Mohammad Rajja
Dr. Mohammad Rajja

General Practitioner


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