Things We Do for No Reason™: Routinely Prescribing Transfusion Premedication To Prevent Acute Transfusion Reactions

Irradiation is another common modification of blood components used to prevent transfusion-associated graft-vs-host-­disease (TA-GVHD) for recipients with significantly compromised cellular immunity. TA-GVHD is a rare but nearly universally fatal delayed complication of transfusion. Note that irradiation does not prevent FNHTRs or ATRs.

Under the premise that platelet-related allergic reactions are the result of recipient reaction to donor plasma proteins, reducing the plasma volume administered should decrease the coadministration of allergy-inducing plasma proteins.¹ Reducing plasma volume can be achieved by two means: using a platelet additive solution that replaces two-thirds of the plasma content in a platelet unit or plasma removal by centrifugation. These two strategies decrease the plasma volume from 300 mL to ~100 mL per unit transfused, which effectively reduces the incidence of platelet-associated ATRs by 50%.¹⁰ For patients with recurrent severe ATRs, blood banks can wash RBC and platelet components, virtually removing all plasma proteins from the units.¹³ Epinephrine should be available at the bedside for patients with a history of severe ATRs.

Volume reduction and washing do negatively affect the quality of the unit: Platelets activate during the process, and transfusions result in a 20%-30% reduction in posttransfusion platelet counts.¹⁴ In addition, product manipulation takes significant blood bank processing time and results in an open system with greater risk of bacterial contamination, leading to a significantly shortened product expiration (24 hours for washed RBCs and 4 hours for washed or volume-reduced platelets).¹ Reserve volume reduction and washing for patients with a history of multiple recurrent or severe ATRs, respectively. Platelet additive solution results in a reduction in posttransfusion count but does not require additional manipulation. Platelet additive solution products may not be available at many centers but could be used selectively (similar to volume reduction) depending on availability and cost.

Avoiding unnecessary transfusions is an essential strategy to prevent ATRs and FNHTRs. Evidence-based patient blood management (PBM), now considered the standard of care, is defined as optimizing anemia and hemostasis in patients with the goal of restricting blood transfusions. Evidence supporting restrictive transfusion strategies continues to accumulate, and numerous hospital systems have implemented PBM programs resulting in a significant nationwide reduction in transfusions since 2008. An effective PBM program reduces unnecessary transfusions and subsequent transfusion reactions.

Finally, appropriate close monitoring of patients undergoing blood transfusion and after completion of a transfusion is highly important. Paying close attention to signs and symptoms can alert the transfusing team to a developing adverse reaction and should prompt immediate cessation of an ongoing transfusion, the critical first step when a transfusion reaction is suspected. Hospitalists may need to take additional actions to treat the patient (eg, antihistamines after an ATR manifests or a diuretic in the setting of transfusion-associated circulatory overload). Report suspected transfusion reactions to the transfusion service. Failing to report a suspected transfusion reaction can lead to catastrophic consequences that can even be fatal.¹⁵

• Do not prescribe an antihistamine or acetaminophen prior to transfusion.
• Reduce the risk of FNHTRs in all transfusion recipients with universal prestorage leukoreduction.
• For individuals with multiple recurrent ATRs to platelets, employ platelet additive solution or platelet volume reduction.
• Reserve washing RBC and platelet components for patients with a history of severe ATRs. Make sure epinephrine is at the patient’s bedside.
• Curb unnecessary blood transfusions to reduce avoidable transfusion reactions.
• Monitor patients undergoing transfusion closely.