Date:
Patient:
Event: Acute transfusion reaction (specify type if known)
History of Present Illness:
Briefly describe the sequence of events during the transfusion, including the time of reaction onset (first signs or symptoms).
Document the type of blood product transfused (e.g., packed red blood cells, platelets, plasma).
Describe the patient’s symptoms in detail (e.g., chills, fever, rash, shortness of breath, chest pain, hypotension).
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate) – Note any changes compared to baseline.
General examination: Assess for signs of allergic reaction (rash, urticaria, angioedema) or hemodynamic instability.
Specific findings based on the type of reaction (e.g., fever for febrile non-hemolytic transfusion reaction, hemoglobinuria for intravascular hemolysis).
Laboratory Findings:
Document any blood tests performed in response to the reaction, including:
Complete blood count (CBC) – May show changes if hemolysis has occurred.
Direct antiglobulin test (DAT) – May be positive in immune-mediated reactions.
Blood cultures (if febrile reaction) – To rule out sepsis.
Lactate dehydrogenase (LDH) – May be elevated if hemolysis has occurred.
Blood Bank Findings:
Document communication and findings from the blood bank regarding the transfused blood product(s).
This may include:
Investigation into potential blood product issues (e.g., bacterial contamination, ABO incompatibility).
Repeat blood bank compatibility testing.
Assessment:
Diagnose the specific type of acute transfusion reaction based on clinical presentation, laboratory findings, and blood bank investigation (if available):
Febrile non-hemolytic reaction
Allergic reaction
Acute hemolytic transfusion reaction (intravascular or extravascular)
Anaphylactoid reaction
Transfusion-related acute lung injury (TRALI)
Bacterial contamination
Management:
Summarize the actions taken to manage the reaction:
Stop the transfusion immediately.
Initiate appropriate treatment based on the type of reaction (e.g., antihistamines for allergic reactions, steroids for TRALI, supportive care for hemolytic reactions).
Maintain hemodynamic stability with fluids and vasopressors (if needed).
Plan:
Continue monitoring vital signs and clinical status.
Order additional laboratory tests as needed.
Complete a transfusion reaction report and submit it to the blood bank and hospital authorities.
Depending on the severity of the reaction and the blood bank investigation, determine if further transfusions are safe to proceed with appropriate blood product selection and precautions.
If necessary, consider alternative blood product options or consult with a transfusion medicine specialist.
Discharge Instructions (if applicable):
Document any restrictions or precautions for future blood transfusions based on the type of reaction.
Provide education to the patient about the signs and symptoms of transfusion reactions.
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. Prompt recognition, diagnosis, and management of acute transfusion reactions are crucial to minimize complications and ensure patient safety.