A 25-year-old female with a history of fibromyomatous and severe menometrorrhagia is scheduled for a blood transfusion. She has become quite fatigued and has developed shortness of breath with minimal exertion. Her hemoglobin is 6.1 mg/dL. While receiving her second unit of RBCs the patient developed a very pruritic rash over the shoulder.
The patient’s vital signs are stable. She is not febrile. Her blood pressure is 120/70 mmHg. What will be the best action to take?
Answers:
The correct answer is #2 - continue blood transfusion, administer antihistamines. The normal miss on this is from over-reaction. You’re giving a transfusion, something bad must have happened. 🙂
But, it’s also (at least in our minds) sort of a trick question. A case vignette usually presents relevant information about a medical diagnostic decision to test for depth of knowledge. Here’s a case that is testing for that, but in a negative way.
If your first reaction to the question was #2, but you figured there had to be more to the question, then they got you. Now, there may be checklists that mandate stopping transfusions and performing a full hemolytic work-up for any reaction, but that’s not right here. The AABB Technical Manual (and textbooks) have a clear map of how to handle the three transfusion-reaction categories: allergic, hemolytic, and septic.
Why This Question Is Often Missed
– Learners may confuse any transfusion reaction with an acute hemolytic or anaphylactic event and feel compelled to stop the transfusion entirely.
– The presence of a rash prompts overreaction—even though isolated urticaria without systemic signs is classified as a mild allergic reaction, which is managed differently.
What the Distractors Indicate
| Option | What It Tests / Implies | Why It’s Wrong Here |
|---|---|---|
| Immediately discontinue the blood transfusion and administer epinephrine | Management of anaphylaxis | No hypotension, bronchospasm, or angioedema—epinephrine and full stop are reserved for severe (anaphylactic) reactions. |
| Immediately discontinue the blood transfusion and administer corticosteroids | Treatment of severe allergic/hemolytic reactions | Corticosteroids are not first-line for mild urticarial reactions and stopping the transfusion isn’t necessary when vitals are stable. |
| Continue blood transfusion rate, report to the blood bank | Administrative protocol emphasis | Reporting is required for any reaction, but you must also treat the patient’s symptoms—simply continuing without therapy is incomplete. |
| Continue the blood transfusion, infuse normal saline, obtain a direct anti-globulin test, and repeat type and cross match | Workup for hemolytic transfusion reaction | Hemolysis signs (fever, hemoglobinuria, positive DAT) are absent—no lab workup is indicated for an isolated rash. |
| Continue blood transfusion, administer antihistamines (Correct) | Management of mild allergic transfusion reaction | Correct – mild urticaria with stable vitals can be treated with antihistamines without stopping the transfusion. |
High-Yield Pearl
Mild allergic transfusion reactions (pruritus, urticaria, no hemodynamic compromise) are treated with antihistamines and do not require stopping the transfusion.
Core Learning Objectives
The “Test Trick” at Play
The vignette deliberately omits systemic symptoms (no hypotension, bronchospasm, fever) to see if you’ll correctly identify an isolated mild allergic reaction rather than reflexively halting transfusion for any rash.
Additional Practice Questions and Remediation
Question 1
A 30-year-old woman develops facial flushing and pruritus after 15 minutes of her first RBC unit. She is afebrile, normotensive, with no respiratory distress. Next step?
A. Administer diphenhydramine and continue transfusion
B. Stop transfusion and draw direct antiglobulin test
C. Give epinephrine intramuscularly and call code
D. Switch to washed RBCs for this unit only
Question 2
A patient with IgA deficiency experiences hypotension, wheezing, and angioedema within 5 mL of a RBC transfusion. What is the best immediate action?
A. Slow the transfusion rate and give diphenhydramine
B. Stop transfusion and administer epinephrine
C. Continue transfusion with acetaminophen premedication
D. Obtain repeat crossmatch and restart at a slower rate
Question 3
During a platelet transfusion, a patient develops fever (38.5 °C) and chills but no rash or respiratory distress. Next step?
A. Stop transfusion and send blood for culture
B. Stop transfusion, give acetaminophen, then resume
C. Give diphenhydramine and continue transfusion
D. Continue transfusion and monitor only
Question 4
A 55-year-old man with myelodysplastic syndrome is 20 minutes into his second unit of packed RBCs when he abruptly develops chills, back pain, dark urine, and his blood pressure falls from 130/80 mmHg to 90/60 mmHg. His temperature spikes to 39.2 °C. What is the best immediate action?
A. Slow the transfusion rate and give acetaminophen
B. Immediately stop the transfusion, give IV fluids, send a direct antiglobulin (Coombs) test, and notify the blood bank
C. Administer diphenhydramine and observe for further symptoms
D. Continue transfusion at a slower rate and obtain a repeat type and crossmatch
Question 5
During a platelet transfusion, a 68-year-old woman suddenly becomes febrile to 40 °C, develops rigors, hypotension (BP 85/50 mmHg), and tachycardia. There is no rash or wheezing. What is the most appropriate next step?
A. Give IV diphenhydramine and continue transfusion
B. Stop the transfusion immediately, draw blood cultures from the patient and the bag, start broad-spectrum antibiotics, and notify the blood bank
C. Administer acetaminophen, then resume transfusion at a slower rate
D. Draw a direct antiglobulin test and send for repeat crossmatch
Mini Case Discussion Prompt
Compare the management and prophylactic strategies for mild allergic transfusion reactions versus febrile non-hemolytic reactions, including when to premedicate and when to switch to washed or leukoreduced products.
This question appears in Med-Challenger Internal Medicine Review with CME
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