Do we really need pre transfusion medications?

From the 2019 HVPAA National Conference

Dr. Shilpa Rampey Venkata Naga (Rutgers NJMS), Dr. Toby Terrwilliger (Rutgers NJMS), Dr. Jennifer Krajewski (Hackensack Meridian)


Transfusion of blood products is common in the setting of pediatric cancer and blood disorders. One of the biggest drawbacks of transfusion of blood products are transfusion reactions. Transfusion reactions are divided broadly into hemolytic and non-hemolytic reactions. While hemolytic reactions are extremely infrequent as a result of vigorous blood typing and cross-matching processes, non-hemolytic reactions are largely idiosyncratic. Febrile non -hemolytic transfusion reactions (FNHTRs) and allergic transfusion reactions (ATRs) are the two most common. ATRs present as pruritus, hives, or anaphylaxis and FNHTRs present as chills, rigors, or a rise in core temperature.

Historically, studies have reported rates of FNHTRs and ATRs in 1 – 30% and 1 – 17% of transfusions, respectively. While often benign and self-limiting, the prevention of these reactions has been an area of significant emphasis among clinicians. Diphenhydramine and acetaminophen are the current favorites for premedication. While both have a relatively safe side effect profile, they are not entirely benign, and can cause sedation and hepatic toxicity. To date, two randomized trials have compared the rates of transfusion reactions in adult oncology and bone marrow patients receiving premedication or placebo (Kennedy et al., 2008; Wang et al., 2002). Both studies found that premedication did not reduce the overall risk of transfusion reaction. Despite multiple publications of negative data in adults, acetaminophen and diphenhydramine still are routinely prescribed prior to transfusions in our pediatric population owing to a lack of safety data and decades of clinical precedent. Currently, there is minimal literature on the use of pre transfusion medications in pediatric patients.


A retrospective chart review was performed over a one year period of all pediatric hematology, oncology and bone marrow transplant patients who received packed red blood cell (pRBC) and platelet transfusions.


In 2017, 97 patients received 670 transfusions. Both acetaminophen and diphenhydramine were given as premedication for 609/670 transfusions; 61 transfusions had either incomplete (diphenhydramine OR acetaminophen) or absent premedication. The difference between the rates with premedications (6/607 = 0.9%) vs patients that received no or incomplete premeds (2/63 = 3.1%), was 2.2% (with the 95% confidence interval is [-5.7%, 10.0%]. The difference of 2.2% is not statistically significant (P=0.169, Fisher exact test).


Based on these data, we are currently designing a prospective, randomized controlled, non-inferiority trial to compare the rate of transfusion reactions in patients receiving pre-medication (acetaminophen and diphenhydramine) versus no premedication with the hypothesis that there will be no difference in reaction rates between the two groups. In addition, we will examine the need for antibiotics in patients who do develop FNHTR & the incidence of adverse effects from pre-medications.

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