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Hematologic

Transfusion Reactions

Blood transfusion reaction High-yield Verified · Sep 2026

Transfusion reactions are adverse events associated with the transfusion of whole blood or one of its components, occurring during the transfusion (acute) or days to weeks later (delayed), and may be immunologic or non-immunologic.

Most transfusions go smoothly, and most reactions start in the first 15 minutes — which is why the nurse starts slowly and stays at the bedside. Symptoms overlap: fever may be a harmless febrile reaction or the first sign of ABO-incompatible hemolysis, and hives may be mild or the start of anaphylaxis. Stop first, then sort it out. TACO and TRALI both flood the lungs but need opposite fluid management.

What’s going wrong in the body

The normal physiology, where it fails, and why the body’s compensation backfires.

01 Immune and non-immune reactions

Two families. StatPearls: "Immune-mediated transfusion reactions typically occur due to mismatch or incompatibility of the transfused product and the recipient." "Non-immunologic reactions are usually caused by the physical effects of blood components or the transmission of disease." Acute reactions occur "during or within 24 hours of a transfusion"; delayed ones days to weeks later.

How often. Mild allergic and febrile non-hemolytic reactions are relatively common; anaphylaxis, acute hemolysis and sepsis are rare. "Fatal adverse events have been reported to occur most commonly with TRALI." StatPearls groups TRALI, TACO, acute hemolytic reactions and anaphylaxis as life-threatening reactions that "require immediate intervention."

Overlapping signs. "The most common signs and symptoms include fever, chills, urticaria (hives), and itching." "However, respiratory distress, high fever, hypotension (low blood pressure), and red urine (hemoglobinuria) can indicate a more serious reaction." Small vital-sign changes during a transfusion can be normal (about ±0.5 °C, ±5 breaths/min, ±10 beats/min, ±20 mm Hg); larger changes do not prove a reaction but call for extra vigilance.

Immune reactions come from incompatibility between product and recipient; non-immune reactions from volume, temperature, storage effects or bacterial contamination.

02 Acute hemolytic reaction — ABO incompatibility

Usually a clerical error. "In most cases, hemolysis due to ABO incompatibility is due to a clerical error." The recipient’s naturally occurring anti-A or anti-B antibodies attack the donor cells. IgM "activates complement, causing intravascular hemolysis"; IgG mainly causes extravascular hemolysis. Cytokines from activated macrophages cause "fever, chills, abdominal flank pain, and back pain."

The classic triad is rare. "Classically, an acute HTR is described as a triad of symptoms: fever, flank pain, and red or brown urine (hemoglobinuria)." "However, this classic presentation is rarely seen. Symptom onset is within 24 hours of the transfusion, usually within the first hour." Other signs include chills, oozing from IV sites, burning at the infusion site, chest or back pain, nausea, shock, dyspnea, oliguria and diffuse bleeding.

Consequences. "In severe cases, it can lead to acute kidney failure, shock, disseminated intravascular coagulation, or death." Signs are harder to detect in children and unconscious patients. Treatment: stop the transfusion, give IV normal saline to protect urine output while monitoring renal function, and support oxygenation.

Why only normal saline. "Normal saline is the only fluid that can be administered with blood products." Hypo-osmolar 5% dextrose lets water enter red cells so they "swell and lyse (intravascular hemolysis)," and citrate in the unit cannot buffer the calcium in other solutions, so clots form in the line.

In ABO-incompatible transfusion, recipient antibodies and complement destroy donor red cells in the bloodstream, releasing free hemoglobin and cytokines that cause kidney failure, shock and DIC — stopping the transfusion at the first sign limits the dose received.

03 Lungs: TACO versus TRALI

TACO — too much volume. "Transfusion-associated circulatory overload is characterized by respiratory distress secondary to cardiogenic pulmonary edema," most common in patients already fluid-overloaded, such as those with heart failure or acute renal failure, especially with large volumes over a short time. Signs: "dyspnea, hypoxia, edema, hypertension, tachycardia, lung crackles, and jugular venous distension." "Management involves diuretics and ventilatory support." Prevention: transfuse only what is needed, as slowly as possible, with diuretics before or between units.

TRALI — lung injury from donor antibodies. "Transfusion-related acute lung injury (TRALI) is a life-threatening complication characterized by a rapid onset of noncardiogenic pulmonary edema and lung injury within 6 hours of the transfusion." Donor antibodies (HLA or neutrophil antigens) react with the recipient’s cells and mediators flood the lungs. Signs: hypoxemia, bilateral infiltrates, pink frothy secretions, hypotension and cyanosis, usually within minutes to 1–2 hours.

Opposite management. TRALI needs oxygen and often intubation — StatPearls: "70% to 80% of affected patients will require endotracheal intubation" — with fluids or pressors for hypotension, and "Clinicians should use diuretics with caution, as their use may result in hypotension." StatPearls: "TACO occurs with rapid transfusion" with hypertension, heart failure, elevated central venous pressure and raised BNP, whereas TRALI brings "respiratory distress disproportionate to fluid volume, earlier onset, fever, hypotension, pink frothy secretions, hypoxemia, and bilateral infiltrates."

Both TACO and TRALI cause respiratory distress; hypertension and fluid overload point to TACO (treated with diuretics), hypotension and fever to TRALI (treated with oxygen, ventilation and blood-pressure support).

Causes & risk factors

Modifiable factors are teaching targets — the patient can act on them.

Clerical or identification error — the usual cause of ABO-incompatible hemolysis. modifiable Heart failure or acute renal failure; large volumes given quickly — TACO. modifiable IgA deficiency with anti-IgA antibodies — anaphylaxis; IgA-deficient donor products help prevent it. Prior transfusion or pregnancy — memory antibodies cause delayed hemolytic reactions (commonly Kidd or Rh antigens). Sickle cell disease — delayed hemolysis can be severe and progress to hyperhemolysis syndrome. Immunocompromised recipient — transfusion-associated graft-versus-host disease. Non-leukoreduced products — febrile non-hemolytic reactions; leukoreduction lowers the risk. Bacterial contamination — poor donor-arm disinfection, bacteria in the donor’s blood, or improper handling. Massive transfusion (10 or more RBC units in 24 hours) — dilutional coagulopathy, low platelets, low calcium, high potassium, hypothermia. Recurrent transfusions — iron overload (generally after 15 to 20 RBC units) and alloimmunization.

Signs & symptoms

Each finding tied to the mechanism that produces it — and the triage it calls for.

Fever with chills, flank or back pain, red or brown urine, hypotension, oozing at the IV site early Report immediately
Why: Acute hemolytic reaction — complement-mediated destruction of donor red cells; onset usually within the first hour.
Hypotension, wheezing or respiratory distress within minutes of starting early Report immediately
Why: Anaphylaxis. "The presence of hypotension or respiratory distress should alert the clinician to the possibility of anaphylaxis."
Hives or itching only early Hold & notify
Why: Mild allergic reaction to a donor plasma protein — but it "can also be associated with the onset of a life-threatening anaphylactic reaction." Stop the transfusion and watch for progression; the clinician decides whether to restart.
Temperature up 1 °C or more from the start of the transfusion, with or without chills Hold & notify
Why: Often a febrile non-hemolytic reaction (donor white-cell cytokines), but it can be the first sign of hemolysis, TRALI or sepsis — so it is a diagnosis of exclusion. "If the temperature rises 1 C or higher from the temperature at the start of transfusion, the transfusion should be stopped."
High fever, rigors and hypotension Report immediately
Why: Suspect acute hemolysis or bacterial contamination (septic reaction).
Dyspnea, hypoxia, crackles, JVD, hypertension, edema Report immediately
Why: TACO — cardiogenic pulmonary edema from volume overload.
Sudden hypoxemia, hypotension, fever, pink frothy secretions within 6 hours Report immediately
Why: TRALI — noncardiogenic pulmonary edema from donor antibodies.
Chest pain, dyspnea, lightheadedness, sudden collapse Report immediately
Why: Venous air embolism — place the patient immediately on the left side, head down.
Small drift in vital signs during the transfusion Expected
Why: About ±0.5 °C, ±5 breaths/min, ±10 beats/min or ±20 mm Hg may be normal; larger changes call for extra vigilance.
Chilling with large volumes of cold blood Expected
Why: Hypothermia from refrigerated products — "The only intervention needed is warming the patient and/or blood product."
Days to weeks later: jaundice, low-grade fever, dark urine, falling hemoglobin late Hold & notify
Why: Delayed hemolytic reaction — a memory antibody response, usually 1 to 2 weeks after transfusion (range 24 hours to 28 days).
Sickle cell disease: hemoglobin lower than before the transfusion, with hemolysis signs late Report immediately
Why: Hyperhemolysis — "A severe form of DHTR" in which "Affected patients will have hemoglobin lower than their pretransfusion hemoglobin." StatPearls: "A hyperhemolytic crisis is potentially fatal if not treated rapidly."
4–30 days later in an immunocompromised patient: fever, rash, liver dysfunction, low blood counts, GI symptoms late Hold & notify
Why: Transfusion-associated graft-versus-host disease — donor lymphocytes engraft; "This is rare but often fatal."

Diagnostics

Test In this disorder Normal
Clerical check at the bedside StatPearls: "A clerical check should be performed by examining the product bag and confirming the patient’s identification." Before any transfusion, two qualified professionals verify the product. Unit label and patient identity match —
Return the unit and send a fresh blood sample Send the bag and tubing if possible with a freshly collected sample; the blood bank runs the transfusion reaction evaluation. Blood bank repeats ABO typing and crossmatch on pre- and post-transfusion samples —
Direct antiglobulin test (DAT, Coombs) In delayed reactions, a positive DAT between 24 hours and 28 days after transfusion with a new red-cell antibody (CDC Biovigilance criteria, via StatPearls). Positive in hemolytic reactions —
Hemolysis labs — haptoglobin, LDH, bilirubin, plasma and urine free hemoglobin Look at serum and urine for pink color. Low or absent haptoglobin, raised LDH and unconjugated bilirubin, hemoglobinemia, hemoglobinuria —
Coagulation — PT, aPTT, fibrinogen, D-dimer Checked in suspected acute hemolysis. Abnormal if DIC develops —
Chest imaging and oxygenation TACO instead shows signs of fluid overload with raised BNP and a response to diuretics. TRALI: new bilateral infiltrates, SpO2 90% or less on room air or PaO2/FiO2 below 300 mm Hg, no evidence of pulmonary vascular overload —
BNP / NT-proBNP Supports volume overload rather than TRALI. Raised in TACO —
Baseline and serial vital signs StatPearls (Blood Transfusion): document after 15 minutes, then every hour, and at the end; StatPearls (Transfusion Reactions): typically every 15 minutes. After a reaction, record every 15 minutes. Notify the clinician before starting if the temperature is above 100 °F. Follow agency policy. Temperature, pulse, BP, respirations and SpO2 before, during and after —
CDC NHSN Hemovigilance case definitions CDC: "surveillance definitions only and are not intended to be used for clinical care" — not bedside diagnostic criteria. Report all transfusion-related deaths to FDA. National surveillance reporting (AHTR, TACO, TRALI and others) CDC NHSN 2026 —

Complications

Black-box warning — most severe: ■ Acute kidney failure, DIC, shock and death (acute hemolysis) Report immediately
ABO-incompatible hemolysis "can lead to acute kidney failure, shock, disseminated intravascular coagulation, or death."
Stop the transfusion immediately, keep the IV line open with 0.9% saline, maintain urine output and monitor renal function, give oxygen as needed.
Black-box warning — most severe: ■ TRALI Report immediately
"TRALI is one of the leading causes of mortality associated with blood transfusion." Survivors can receive future transfusions but not from the same donor.
StatPearls reports mortality of about 10% (Blood Transfusion chapter) and more than 12% once diagnosed (TRALI chapter); most other cases resolve within 96 hours with supportive care.
Black-box warning — most severe: ■ Anaphylaxis Report immediately
Hypotension and bronchospasm within minutes; treat with epinephrine, bronchodilators and corticosteroids.
Warning: TACO Report immediately
Cardiogenic pulmonary edema in patients with heart or kidney disease; a life-threatening reaction managed with diuretics and ventilatory support.
Warning: Septic reaction Report immediately
Bacterial or endotoxin contamination of the unit — high fever, rigors, hypotension.
Caution: Delayed hemolysis, post-transfusion purpura, iron overload, alloimmunization Hold & notify
Delayed hemolysis 1–2 weeks later (severe in sickle cell disease); post-transfusion purpura with low platelets and bleeding 5 to 10 days later; iron overload after many units; antibodies that complicate future matching.

Medications for this condition

Why each class is prescribed here — every card links to its full pharmacology page.

Antihistamines First-line
Respiratory · diphenhydramine (1st-gen)

Mild allergic reactions (hives, itching). StatPearls: "antihistamines (such as diphenhydramine) can be given for a mild allergic reaction." The transfusion is stopped first; the clinician may restart it only if the hives wane and there is no dyspnea, hypotension or anaphylaxis. Premedication does not prevent febrile reactions — "Premedication with acetaminophen or an antihistamine does not help reduce the risk of FNHTR."
Corticosteroids
Endocrine · prednisone

Severe allergic reactions — "More severe symptoms can be treated with bronchodilators, corticosteroids, and epinephrine." In a delayed hemolytic reaction with a brisk hemoglobin fall, clinicians may consider glucocorticoids, IVIG or rituximab (StatPearls).
Vasopressors & Inotropes High-alert
Cardiovascular · norepinephrine

Hypotension in TRALI and shock — "hemodynamic support with fluid resuscitation or pressors may be necessary." For surveillance reporting, NHSN grades a reaction life-threatening when major intervention such as vasopressors, intubation or ICU transfer is needed.
Loop Diuretics
Renal · furosemide

TACO — "Management involves diuretics and ventilatory support"; diuretics before or between transfusions help prevent it in at-risk patients. May also be needed to maintain urine output in acute hemolysis. Use with caution in TRALI, where diuretics "may result in hypotension."

Beyond medications

  • Correct identification — two qualified professionals verify patient and product before administration; consent and a history first.
  • 0.9% sodium chloride only, through filtered Y-tubing; flush with normal saline afterward.
  • Start within 20 to 30 minutes of release and finish within 4 hours; packed red cells one unit at a time.
  • Slow start and supervision for the first 15 minutes — "most transfusion reactions occur during this period."
  • Oxygen and airway support — TRALI often needs intubation; TACO needs ventilatory support.
  • Blood warmer for rapid transfusion of cold components (trauma, operating room) to prevent hypothermia.
  • Air embolism — immediately place the patient in the left lateral decubitus, Trendelenburg or left-side head-down position.
  • Prevention in the blood supply — leukoreduction (febrile reactions), IgA-deficient donor products (anti-IgA antibodies), inactivating lymphocytes (TA-GVHD), excluding high-risk plasma donors (TRALI).

Nursing considerations

The RN-specific layer — each action paired with the reason it matters.

Assessment
Before starting, take a history and baseline vital signs — temperature, pulse, BP, respirations, SpO2 — plus lung sounds and urine output; notify the clinician if the temperature is above 100 °F.
Why: A baseline makes a reaction recognizable; heart or kidney disease signals TACO risk.
Stay with the patient for the first 15 minutes and infuse slowly, then monitor vital signs per policy through the end of the transfusion.
Why: "Staff should supervise the patient for the first 15 min because most transfusion reactions occur during this period."
Watch for fever, chills, hives, itching, dyspnea, hypotension, back or flank pain, dark urine and oozing at the IV site — and in unconscious or pediatric patients, for changes they cannot report.
Why: Signs overlap; serious reactions may start like mild ones, and some are hard to detect in these groups.
Interventions
If any reaction is suspected: STOP the transfusion, disconnect the blood tubing, keep the IV open with 0.9% saline, stay with the patient, and notify the clinician and blood bank.
Why: StatPearls: "All suspected reactions should result in immediately stopping the transfusion and notifying the blood bank and treating clinician."
Perform a clerical check of the bag against the patient’s identification, then return the bag and tubing with a freshly drawn blood sample.
Why: Most ABO hemolysis is a clerical error; the blood bank needs the unit and new sample to evaluate the reaction.
Record vital signs every 15 minutes after a reaction; give oxygen, antihistamines, antipyretics, diuretics or epinephrine as ordered for the reaction type.
Why: Treatment is mostly supportive and depends on the type.
Do not restart a stopped transfusion on your own; only the clinician decides, and only for a mild allergic reaction that resolves or a febrile reaction after other causes are excluded.
Why: Hives can precede anaphylaxis; fever can be the first sign of hemolysis, TRALI or sepsis.
For patients at TACO risk, transfuse the minimum needed as slowly as possible and anticipate diuretics between units.
Why: Prevention of circulatory overload in heart failure or renal failure.
Patient and family teaching
Before starting, explain the signs of a reaction and ask the patient to report any new symptom right away during the transfusion.
Why: StatPearls: "The patient should inform the nursing staff of any signs or symptoms that occur during the transfusion."
After discharge, report jaundice, dark urine, fever or fatigue in the next weeks; immunocompromised patients report fever or rash 4–30 days later.
Why: Delayed hemolytic reactions and TA-GVHD appear days to weeks after the transfusion.
Carry a record of any red-cell antibody found and tell future care teams.
Why: Clinicians document the alloantibody and notify patients so future transfusions avoid that antigen.
Reassure: most transfusions go smoothly, and the risk of catching a virus is low because donated blood is carefully screened.
Why: MedlinePlus: "The risk of catching a virus from a blood transfusion is low."

How a real nurse thinks

The clinical-judgment loop, worked for a typical presentation — reasoning, not reference.

  1. 1
    Recognize cues

    Early hives without dyspnea or hypotension — a mild allergic pattern. Later, dyspnea, hypoxia, hypertension, tachycardia, JVD and spreading crackles in a patient with heart failure receiving a second hour of red cells; no fever.

  2. 2
    Analyze cues

    Hypertension, JVD and crackles with heart failure point to TACO rather than TRALI, which brings hypotension, fever and pink frothy secretions. No fever or flank pain makes acute hemolysis less likely, but any reaction starts with the same steps.

  3. 3
    Prioritize

    Airway and breathing: stop the transfusion and support oxygenation — respiratory distress with TACO is an emergency.

  4. 4
    Generate solutions

    Stop the transfusion, disconnect the blood tubing, keep the IV open with 0.9% saline, give oxygen, notify the clinician, anticipate a diuretic, do the clerical check and return the bag and tubing with a fresh sample.

  5. 5
    Take action

    The nurse stops the transfusion, disconnects the blood tubing, keeps the line open with saline, starts oxygen, notifies the provider, and checks the bag against the patient’s ID. A loop diuretic is ordered; vital signs are recorded every 15 minutes; the bag and tubing go to the blood bank with a new blood sample.

  6. 6
    Evaluate

    Within the hour, breathing eases, SpO2 is 94% on oxygen, BP 148/84 and urine output increases. The second unit is deferred; if given later, it will run as slowly as possible with a diuretic between units.

Scenario — you’re the nurse

Work each question before revealing the answer. Rationales explain the wrong options too.

Medical unit · 1400

A 78-year-old man with heart failure and chronic anemia (hemoglobin 6.9 g/dL) is receiving his first of two ordered units of packed red blood cells. Baseline: T 36.8 °C, HR 88, BP 138/76, RR 18, SpO2 95% on room air, a few bibasilar crackles.

1410 (10 minutes) — Reports itching; a few hives on the chest. BP 136/78, no dyspnea
Plan after clinician review — Antihistamine given; hives faded; transfusion restarted by the clinician’s order
1540 — Increasing dyspnea, sitting bolt upright; RR 30; SpO2 88%; BP 172/96; HR 118; JVD; crackles now halfway up both lungs; T 36.9 °C
Q1 Multiple choice
At 1410 the patient develops itching and a few hives. What should the nurse do first?
  1. A. Slow the transfusion rate and recheck in 30 minutes
  2. B. Stop the transfusion and keep the IV open with 0.9% saline
  3. C. Give acetaminophen and continue the transfusion
  4. D. Remove the IV catheter
Reveal answer & rationale
Answer: B
All suspected reactions start with stopping the transfusion and keeping the IV line open with 0.9% saline (B); hives "can also be associated with the onset of a life-threatening anaphylactic reaction." Slowing the rate leaves blood running (A). Acetaminophen does not treat an allergic reaction (C). The IV access is kept for treatment (D).
Q2 Select all that apply
Which findings at 1540 support TACO rather than TRALI? Select all that apply.
  1. A. BP 172/96
  2. B. Jugular venous distension
  3. C. History of heart failure
  4. D. Temperature 36.9 °C with no fever
  5. E. Pink frothy secretions
  6. F. Hypotension
Reveal answer & rationale
Answer: A, B, C, D
TACO shows hypertension (A), JVD (B) and occurs in patients with heart or kidney disease (C); fever is a feature of TRALI, so its absence fits TACO (D). Pink frothy secretions (E) and hypotension (F) are TRALI features.
Q3 Multiple choice
The provider confirms TACO. Which order does the nurse anticipate?
  1. A. A fluid bolus of 0.9% saline
  2. B. A loop diuretic
  3. C. Restarting the transfusion at a faster rate
  4. D. A vasopressor infusion
Reveal answer & rationale
Answer: B
TACO "Management involves diuretics and ventilatory support" (B). A fluid bolus would worsen overload (A). The transfusion stays stopped (C). Pressors are for the hypotension of TRALI or shock (D).
Q4 Select all that apply
After stopping a transfusion for a suspected reaction, which actions are correct? Select all that apply.
  1. A. Disconnect the blood tubing from the patient
  2. B. Discard the bag and tubing in the biohazard bin
  3. C. Check the bag label against the patient’s identification
  4. D. Send the bag and tubing to the blood bank with a fresh blood sample
  5. E. Hang 5% dextrose to keep the vein open
  6. F. Stay with the patient and record vital signs every 15 minutes
Reveal answer & rationale
Answer: A, C, D, F
Disconnect the blood tubing (A), do a clerical check (C), return the bag and tubing with a freshly collected sample (D), and stay and monitor every 15 minutes (F). The bag is returned, not discarded (B). Only 0.9% saline is used — 5% dextrose causes red cells to "swell and lyse" (E).
Q5 Multiple choice
Ten days after a transfusion, a patient with sickle cell disease has jaundice, dark urine and a hemoglobin lower than before the transfusion. The nurse suspects:
  1. A. Febrile non-hemolytic reaction
  2. B. Delayed hemolytic transfusion reaction
  3. C. TACO
  4. D. Mild allergic reaction
Reveal answer & rationale
Answer: B
Delayed hemolytic reactions usually present 1 to 2 weeks after transfusion with jaundice and an inappropriate hemoglobin response, and are "particularly significant in patients with sickle cell disease" — a hemoglobin below the pretransfusion level suggests hyperhemolysis, which "is potentially fatal if not treated rapidly" (B). Febrile reactions occur during or within 4 hours (A). TACO causes respiratory distress (C). An allergic reaction does not present as hemolysis 10 days later (D).

Common questions

What causes transfusion reactions?
Common causes and risk factors include clerical or identification error — the usual cause of abo-incompatible hemolysis., heart failure or acute renal failure; large volumes given quickly — taco., iga deficiency with anti-iga antibodies — anaphylaxis; iga-deficient donor products help prevent it., prior transfusion or pregnancy — memory antibodies cause delayed hemolytic reactions (commonly kidd or rh antigens)., sickle cell disease — delayed hemolysis can be severe and progress to hyperhemolysis syndrome., and others.
What is the first thing a nurse does when a transfusion reaction is suspected?
Stop the transfusion immediately, disconnect the blood tubing, keep the IV line open with 0.9% saline, stay with the patient, and notify the clinician and blood bank. Then do a clerical check and return the bag and tubing with a fresh blood sample.
Why must the nurse stay with the patient for the first 15 minutes?
StatPearls: "most transfusion reactions occur during this period." The blood runs slowly at first so a reaction can be caught after only a small volume.
Why is only normal saline used with blood?
Hypo-osmolar solutions such as 5% dextrose let water into red cells so they swell and burst, and citrate in the unit cannot buffer the calcium in other solutions, so clots can form in the line.
How do you tell TACO from TRALI?
TACO is volume overload: hypertension, JVD, crackles, raised BNP, often in heart or kidney disease, treated with diuretics. TRALI is lung injury from donor antibodies within 6 hours: hypotension, fever, pink frothy secretions and bilateral infiltrates, treated with oxygen and ventilation — diuretics only with caution.
Does premedication with acetaminophen or diphenhydramine prevent reactions?
Not febrile reactions: "Premedication with acetaminophen or an antihistamine does not help reduce the risk of FNHTR." Leukoreduced products lower that risk.

Sources

Reviewed by Hae Suk Lee, RN

Educational summary for nursing students. Scenarios are fictional teaching cases. Always verify against current guidelines and your institution's protocols before acting in practice. Not medical advice.

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