A 50-year-old woman is evaluated in the post-anesthesia care unit due to sudden onset of severe nausea and right flank pain. The patient underwent a total abdominal hysterectomy and tumor debulking for metastatic ovarian cancer. The procedure was complicated by bleeding and a ureteral laceration that was repaired intraoperatively. Immediately afterwards, her hemoglobin level was 6.8 g/dL. A packed red blood cell transfusion was initiated 10 minutes ago. Now, in addition to nausea and right flank pain, she has developed pain and oozing along the IV site. Temperature is 38.5 C (101.3 F), blood pressure is 90/50 mm Hg, pulse is 130/min, and respirations are 26/min. Cardiac examination reveals tachycardia with weak pulses. The lungs are clear bilaterally. The skin examination is normal. The urine is dark red. Which of the following would most likely establish the diagnosis in this patient?

Question

A 50-year-old woman is evaluated in the post-anesthesia care unit due to sudden onset of severe nausea and right flank pain.  The patient underwent a total abdominal hysterectomy and tumor debulking for metastatic ovarian cancer.  The procedure was complicated by bleeding and a ureteral laceration that was repaired intraoperatively.  Immediately afterwards, her hemoglobin level was 6.8 g/dL.  A packed red blood cell transfusion was initiated 10 minutes ago.  Now, in addition to nausea and right flank pain, she has developed pain and oozing along the IV site.  Temperature is 38.5 C (101.3 F), blood pressure is 90/50 mm Hg, pulse is 130/min, and respirations are 26/min.  Cardiac examination reveals tachycardia with weak pulses.  The lungs are clear bilaterally.  The skin examination is normal.  The urine is dark red.  Which of the following would most likely establish the diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d899_d5f7_bc81_934ace382b44_MD0003_00 This patient with fever, flank pain, and dark red urine 10 minutes after transfusion is having an acute hemolytic transfusion reaction (AHTR), a rare but potentially fatal reaction due to transfusion of mismatched blood (eg, ABO incompatibility). The most common etiology is clerical error (eg, patient misidentification). AHTR typically occurs within minutes to hours of transfusion due to host antibodies attacking donor blood antigens. The result is massive red blood cell destruction (ie, intravascular hemolysis), which leads to toxic hemoglobin buildup in the kidney, renal tubular cell injury, and subsequent acute renal failure. Therefore, findings that raise suspicion for AHTR include flank pain and dark red urine (ie, hemoglobinuria) as well as fever, tachycardia, and hypotension (due to inflammatory cytokine release) shortly following a transfusion. Patients may also have elevated lactate dehydrogenase levels (from hemolysis) and disseminated intravascular coagulation (eg, oozing intravenous site). Diagnosis of AHTR is with a positive direct Coombs test, reflecting antibody-coated red blood cells. Management includes immediate cessation of transfusion, aggressive intravenous fluid administration, and supportive care. (Choice A) Blood culture and antibiotics are indicated for a transfusion-transmitted bacterial infection (TTBI) or for urinary tract infection (UTI), which can present with fever, tachycardia, and hypotension. However, TTBI typically develops over hours (not minutes), and flank pain and hemoglobinuria are usually not present. UTI can cause flank pain (eg, pyelonephritis) and hematuria, but AHTR is a much more likely explanation of this patient's sudden-onset hypotension and acute disseminated intravascular coagulation within minutes of a transfusion. (Choices B and E) Cystoscopy and renal ultrasound can identify a urinary tract obstruction or renal mass, which may present with flank pain and dark red urine. However, these conditions do not cause hypotension or acute disseminated intravascular coagulation. (Choice D) IgA levels are measured in patients with a suspected anaphylactic transfusion reaction, which typically presents within seconds to minutes of transfusion initiation. Patients with this reaction have angioedema and respiratory distress, which are not seen in this patient. seconds to minutes Educational objective: Acute hemolytic transfusion reaction is a rare but potentially fatal condition due to transfusion of mismatched blood (eg, ABO incompatibility). Patients can develop fever, hypotension, flank pain, hemoglobinuria, and disseminated intravascular coagulation within minutes to hours of transfusion. Diagnosis is with a positive direct Coombs test. References: Adverse reactions to transfusion of blood products and best practices for prevention. (http://www.ncbi.nlm.nih.gov/pubmed/28778288) Hemolytic transfusion reactions. (http://www.ncbi.nlm.nih.gov/pubmed/31291517)

A 50-Year-Old Woman Is Evaluated in the Post-Anesthesia Care Unit