A 45-year-old woman with a history of chronic menorrhagia is hospitalized for an elective hysterectomy. Her preoperative hemoglobin is 7 g/dL. She is transfused with 2 units of packed red blood cells. Two hours after starting the transfusion, the patient reports chills and malaise. Her temperature is 38.8 C (102 F), blood pressure is 120/76 mm Hg, pulse is 100/min, and respirations are 18/min. The transfusion is stopped, and she receives acetaminophen. Direct antiglobulin test and plasma free hemoglobin level are negative. Urinalysis is within normal limits. The reaction resolves 6 hours after the transfusion began. Which of the following actions could have prevented this reaction?

Question

A 45-year-old woman with a history of chronic menorrhagia is hospitalized for an elective hysterectomy.  Her preoperative hemoglobin is 7 g/dL.  She is transfused with 2 units of packed red blood cells.  Two hours after starting the transfusion, the patient reports chills and malaise.  Her temperature is 38.8 C (102 F), blood pressure is 120/76 mm Hg, pulse is 100/min, and respirations are 18/min.  The transfusion is stopped, and she receives acetaminophen.  Direct antiglobulin test and plasma free hemoglobin level are negative.  Urinalysis is within normal limits.  The reaction resolves 6 hours after the transfusion began.  Which of the following actions could have prevented this reaction?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bddb_0313_8f63_3bc82e4f14f7_MD0005_00 11ec2b69_bddb_0314_8f63_7d546f01a142_MD0005_00 This patient most likely has a febrile nonhemolytic transfusion reaction, the most common adverse reaction that occurs within 1-6 hours of transfusion. When red cells and plasma are separated from whole blood, small amounts of residual plasma and/or leukocyte debris may remain in the red cell concentrate. During blood storage, these leukocytes release cytokines, which when transfused can cause transient fevers, chills, and malaise without hemolysis. Management includes stopping the transfusion to exclude other serious reactions, administering antipyretics, and using leukoreduced blood products for future transfusions. Leukoreduction involves reducing the number of transfused leukocytes through filtering or other methods such as saline washing, freezing and deglycerolizing, or buffy coat removal. It also reduces the risk of human leukocyte antigen alloimmunization and transmission of cytomegalovirus (which typically resides in leukocytes). Premedication with antipyretics and antihistamines has not been shown to significantly reduce transfusion reactions. (Choice A) Careful cross-matching of blood prevents acute hemolytic reactions, which present with fever, chills, flank pain and hemoglobinuria within an hour of transfusion. These can progress to renal failure and disseminated intravascular coagulation. The direct antiglobulin test (Coombs) is positive and plasma free hemoglobin is >25 mg/dL. Urinalysis also shows hemoglobinuria. (Choice C) Whole blood contains numerous leukocytes and increases the risk of febrile reaction. Therefore, it is rarely used except in cases of acute massive hemorrhage (eg, trauma). (Choice D) Warming blood is recommended only during rapid massive transfusion to prevent hypothermia. (Choice E) Residual plasma in red cell concentrates contains proteins, including immunoglobulin A (IgA). IgA-deficient patients develop antibodies against IgA. These antibodies can react with IgA-containing donor products and induce an anaphylactic reaction (angioedema, hypotension, and respiratory distress) that can progress rapidly to loss of consciousness, shock, and respiratory failure. To reduce this risk, red cells should be washed to remove as much of the plasma as possible for patients with IgA deficiency or prior allergic transfusion reaction. Educational objective: Febrile nonhemolytic transfusion reaction is the most common adverse reaction that occurs within 1-6 hours of transfusion. Patients usually develop fever, chills, and malaise without hemolysis. Leukoreduction of donor blood can prevent febrile nonhemolytic reaction and reduce the risk of human leukocyte antigen alloimmunization and cytomegalovirus transmission. References: Leukoreduced blood components: Advantages and strategies for its implementation in developing countries. (http://www.ncbi.nlm.nih.gov/pubmed/20376259) Universal leukoreduction decreases the incidence of febrile nonhemolytic transfusion reactions to RBCs. (http://www.ncbi.nlm.nih.gov/pubmed/14692963)

A 45-Year-Old Woman with a History of Chronic Menorrhagia Is