A 29-year-old woman with chronic anemia comes to the emergency department with fatigue and progressive dyspnea. Physical examination shows pallor but no jaundice. Lungs are clear on auscultation and abdominal examination is benign. Laboratory results are as follows: Packed red blood cell transfusion is started. Thirty minutes later, the patient complains of severe bilateral flank pain. She has received multiple blood transfusions in the past, but all were uncomplicated. Her temperature is 38.3 C (101 F), blood pressure is 100/70 mm Hg, pulse is 120/min, and respirations are 16/min. Pulse oximetry is 97% on room air. Urine is dark. Which of the following is the best next step in management of this patient?

Question

A 29-year-old woman with chronic anemia comes to the emergency department with fatigue and progressive dyspnea.  Physical examination shows pallor but no jaundice.  Lungs are clear on auscultation and abdominal examination is benign.  Laboratory results are as follows:  Packed red blood cell transfusion is started.  Thirty minutes later, the patient complains of severe bilateral flank pain.  She has received multiple blood transfusions in the past, but all were uncomplicated.  Her temperature is 38.3 C (101 F), blood pressure is 100/70 mm Hg, pulse is 120/min, and respirations are 16/min.  Pulse oximetry is 97% on room air.  Urine is dark.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf58_c92a_8f63_43495f37e71f_MD0005_00 This patient is likely having an acute hemolytic transfusion reaction (AHTR), which typically develops within an hour after the transfusion is started. AHTR is a medical emergency usually caused by ABO incompatibility (possibly due to clerical error) or presence of other antibodies. Patients who require chronic red cell transfusions (eg, African American patients with sickle cell anemia) may form multiple antibodies to common Rh, Kell, or other blood group antigens. Patients typically present with fever, chills, hemoglobinuria, flank pain, and discomfort at the infusion site. This may advance to renal failure (due to immune complex deposition) and disseminated intravascular coagulation (DIC). Diagnosis is made by a positive direct Coombs test, pink plasma (plasma free hemoglobin >25 mg/dL), hemoglobinuria, and repeat type and cross-match showing a mismatch. AHTR should be managed by immediately stopping the transfusion and aggressively hydrating the patient with normal saline (not Ringer's or dextrose) to treat the hypotension and prevent renal failure. (Choice A) Blood transfusion maybe continued if it is confirmed that the patient has only an urticarial reaction to the transfusion (hives), without serious reactions. This patient has hemoglobinuria and bilateral flank pain suggestive of acute hemolytic reaction. (Choice B) Most bacteria, with the exception of some Gram-negative species (eg, Pseudomonas), do not grow at the cold temperatures at which blood is stored. Patients who are transfused with bacteria-contaminated blood have fever and chills, followed by fulminant septic shock and DIC. Severe flank pain is unusual. (Choice C) Transfusion-associated circulatory overload causes dyspnea, tachycardia, hypertension and hypoxemia due to rapid transfusion of blood products in individuals with depressed cardiac function. Patients develop clinical hypervolemia with increased central venous pressures, pulmonary edema and elevated N-terminal prohormone of brain natriuretic peptide (NT-proBNP). Treatment includes diuretics, oxygen, and possibly noninvasive positive-pressure ventilation. (Choice D) Individuals who are IgA-deficient are at risk of developing anaphylactic reaction to blood products due to the presence of anti-IgA IgG antibodies. Anaphylaxis typically occurs within seconds to minutes of transfusion. Patients present with angioedema, hypotension, and difficulty breathing, which can progress rapidly to loss of consciousness, shock, and respiratory failure. Management includes epinephrine, antihistamines, and glucocorticoids as well as circulatory and respiratory support. Educational objective: Acute hemolytic transfusion reaction is a life-threatening reaction from transfusion of mismatched blood (eg, ABO mismatch). Patients rapidly develop fever, flank pain, hemolysis, oliguric renal failure, and disseminated intravascular coagulation within an hour of transfusion. Febrile nonhemolytic transfusion reactions are the most common adverse reaction to transfusion and present with fever and chills within 1-6 hours of transfusion. Premedication with antihistamines and acetaminophen does not prevent blood transfusion reactions. References: Transfusion of blood and blood products: indications and complications. (http://www.ncbi.nlm.nih.gov/pubmed/21404983) Risks of transfusion. (http://www.ncbi.nlm.nih.gov/pubmed/22024787) Febrile nonhemolytic transfusion reactions. Management by premedication and cost implications in adult patients. (http://www.ncbi.nlm.nih.gov/pubmed/15335265)

A 29-Year-Old Woman with Chronic Anemia Comes to the Emergency