A 55-year-old man is hospitalized after a massive hemorrhage from a duodenal ulcer. The bleeding is stopped with endoscopic manipulation. The patient receives 2 L of intravenous fluids, followed by 2 units of packed red blood cells. Two hours after the transfusion is started, he develops chills and malaise. Temperature is 38.7 C (101.7 F), blood pressure is 120/76 mm Hg, pulse is 100/min, and respirations are 20/min. The transfusion is stopped, and the patient is given acetaminophen. Direct antiglobulin and plasma-free hemoglobin level tests are negative. Urinalysis is within normal limits. The symptoms resolve within 6 hours of transfusion discontinuation. Which of the following is the best procedure for preventing this type of transfusion reaction?

Question

A 55-year-old man is hospitalized after a massive hemorrhage from a duodenal ulcer.  The bleeding is stopped with endoscopic manipulation.  The patient receives 2 L of intravenous fluids, followed by 2 units of packed red blood cells.  Two hours after the transfusion is started, he develops chills and malaise.  Temperature is 38.7 C (101.7 F), blood pressure is 120/76 mm Hg, pulse is 100/min, and respirations are 20/min.  The transfusion is stopped, and the patient is given acetaminophen.  Direct antiglobulin and plasma-free hemoglobin level tests are negative.  Urinalysis is within normal limits.  The symptoms resolve within 6 hours of transfusion discontinuation.  Which of the following is the best procedure for preventing this type of transfusion reaction?

Quizplus · Accepted Answer

11ec25c8_d40d_bdf6_bc81_af48131e68d5_MD0003_00 Febrile nonhemolytic transfusion reaction (FNHTR), the most common adverse transfusion reaction, is a benign occurrence caused by cytokine release from leukocytes within the donor blood product. During preparation of blood products, whole blood is separated into red blood cells and plasma. However, small amounts of leukocyte debris remain in the red cell concentrate. During blood storage, these leukocytes can release cytokines, which when transfused can cause transient fever, chills, and malaise within 1-6 hours of transfusion initiation. Management includes transfusion cessation (to exclude other serious reactions) and antipyretic administration. Risk of recurrent FNHTR is high after a first episode, and prevention is best achieved by using leukoreduced blood products for future transfusions. Leukoreduction involves filtering out most of the leukocytes after blood collection but before blood storage, thereby minimizing cytokine production within the packed red blood cell product. Leukoreduction also reduces the risk of human leukocyte antigen alloimmunization and transmission of cytomegalovirus (which typically resides in leukocytes). Many facilities empirically leukoreduce all blood products, but this process is not universal. (Choice A) Careful cross-matching of blood prevents acute hemolytic transfusion reaction (AHTR), which is caused by mismatched donor and recipient blood. Symptoms include chills, flank pain, and gross hematuria within an hour of transfusion. Unlike this patient, those with AHTR have a positive direct antiglobulin (Coombs) test, increased plasma-free hemoglobin, and hemoglobinuria. (Choices B and E) Citrate, which binds ionized calcium, is the main anticoagulant used for blood product storage and can cause hypocalcemia if a massive transfusion is required (eg, cardiac surgery). Calcium gluconate infusion is used to prevent or treat severe hypocalcemia. Similarly, warming the blood product is recommended during rapid, massive transfusion to prevent hypothermia and arrhythmia. (Choice C) Premedication with antipyretics or antihistamines (eg, diphenhydramine), which was previously used in some centers, has been found not to reduce the incidence of FNHTR in several studies. Educational objective: Febrile nonhemolytic transfusion reaction (FNHTR) is the most common adverse reaction and is caused by release of cytokines from leukocytes in the stored blood product. Symptoms develop within 1-6 hours and include transient fever, chills, and malaise. Leukoreduction of donor blood helps prevent FNHTR. References: Leukoreduced blood components: advantages and strategies for its implementation in developing countries. (http://www.ncbi.nlm.nih.gov/pubmed/20376259)

A 55-Year-Old Man Is Hospitalized After a Massive Hemorrhage from a Duodenal