Perioperative medicine and anaesthesia for PLAB 1

A 62 year old woman receiving her first unit of red cells develops rigors, a fever rising from 36.9 to 38.9°C, loin pain and dark urine 10 minutes after it started. Her blood pressure has fallen to 88/50 mmHg and her pulse is 120. She feels a sense of impending doom. The transfusion is still running. What is the SINGLE most likely diagnosis?

1. Acute haemolytic reaction correct Correct. Starting within minutes with fever, shaking, loin pain, dark urine, low blood pressure and a feeling that something terrible is happening. This is red cells being destroyed suddenly, almost always from the wrong blood group.
2. Transfusion-related acute lung injury (TRALI) Breathlessness and fluid on the lungs with low blood pressure within 6 hours. It does not fit fever, loin pain and haemoglobinuria minutes into a transfusion.
3. Transfusion reactions A bad reaction to a blood product, sorted by when it happens and what it looks like. Here, fever, loin pain and haemoglobinuria minutes into a transfusion points elsewhere.
4. Anaphylaxis Low blood pressure, wheeze and swelling under the skin, classically in people short of the IgA antibody. But fever, loin pain and haemoglobinuria minutes into a transfusion does not point to it.
5. Bacterial contamination A fast, high fever, shaking and shock from a blood bag that has been infected with bacteria. That does not match fever, loin pain and haemoglobinuria minutes into a transfusion.

The point: Transfusion reactions are told apart by when they happen and what they look like. An acute reaction from destroyed red cells (haemolytic reaction), usually from the wrong blood group being given because of a clerical mistake, happens within minutes with fever, shaking, loin or back pain, low blood pressure and dark urine from blood breakdown products; stop the transfusion, keep the drip line open, check the bag against the patient, and tell the blood bank. A mild fever reaction with no other cause gives just a fever and shaking with nothing else; slow or stop the transfusion and give paracetamol. A minor allergic reaction gives a raised itchy rash (urticaria); slow it and give an antihistamine. Anaphylaxis gives low blood pressure, wheeze and swelling under the skin, classically in patients short of a particular antibody (IgA deficiency); stop and give adrenaline. Transfusion-associated circulatory overload (TACO) gives breathlessness, high blood pressure and fluid on the lungs in a patient given too much, too fast; slow or stop and give a water tablet (diuretic). Transfusion-related acute lung injury (TRALI) gives breathlessness and fluid on the lungs with low blood pressure within 6 hours; stop and support the breathing. Infected blood gives a fast fever and shock.

Source: British Society for Haematology — Guideline on the administration of blood components British Society for Haematology · tier 2, specialty society or college

A 62 year old woman receiving her first unit of red cells develops rigors, a fever rising from 36.9 to 38.9°C, loin pain and dark urine 10 minutes after it started. Her blood pressure has fallen to 88/50 mmHg and her pulse is 120. She feels a sense of impending doom. The transfusion is still running. What is the SINGLE most appropriate initial investigation?

1. Full blood count, haptoglobin, LDH and bilirubin Signs of red cells being destroyed, in a suspected reaction from destroyed red cells. But fever, loin pain and haemoglobinuria minutes into a transfusion does not point to it.
2. Stop the transfusion and check the unit against the patient correct Correct. The first thing to do, and it catches the clerical mix-up that causes most of these reactions, which could also be protecting a second patient somewhere else.
3. Coagulation screen and renal function For a reaction from destroyed red cells complicated by a widespread clotting problem or kidney injury. Here, fever, loin pain and haemoglobinuria minutes into a transfusion points elsewhere.
4. Return the unit and take samples to the blood bank For a repeat blood group and cross-match, a test for antibodies on the red cells, and growing a culture from the bag. It does not fit fever, loin pain and haemoglobinuria minutes into a transfusion.
5. Chest radiograph Tells the fluid on the lungs from overload apart from the fluid on the lungs from lung injury. That does not match fever, loin pain and haemoglobinuria minutes into a transfusion.

The point: Transfusion reactions are told apart by when they happen and what they look like. An acute reaction from destroyed red cells (haemolytic reaction), usually from the wrong blood group being given because of a clerical mistake, happens within minutes with fever, shaking, loin or back pain, low blood pressure and dark urine from blood breakdown products; stop the transfusion, keep the drip line open, check the bag against the patient, and tell the blood bank. A mild fever reaction with no other cause gives just a fever and shaking with nothing else; slow or stop the transfusion and give paracetamol. A minor allergic reaction gives a raised itchy rash (urticaria); slow it and give an antihistamine. Anaphylaxis gives low blood pressure, wheeze and swelling under the skin, classically in patients short of a particular antibody (IgA deficiency); stop and give adrenaline. Transfusion-associated circulatory overload (TACO) gives breathlessness, high blood pressure and fluid on the lungs in a patient given too much, too fast; slow or stop and give a water tablet (diuretic). Transfusion-related acute lung injury (TRALI) gives breathlessness and fluid on the lungs with low blood pressure within 6 hours; stop and support the breathing. Infected blood gives a fast fever and shock.

Source: British Society for Haematology — Guideline on the administration of blood components British Society for Haematology · tier 2, specialty society or college

A 62 year old woman receiving her first unit of red cells develops rigors, a fever rising from 36.9 to 38.9°C, loin pain and dark urine 10 minutes after it started. Her blood pressure has fallen to 88/50 mmHg and her pulse is 120. She feels a sense of impending doom. The transfusion is still running. What is the SINGLE most appropriate immediate management?

1. Slow or stop the transfusion and give an antipyretic For a mild fever reaction with no other cause, which is usually not serious. It does not fit fever, loin pain and haemoglobinuria minutes into a transfusion.
2. Stop, give oxygen and provide respiratory support For lung injury from the transfusion, which is treated by supporting the breathing and often needs a ventilator. That does not match fever, loin pain and haemoglobinuria minutes into a transfusion.
3. Slow the transfusion and give an antihistamine For a minor allergic reaction with just a rash. Here, fever, loin pain and haemoglobinuria minutes into a transfusion points elsewhere.
4. Stop, take cultures and start broad-spectrum antibiotics For a suspected infected blood bag with fever and shock. But fever, loin pain and haemoglobinuria minutes into a transfusion does not point to it.
5. Stop the transfusion and give supportive treatment correct Correct. The transfusion is stopped, the line is kept open for fluids, and the blood bank is told, with the bag and blood samples sent back to them.

The point: Transfusion reactions are told apart by when they happen and what they look like. An acute reaction from destroyed red cells (haemolytic reaction), usually from the wrong blood group being given because of a clerical mistake, happens within minutes with fever, shaking, loin or back pain, low blood pressure and dark urine from blood breakdown products; stop the transfusion, keep the drip line open, check the bag against the patient, and tell the blood bank. A mild fever reaction with no other cause gives just a fever and shaking with nothing else; slow or stop the transfusion and give paracetamol. A minor allergic reaction gives a raised itchy rash (urticaria); slow it and give an antihistamine. Anaphylaxis gives low blood pressure, wheeze and swelling under the skin, classically in patients short of a particular antibody (IgA deficiency); stop and give adrenaline. Transfusion-associated circulatory overload (TACO) gives breathlessness, high blood pressure and fluid on the lungs in a patient given too much, too fast; slow or stop and give a water tablet (diuretic). Transfusion-related acute lung injury (TRALI) gives breathlessness and fluid on the lungs with low blood pressure within 6 hours; stop and support the breathing. Infected blood gives a fast fever and shock.

Source: British Society for Haematology — Guideline on the administration of blood components British Society for Haematology · tier 2, specialty society or college