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. Onset within minutes with fever, rigors, loin pain, haemoglobinuria, hypotension and a sense of impending doom. This is acute haemolysis, almost always from ABO incompatibility.
2. Transfusion-related acute lung injury (TRALI) Dyspnoea and pulmonary oedema with hypotension within 6 hours. Fever, loin pain and haemoglobinuria minutes into a transfusion makes it worth distinguishing.
3. Transfusion reactions An adverse reaction to a blood component, classified by its timing and features. Fever, loin pain and haemoglobinuria minutes into a transfusion fits.
4. Anaphylaxis Hypotension, wheeze and angioedema, classically in IgA deficiency. Fever, loin pain and haemoglobinuria minutes into a transfusion raises it.
5. Bacterial contamination Rapid high fever, rigors and shock from an infected unit. Fever, loin pain and haemoglobinuria minutes into a transfusion makes it dangerous.

The point: Transfusion reactions are identified by their timing and features. An acute haemolytic reaction, usually ABO incompatibility from a clerical error, occurs within minutes with fever, rigors, loin or back pain, hypotension and haemoglobinuria; stop the transfusion, keep the line, check the unit against the patient, and inform the blood bank. A febrile non-haemolytic reaction gives an isolated fever and rigors without other features; slow or stop the transfusion and give an antipyretic. A minor allergic reaction gives urticaria; slow it and give an antihistamine. Anaphylaxis gives hypotension, wheeze and angioedema, classically in IgA-deficient patients; stop and give adrenaline. Transfusion-associated circulatory overload (TACO) gives dyspnoea, hypertension and pulmonary oedema in a patient given too much too fast; slow or stop and give a diuretic. Transfusion-related acute lung injury (TRALI) gives dyspnoea and pulmonary oedema with hypotension within 6 hours; stop and give respiratory support. Bacterial contamination gives rapid 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 Markers of haemolysis in a suspected haemolytic reaction. Fever, loin pain and haemoglobinuria minutes into a transfusion indicates it.
2. Stop the transfusion and check the unit against the patient correct Correct. The first action, and it identifies the clerical mismatch that causes most of these reactions, potentially protecting a second patient too.
3. Coagulation screen and renal function For a haemolytic reaction complicated by disseminated intravascular coagulation and renal injury. Fever, loin pain and haemoglobinuria minutes into a transfusion makes it worthwhile.
4. Return the unit and take samples to the blood bank For a repeat group and crossmatch, direct antiglobulin test, and culture of the unit. Fever, loin pain and haemoglobinuria minutes into a transfusion makes it necessary.
5. Chest radiograph Distinguishes the pulmonary oedema of overload and lung injury. Fever, loin pain and haemoglobinuria minutes into a transfusion makes it useful.

The point: Transfusion reactions are identified by their timing and features. An acute haemolytic reaction, usually ABO incompatibility from a clerical error, occurs within minutes with fever, rigors, loin or back pain, hypotension and haemoglobinuria; stop the transfusion, keep the line, check the unit against the patient, and inform the blood bank. A febrile non-haemolytic reaction gives an isolated fever and rigors without other features; slow or stop the transfusion and give an antipyretic. A minor allergic reaction gives urticaria; slow it and give an antihistamine. Anaphylaxis gives hypotension, wheeze and angioedema, classically in IgA-deficient patients; stop and give adrenaline. Transfusion-associated circulatory overload (TACO) gives dyspnoea, hypertension and pulmonary oedema in a patient given too much too fast; slow or stop and give a diuretic. Transfusion-related acute lung injury (TRALI) gives dyspnoea and pulmonary oedema with hypotension within 6 hours; stop and give respiratory support. Bacterial contamination gives rapid 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. Restart cautiously only for a mild febrile or allergic reaction Some mild reactions allow cautious continuation once settled, unlike serious ones. Fever, loin pain and haemoglobinuria minutes into a transfusion makes it conditional.
2. Stop the transfusion and give supportive treatment correct Correct. The transfusion stops, the line is kept for fluids, and the blood bank is informed with the unit and samples returned.
3. Slow or stop the transfusion and give an antipyretic For a febrile non-haemolytic reaction, which is usually mild. Fever, loin pain and haemoglobinuria minutes into a transfusion meets that.
4. Stop, take cultures and start broad-spectrum antibiotics For suspected bacterial contamination with fever and shock. Fever, loin pain and haemoglobinuria minutes into a transfusion makes it urgent.
5. Slow the transfusion and give an antihistamine For a minor allergic reaction with urticaria alone. Fever, loin pain and haemoglobinuria minutes into a transfusion makes it appropriate.

The point: Transfusion reactions are identified by their timing and features. An acute haemolytic reaction, usually ABO incompatibility from a clerical error, occurs within minutes with fever, rigors, loin or back pain, hypotension and haemoglobinuria; stop the transfusion, keep the line, check the unit against the patient, and inform the blood bank. A febrile non-haemolytic reaction gives an isolated fever and rigors without other features; slow or stop the transfusion and give an antipyretic. A minor allergic reaction gives urticaria; slow it and give an antihistamine. Anaphylaxis gives hypotension, wheeze and angioedema, classically in IgA-deficient patients; stop and give adrenaline. Transfusion-associated circulatory overload (TACO) gives dyspnoea, hypertension and pulmonary oedema in a patient given too much too fast; slow or stop and give a diuretic. Transfusion-related acute lung injury (TRALI) gives dyspnoea and pulmonary oedema with hypotension within 6 hours; stop and give respiratory support. Bacterial contamination gives rapid 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