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Emergency transfusing an incompatible blood type.


jschlosser
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A physician at our small rural hospital has commented that in a situation when a trauma is bleeding out he would give all the blood that we stock. We stock only 2 O negs, 2 O pos and 2 A pos. I however feel uncomfortable giving our A pos to anyone not typed because if the patient was stabilized and the the A pos was still circultaing I feel that that would be a significant  problem. It may never happen but I would like to be prepared. Thanks much in advance

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A long time ago now, I was working in a very large London teaching hospital, when we received a patient who was a group B police officer (this was about the time when the IRA were active in London, but this case, as far as is known, ha nothing whatsoever to do with them).  He had received multiple stab wounds.

We soon went through our stock of group B, and eventually got through out stock of group O.  Although we had ordered more stock to be delivered by "Blues and twos", at this stage we had a choice.  We either transfused him with group A, or we let him die.  The doctors in charge decided to give him group A.

He survived, and when the emergency order of stocks has arrived, we switched back to group B, and then group O.  Yes, his renal function was shot to pieces for a while, but, to be honest, that was probably the least of his worries at the time.  I'm not saying that this would work every time, because it won't, but you can treat a haemolytic transfusion reaction, even an acute haemolytic transfusion reaction; death is difficult to treat.

As Prof Brian McClelland MB ChB ND Linden FRCP(E) FRCPath (former Director of the Scottish National Blood Transfusion Service) once wrote in Thomas D, Thompson J, Ridler B.  A Manual for Blood Conservation.  1st edition.  2005.  tfm Publishing Ltd, "Transfusion has risks, but bleeding to death is fatal."!

To my own shame, I once did a book review of this for the BBTS, and misquoted the title as, "A Manual for Blood Conversation."!  The embarrassment!

Edited by Malcolm Needs
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1 hour ago, sgrassley said:

I would probably switch my inventory to stock only 'O'. :) 

Sorry, but that is almost certainly not a possibility anywhere, otherwise we would have all done it years ago.

As I said above, if you give everyone group O red cells, because they can all have those (except Oh individuals, oh, and individuals with other antibodies than anti-A and anti-B), you will run out of the group O units you require for group O patients.

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Although I agree that treating a transfusion reaction is a lot easier than treating exsanguination, in this small hospital setting where they have only 6 units of blood to begin with, I don't think it would go so well to switch to incompatible after only 4u transfused.

I'm with the group suggesting the hospital switch to stocking 4 O Pos + 2 O Neg RBCs.  It is possible, don't let your provider tell you otherwise.

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The decision that a patient is in immediate risk of exsanguination and death is one that can only made at the bedside.  That said, I think many trauma patients are overtransfused these days, particularly with plasma and platelets being given in most hospitals along with the first red cells.  So I'd be very clear that the ordering practitioner believes that death is imminent without transfusion. 

And hopefully the patient would have already received tranexamic acid, and probably DDAVP as well to mitigate or even stop bleeding.  These are evidence based, inexpensive, effective and safe drugs that can make the difference between surviving and not surviving, and between needing only a few units of red cells versus many more.  Not all physicians have accepted these data, even trauma surgeons in some cases.  

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On 12/12/2019 at 9:19 AM, Neil Blumberg said:

The decision that a patient is in immediate risk of exsanguination and death is one that can only made at the bedside.  That said, I think many trauma patients are overtransfused these days, particularly with plasma and platelets being given in most hospitals along with the first red cells.  So I'd be very clear that the ordering practitioner believes that death is imminent without transfusion. 

And hopefully the patient would have already received tranexamic acid, and probably DDAVP as well to mitigate or even stop bleeding.  These are evidence based, inexpensive, effective and safe drugs that can make the difference between surviving and not surviving, and between needing only a few units of red cells versus many more.  Not all physicians have accepted these data, even trauma surgeons in some cases.  

I would suspect that very few critical access hospitals would have tranexamic acid and DDAVP in stock in their pharmacies. This type of patient would be a very rare event for them. Treatment would be limited to stabilizing as much as possible and transfer as soon as humanly possible. Then that patient might well become my problem, but we are better equipped to handle it.

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