Incompatible Blood

[jojo808]

2 units O positive trauma blood were requested and sent to the ER. After back from ER, found that the patient had a historical Anti-E while doing the history check. The ER MD was notified and after he found out that the workup would take 45min to an hour he said to continue with the trauma blood (Hgb 5.3, not sure of clinical condition). Hindsight, I could have said about 15 min to screen for E neg units but I didn't know if the patient had made new antibodies and was just thinking about the panels and identification. Anyway, 1 out of the 2 units was E pos (incompatible). The MD and pathologist were notified. Going forward, how long would it take for a delayed transfusion reaction (DSTR or DHTR?) to occur? What would you do for the follow-up for this situation? What should be done? Thank you in advance!!

 

[jayinsat]

5 hours ago, jojo808 said:

2 units O positive trauma blood were requested and sent to the ER. After back from ER, found that the patient had a historical Anti-E while doing the history check. The ER MD was notified and after he found out that the workup would take 45min to an hour he said to continue with the trauma blood (Hgb 5.3, not sure of clinical condition). Hindsight, I could have said about 15 min to screen for E neg units but I didn't know if the patient had made new antibodies and was just thinking about the panels and identification. Anyway, 1 out of the 2 units was E pos (incompatible). The MD and pathologist were notified. Going forward, how long would it take for a delayed transfusion reaction (DSTR or DHTR?) to occur? What would you do for the follow-up for this situation? What should be done? Thank you in advance!!

 

You did everything that was required in this situation. The patient was a trauma and needed emergency transfusion. The risk of death outweighed the risk of a hemolytic transfusion reaction in that scenario, according to the treating physician. I once had a trauma surgeon tell me "I can treat a transfusion reaction but I can't treat death!" That put things in perspective for me. That is why thy sign the consent.

Next step would be to report this to your risk management department so that follow-up can be made, including monitoring the patient for the s/s of DTR. 

[AMcCord]

1 hour ago, jayinsat said:

You did everything that was required in this situation. The patient was a trauma and needed emergency transfusion. The risk of death outweighed the risk of a hemolytic transfusion reaction in that scenario, according to the treating physician. I once had a trauma surgeon tell me "I can treat a transfusion reaction but I can't treat death!" That put things in perspective for me. That is why thy sign the consent.

Next step would be to report this to your risk management department so that follow-up can be made, including monitoring the patient for the s/s of DTR. 

Agree! Save the life first.

Our medical director would likely order at least one DAT the next day, possibly for additional days, to monitor. Anti-E is generally relative benign (though I have seen one patient who had an acute hemolytic reaction), We might also monitor plasma Hgb or haptoglobin, depending on the antibody involved.

[applejw]

You did everything necessary as others have said. At our facility, physicians seem to be unphased by the use of emergency released blood - we issue a lot of it.  It is not uncommon to discover that the patient has a historical antibody that may or may not be demonstrating. The physician and pathologist are notified when the history is discovered and the physician makes the medical decision to continue or stop the transfusion at that point. We perform antigen testing of the unit(s) and perform AHG compatibility testing of all units that are issued.  Further laboratory testing is ordered by the physicians caring for the patient. The most immediate concern is an acute hemolytic reaction and that is rare. Shortened survival of incompatible transfused red cells is expected.

[jojo808]

Thanks everyone, can you share what would you look for in a delayed transfusion reaction? Anything other than bilirubin, LD, haptoglobin. Treatment would just be to treat the symptoms yes? Any other info is apprecitated.

[Malcolm Needs ☆]

This may or may not help.

Clinical Aspects of Transfusion Reactions.pptx

[exlimey]

I agree with all the previous comments. You cannot manage a transfusion reaction in a patient who has died from lack of blood.

One thing to add: In the time before time......emergency release units were always O negs. However, today's practice has evolved in a risk-based manner and it is now accepted that O pos units can fulfil this function. Perhaps ironically, if the old practice had been employed in this case (use O negs), it would have been very unlikely that this patient would get a E+ unit.

[JJSPLAYHOUSE]

19 hours ago, exlimey said:

I agree with all the previous comments. You cannot manage a transfusion reaction in a patient who has died from lack of blood.

One thing to add: In the time before time......emergency release units were always O negs. However, today's practice has evolved in a risk-based manner and it is now accepted that O pos units can fulfil this function. Perhaps ironically, if the old practice had been employed in this case (use O negs), it would have been very unlikely that this patient would get a E+ unit.

@exlimeyI agree, but with the overuse of O negs and the continuous donor shortages, O pos have become the standard emergency unit for anyone not female within childbearing age.

[Ensis01]

On 4/19/2023 at 3:26 PM, exlimey said:

I agree with all the previous comments. You cannot manage a transfusion reaction in a patient who has died from lack of blood.

Agreed. I would however like to add the caveat that some physicians do not understand the risks associated with antibody history and uncrossmatched blood, so getting a pathologist involved to ensure the situation is truly life/death. 

[Mabel Adams]

If we know the patient has anti-E, for us that would justify using O neg for uncrossmatched if it didn't deplete the O neg supply too much and we could screen O pos for E quickly.  More so for known anti-D.  Not saying anything was done wrong in this case.