Transfusion Reaction?

[Stoogiesfreak]

We have a patient that came in to L/D and delivered a normal infant with no issues. Patient's Hgb dropped and 3 units of PRBC were ordered. The patient is A Pos with negative ABS. No previous history, and crossmatch compatible.

During the first portion of the second unit she had some sort of reaction. Her serum is now icteric and her Hgb has dropped from 9.3 to 8.0. Hgb. was 7.7 pretransfusion.

Direct coombs testing is negative both IgG and Poly. All rechecks are fine and all compatibility testing is compatible with both pre and post samples.

Something definately happened, but I could use some ideas!

thanks,

John

[Malcolm Needs ☆]

What is the ethnic origin of the lady John?

I was wondering about hyperhaemolysis, but, come to think of it, if it were that, she would have been very ill and also reacted to the third unit, so it's probably not that.

If the Hb dropped that much though, it certainly sounds like she haemolysed, as she dropped about a gram, but, on the other hand, if only the first portion of the second unit was transfused, the problem could actually either lie with the first unit, or "innocent bystander" autologous red cells were also destroyed.

Strange! I'll have to have a deeper think!

[Auntie-D]

Bacterial?

[Malcolm Needs ☆]

Could be, but I would have thought that she would have been systemically very ill, and almost certainly would have required IV antibiotics.

[Auntie-D]

Could be, but I would have thought that she would have been systemically very ill, and almost certainly would have required IV antibiotics.

Just covering all bases Our medics are notoriously bad for not providing relevant information. Sample today ?LRTI but failed to mention that they were on chemotherapy which would have gone a long way to explaining the Hb of 70, neutrophil count of 0.5 and platelet count of 28. It would have also saved us a phonecall - the GP was completely unconcerned as those were the results they were expecting...

[Stoogiesfreak]

I have a culture started on the unit. After some checking I found that she is 28 weeks pregnant, and having issues, but I don't know exactly what issues. I did a D-Dimer and it is 4060 ng/mL - our upper range is 400 ng/mL. Protime and Ptt are within normal limits and the platelet count is 248,000.

Malcolm, ethnic origin is Caucasian. No previous blood bank history at any facility. Her last Hgb is 8.6 so she has stopped the hemolysis process, or at least it appears so. The physician wants to transfuse the third unit, but I have said "NO", feeling it too risky right now.

Thanks for all the input - I am a little confused by this one!

Thanks,

John

[Auntie-D]

I have a culture started on the unit. After some checking I found that she is 28 weeks pregnant, and having issues, but I don't know exactly what issues. I did a D-Dimer and it is 4060 ng/mL - our upper range is 400 ng/mL. Protime and Ptt are within normal limits and the platelet count is 248,000.

D-dimers are raised in pregnancy anyway so this has no significance unless you are querying DIC (but it's too low to point to that anyway).

[AMcCord]

Just a thought... Have you considered external problems? - be imaginative, because nursing and medical staff can be, too. Did they run something with the blood that they shouldn't have, other than 0.9% saline, like wringers lactate, antibiotics, etc? Did they administer a IV push med utilizing the IV line the blood was running in? Did they use a blood warmer that was too warm? I found out that someone in surgery was putting saline in a blanket warmer prior to use - if that had ever run with blood, there could have been a problem, because blanket warmers are a lot warmer than blood warmers.

[Stoogiesfreak]

Thanks, we are considering "outside" sources as our pathologist has pretty much ruled out a cause from the blood itself. The cultures are negative, and the only thing is making any sense is like you say - an outside source. We are still investigating, and the patient has improved No more transfusions have been given.

Thanks! It always helps to have input from someone that has been in the "trenches". Appreciate the information.

regards,

John

[rravkin@aol.com]

John,

There was a thread on this site not too long ago that delt with a similar problem where there was an unexplained hemolysis of transfused rbc's; I do not remember the tiltle. It was theorized that the patient had a hyperactive monocyte population that was causing the hemolysis. One suggestion that was made was to transfuse any further PC's in aliquotes instead of a whole packed red cell unit.

[Stoogiesfreak]

Thanks! I will look that up. We have not yet found a cause that is concrete. Thanks for the information. I appreciate it.

John

[Abid]

Icteric serum appear after 3 to 6 h of hemolytic transfusion reaction. Before this time the serum would be reddish or pink. Was the original serum used for x-match icteric?

The drop of Hb may be due to ongoing bleeding.

Maybe the reaction was not hemolytic!

[Stoogiesfreak]

The original sample was not hemolzed and had a "normal" appearance. The unit was started and the "post" sample was collected within 4 hours of the start of the transfusion. It was icteric. We have pretty much ruled out a hemolytic reaction, and the patient received an additional unit with no problems. The serum returned to "normal" appearance within 2 days. Cultures were negative. She is also a placenta previa which may account for some of the issues we are seeing. So far the patient is doing fine and her pregnancy continues with no problems to date. ??

thank!

John

[Auntie-D]

Just a thinking sideways thought here - if the subsequent sample was normal, could the post transfusion sample have been from a different patient? What were the chemistry delta checks like on the other parameters in which there shouldn't have been intra-sample variability?

[Stoogiesfreak]

That was the other oddity. Her chemistries were not outstanding. They matched previous results with only very minor increases in liver enzymes. Her liver enzymes were just barely above the reference ranges. The increases were not enough to trigger out delta checks. The only test we could find that increased significantly was her D-Dimer - somewhere around 4000. Our pathologist said that could be associated with the placenta previa.

Thank for the input - it is appreciated!

John

[Eoin]

Hi John,

Can be tricky little devils can't they?

Have you contacted supplier re donor, giving sequence?

My only addition to what has already been said is for an acute non-immune HTR - where the investigation does not reveal serologic abnormalities or misidentification errors (or haematuria for non-febrile haemolytic Tx reaction) is in most cases, a handling, storage, or transfusion error or malfunction that results in physical or chemical destruction of red cells. (Wrong giving set - other additives into line- saw one years ago where line was obviously heat affected - it had been draped over a central heater on the wall)

Would be very interested in Follow-Up

Cheers & good luck.

Eoin

[Stoogiesfreak]

Thanks Eoin,

That part of this story has not been investigated. The patient is current ih-house and her pregnancy continues with no additional problems. She is about 31-32 weeks now.

I will check on the items you mentioned. We just may find an answer!

Thanks for your input - alway nice to hear from an Irish! With the surname of Orr it is pretty obvious where my family came from.

Thanks again,

John

[Stoogiesfreak]

Update:

Patient came in last night and delivered a healthy baby. So far no blood use, but all is going nicely. No blood necessary at this point. Crossmatch compatible, ABS - negative, and DAT negative. No evidence of any issues at this point.

Good News!

Thanks for everyone's help.

John

[Malcolm Needs ☆]

Thanks for the update John. I'm so glad everything is going okay, for all concerned.