Severe Hemolysis post transfusion

[richj]

Hello,

 

Recently a cardiac patient with cardiogenic shock,   OPOS  with Anti-E received 2 units of OPOS E- rbcs.  During the 2nd unit, the patient's vitals were unremarkable with no signs or symptoms of a transfusion reaction other than when labs were being drawn, multiple samples were severely hemolyzed.

The transfusion was stopped after 190 ml and a transfusion reaction investigation was ordered.

All testing was unremarkable, DAT negative pre and post, antibody ID panels pre and post Anti-E only. Antigen typing rechecked and ABO/RH blood groups fine, no clerical error.

 

Question.

Has anyone seen this type of hemolysis in a cardiogenic patient on a balloon pump.

A nurse with 12 years experience on the CCU had never seen such hemolysis.

A CBC drawn during the transfusion did show 2+ spherocytes.

 

Thoughts, further testing?

No urine received

 

Thanks

Richard

[Malcolm Needs ☆]

Quick thought, as I am about to go to bed, but, did the patient have an auto-anti-H, anti-HI or anti-I at RT, but not detectable by IAT at 37^oC, and was the blood transfused straight from the fridge?  Also the patient of small stature?

[SMW]

My guess would be it was something other than the blood that was infused (inadvertently?) that caused the hemolysis, e.g., a hypotonic solution.  They may have also used something other than saline as a cold cardioplegia solution, e.g., water!  Hemolysis was a common occurrence years ago (with no transfusions) when water rather than saline was used as an irrigation solution for TURPs.

[galvania]

I would also look for something that was nothing to do with the transfusion - as SMW says, water would be a good candidate, but could also be mechanical.  And, infected blood maybe???????

[Auntie-D]

Have they been investigated for cold antibodies? If not, did they use a blood warmer? I have a glimmer somewhere in the back of my head of an idea that cardiac bypass patients are usually screened for cold antibodies?

[L106]

My guess would be it was something other than the blood that was infused (inadvertently?) that caused the hemolysis, e.g., a hypotonic solution.  They may have also used something other than saline as a cold cardioplegia solution, e.g., water!  Hemolysis was a common occurrence years ago (with no transfusions) when water rather than saline was used as an irrigation solution for TURPs.

 

We have observed both of these problems that SMW has mentioned.

[richj]

Thank you for your responses.

 

Malcolm,  I performed a tube screen and re crossmatched the possible offending units using saline IAT method. There was no agglutination at the room temperature phase. I was trying to rule out a possible cold antibody but not sure if that is enough to rule out what you suggest. The blood does have to be transfused within 15 minutes once removed from a controlled environment.

 

Galvania, I thought of infected blood (septic shock even) but the blood bag returned looks normal, the patient had no spike in temp and the film is not septic.

 

I guess I would have to check the chart and ask questions regarding hypotonic solutions.

 

Just wanted to get a feel whether our SOP could be ameliorated to help figure out the 'mystery of the disappearing red cells'

 

Thanks

Richard

 

[jojo808]

My first thought was to check that they used the correct Saline solution. 

[AMcCord]

Another wild idea. We had this pop up in Pre-op/Surg though thankfully nipped it in the bud before any patient issues resulted (that we know of). We had someone in Anesthesia thinking that routinely warming the blood up by infusing it with warm saline was a good idea. The bad idea was that he was warming the saline in a blanket warmer and that temp was NOT appropriate for blood products.

And I'm assuming that the transfusions were not done using a pressure cuff to speed things along?

Does the patient have a multi-lumen line and an incompatible solution was infusing  through a different lumen at the same time as the blood?

Edited January 25, 2016 by AMcCord

[bxcall1]

The nurse doing the line draw hemolyzed it! Happens all the time around here. They don't understand that you have to pull the plunger back gently and they just pull it all the way back even when the blood flow is not good.

[Auntie-D]

On 2/3/2016 at 8:40 PM, bxcall1 said:

The nurse doing the line draw hemolyzed it! Happens all the time around here. They don't understand that you have to pull the plunger back gently and they just pull it all the way back even when the blood flow is not good.

Or leave the tourniquet on for ages whilst they get themselves organised and the patient's arm is going blue...