Intra-operative crises20 / 21
Acute haemolytic transfusion reaction during hip revision58-year-old woman, 72 kg, group A positive, transfused many times in the past; no regular drugs
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Know this first
- AHTR: recipient antibodies, usually ABO from clerical error, cause intravascular haemolysis.
- Past transfusion can sensitise to Kidd, Kell and Duffy antigens.
- General anaesthesia masks flank pain, fever and chills; hypotension, haemoglobinuria and oozing remain.
- Keep urine output at least 75–100 mL/h: fluids, then mannitol, then furosemide.
- Fibrinogen under 150 mg/dL suggests DIC rather than dilution.
The patient
58-year-old woman, 72 kg, group A positive, transfused many times in the past; no regular drugs.
Elective revision hip arthroplasty under general anaesthesia.
Blood loss 1.4 L so far; the second unit of red cells is running.
Vitals: BP 118/70, HR 82, SpO2 99%, temperature 36.4 °C.
The examiner asks
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Consider
What are your transfusion concerns?
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- A 58-year-old, transfused many times before, for revision hip arthroplasty with major bleeding. Patient
- Her past transfusions may have left antibodies against Kell, Kidd or Duffy antigens. Disease
- So she needs a current antibody screen and fully crossmatched units.
- Under anaesthesia she can't report flank pain, chills or anxiety; haemolysis is masked.
- Revision hips bleed heavily, so she will need several units. Surgery
Prepare
How do you make each unit safe?
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- Two-person bedside check: her wristband against the unit and its label. Disease
- ABO reactions mostly come from clerical error, so the check is never skipped in a rush.
- I watch for the signs anaesthesia leaves visible: hypotension, red urine and oozing.
- Temperature, urine colour and output monitored through each unit. After surgery
Crisis
Ten minutes into the unit, BP falls to 72/40, HR 124, and the catheter bag shows dark red urine. What do you do?
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- Acute haemolytic reaction until proven otherwise: stop the transfusion now. (Crisis)
- Her identity rechecked against the unit; blood bank told at once.
- New giving set; crystalloid and a vasopressor to protect her kidneys' perfusion.
- Urine output kept at least 75–100 mL/h: fluid first, then mannitol, then furosemide.
- Her urine is alkalinised as well.
- Unit and bag back to the blood bank with her blood and urine samples.
- Tests: DAT, LDH, haptoglobin, bilirubin, plasma and urine haemoglobin.
Crisis
Twenty minutes later the surgeon reports diffuse oozing from the wound and from the cannula sites. What now?
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- DIC from haemolysis is likely: platelets, PT, PTT and fibrinogen sent now. Crisis
- Fibrinogen under 150 mg/dL with low platelets points to DIC, not dilution.
- Cryoprecipitate to keep fibrinogen at least 150 mg/dL while she bleeds.
- Platelets and plasma guided by her results.
- Any further red cells crossmatched again on a fresh sample.
- Surgery finished fast; ICU for renal monitoring; incident reported to the transfusion service. After surgery
Fatal mistakes
- Continuing the unit.
- No identity recheck.
- Not telling the blood bank.
- Letting her urine output fall.
Checked against: Barash 9e · Miller 10e
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