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Difficulty: MediumHematology and Oncology

While undergoing induction chemotherapy for acute myeloid leukemia, a 5454-year-old male patient receives a transfusion of packed red blood cells due to a hemoglobin level of 6.8 g/dL6.8 \text{ g/dL}. Approximately twenty minutes after the infusion begins, the patient acutely develops rigors, severe lower back pain, and a feeling of impending doom. Vital signs reveal a temperature of 39.4∘C39.4^\circ\text{C} (102.9∘F102.9^\circ\text{F}), blood pressure of 88/54 mmHg88/54 \text{ mmHg}, heart rate of 122/min122/\text{min}, and respiratory rate of 24/min24/\text{min}. Urine collected from his catheter is noted to be dark and reddish-brown. Which of the following is the most appropriate initial step in the management of this patient?

  1. Stop the transfusion and rapidly infuse intravenous normal salineAnswer
  2. B
    Discontinue the transfusion and administer broad-spectrum intravenous antibiotics
  3. C
    Interrupt the transfusion and transport the patient for an urgent computed tomography scan of the abdomen
  4. D
    Continue the transfusion while administering intravenous diphenhydramine and oral acetaminophen
  5. E
    Terminate the transfusion and formally reprimand the medical staff for an administration error

Answer

The most appropriate initial step is to stop the transfusion and rapidly infuse intravenous normal saline.
The patient's presentation of fever, rigors, flank pain, dark urine (hemoglobinuria), and hypotension occurring within minutes of starting a red blood cell transfusion is the classic presentation of an acute hemolytic transfusion reaction (AHTR). This is typically caused by preformed host antibodies attacking donor red blood cells (e.g., ABO incompatibility), leading to massive intravascular hemolysis. The destroyed red blood cells release hemoglobin, which can precipitate in the renal tubules and cause acute kidney injury. The most critical first step is to immediately stop the transfusion. This must be followed closely by aggressive intravenous fluid resuscitation with normal saline to support blood pressure, maintain renal perfusion, and promote diuresis to prevent acute tubular necrosis.

Step-by-Step Solution

1
Analyze the patient's acute symptoms and vital signs.
The patient developed fever, rigors, flank pain, hypotension, and dark urine shortly after starting a blood transfusion.
Identifying the temporal relationship between the transfusion and the onset of systemic symptoms is crucial for diagnosis.
2
Establish the most likely diagnosis.
The presentation is classic for an acute hemolytic transfusion reaction (AHTR), likely due to ABO incompatibility.
The triad of fever, flank pain, and red-brown urine (hemoglobinuria) during a transfusion strongly indicates intravascular hemolysis.
3
Determine the most appropriate initial management.
The immediate priority is to stop the transfusion and administer aggressive intravenous fluids.
Stopping the transfusion prevents further reaction, while vigorous hydration maintains blood pressure and protects the kidneys from acute tubular necrosis caused by free hemoglobin.

Key Concept

The classic presentation of an acute hemolytic transfusion reaction includes fever, flank pain, hemoglobinuria, and hypotension. The most critical first step in management is stopping the transfusion immediately and administering aggressive intravenous hydration.
Estimated Time:1m 0s
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Topics

Hematology and Oncology

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