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Difficulty: EasyHematology and Oncology

A 52-year-old man is recovering on the surgical ward following an extensive bowel resection for ischemic colitis. On postoperative day 2, his hemoglobin is found to be 6.5 g/dL, and a transfusion of packed red blood cells is initiated. Approximately 25 minutes after the transfusion begins, the patient suddenly develops severe chills, a temperature of 39.2°C (102.6°F), and worsening right flank pain. His blood pressure drops to 90/60 mm Hg, and his heart rate increases to 118/min. A Foley catheter placed in the operating room now drains dark, reddish-brown urine. Which of the following is the most appropriate initial step in management?

  1. Stop the transfusion and begin vigorous intravenous hydration with normal salineAnswer
  2. B
    Administer acetaminophen and continue the transfusion, as this is typical postoperative atelectasis
  3. C
    Administer empiric broad-spectrum intravenous antibiotics for presumed hospital-acquired infection
  4. D
    Transfer the patient immediately to radiology for a computed tomography scan of the abdomen
  5. E
    Obtain an arterial blood gas to calculate the expected respiratory compensation

Answer

The most appropriate initial step is to immediately stop the transfusion and initiate vigorous intravenous hydration with normal saline.
The patient's presentation of fever, chills, flank pain, hypotension, and dark urine (hemoglobinuria) occurring within minutes of starting a packed red blood cell transfusion is the classic presentation of an acute hemolytic transfusion reaction (AHTR). AHTR is a medical emergency usually caused by ABO incompatibility resulting from a clerical error. The very first and most crucial step in management is to stop the transfusion immediately to limit the amount of incompatible blood entering the patient's circulation. Following this, the administration of vigorous intravenous normal saline is critical to maintain urine output and prevent acute tubular necrosis from the toxic effects of free hemoglobin on the kidneys.

Step-by-Step Solution

1
Recognize the clinical presentation of an acute hemolytic transfusion reaction (AHTR).
The combination of rapid-onset fever, flank pain, hypotension, and hemoglobinuria shortly after starting a blood transfusion confirms suspected AHTR, typically due to ABO incompatibility.
Identifying the etiology of sudden clinical deterioration during a transfusion dictates the immediate response.
2
Determine the most critical immediate intervention for AHTR.
The transfusion must be stopped immediately, and intravenous fluids must be administered.
Stopping the transfusion prevents further administration of incompatible blood, while aggressive normal saline hydration minimizes the risk of acute kidney injury from hemoglobin-induced tubular necrosis.

Key Concept

The initial management of an acute hemolytic transfusion reaction requires immediately stopping the transfusion and providing aggressive intravenous fluid resuscitation to prevent acute kidney injury.
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Topics

Hematology and Oncology

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