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Difficulty: MediumHematology and Oncology

A 45-year-old woman is receiving a transfusion of packed red blood cells for severe anemia secondary to abnormal uterine bleeding. Thirty minutes into the transfusion, she develops sudden-onset chills, severe flank pain, and dyspnea. Her temperature is 39.2°C (102.6°F), blood pressure is 85/50 mm Hg, and heart rate is 120/min. Arrange the following management steps in the most appropriate chronological sequence.

  1. 1Stop the transfusion of packed red blood cells immediately.
  2. 2Initiate aggressive intravenous hydration with normal saline.
  3. 3Send the remaining donor blood unit and a new patient blood sample to the blood bank.
  4. 4Monitor coagulation studies and renal function for disseminated intravascular coagulation (DIC).

Answer

The correct sequence of management is: 1) Stop the transfusion immediately, 2) Initiate aggressive intravenous hydration, 3) Send samples and the blood unit to the blood bank, and 4) Monitor for systemic complications such as DIC.
This patient's presentation of sudden-onset fever, chills, flank pain, and hemodynamic instability shortly after beginning a blood transfusion is classic for an acute hemolytic transfusion reaction (AHTR), most commonly caused by ABO incompatibility due to a clerical error. The sequence of management prioritizes immediate cessation of harm, followed by physiological resuscitation, diagnostic confirmation, and finally, surveillance for downstream complications. Therefore, the transfusion must be stopped immediately. Next, aggressive intravenous fluid resuscitation with normal saline is paramount to manage shock and maintain brisk urine output, which prevents free hemoglobin from precipitating in the renal tubules and causing acute tubular necrosis. Only after the patient is hemodynamically supported should the provider focus on diagnostic steps, which include sending the remaining blood product and a new patient blood sample to the blood bank for a direct antiglobulin test (Coombs test) and repeat crossmatching. Finally, the patient must be continually monitored over the coming hours for the development of severe complications associated with AHTR, specifically acute kidney injury (AKI) and disseminated intravascular coagulation (DIC).

Step-by-Step Solution

1
Recognize the signs of an acute hemolytic transfusion reaction (fever, flank pain, hypotension) and immediately stop the transfusion.
Halts further administration of incompatible red blood cells.
To minimize the ongoing immune response and limit the severity of intravascular hemolysis.
2
Administer aggressive intravenous normal saline.
Restores intravascular volume and promotes brisk diuresis.
To correct hypotensive shock and flush the kidneys, preventing hemoglobin precipitation and acute tubular necrosis.
3
Send the remaining blood bag and a new patient blood sample to the blood bank.
Allows the laboratory to perform a direct antiglobulin test (DAT) and repeat crossmatching.
To definitively confirm the diagnosis of an immune-mediated acute hemolytic reaction, which is most often caused by a clerical error resulting in ABO incompatibility.
4
Monitor serial coagulation parameters and renal function.
Detects the onset of disseminated intravascular coagulation (DIC) or progressive acute kidney injury (AKI).
Massive release of red blood cell contents, including tissue factor-like substances, frequently triggers DIC, requiring ongoing surveillance after initial stabilization.

Key Concept

Management of Acute Hemolytic Transfusion Reaction (AHTR)
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Topics

Hematology and Oncology

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