This patient is experiencing an acute hemolytic transfusion reaction. The key signs and symptoms are fever, flank pain, distress, reddish brown urine, and elevated lab values indicating hemolysis. To manage this medical emergency, the transfusion should be stopped immediately and IV fluids given to maintain urine output while further tests are run. Complications could include DIC or ARF if not treated promptly.

1. Namrata Dass

2. Objectives Early identification of common transfusion reaction To differentiate severe from benign transfusion reaction Management of transfusion

3. Introduction

4. Case scenario 2 A 35-year-old woman was hospitalized for anemia 2/2 sickle cell disease, she is receiving 2 units of PRBC. Her 1 st unit of blood was transfused without events but 5minutes into her 2 nd unit, She complains of new flank pain and fever. On exam she appears very anxious, diaphoretic and in acute distress, she is febrile to 38.8C with Bp 100/60mmHg, HR 101 bpm, 18cpm, Pox 98% 0n RA She has no skin rash but is oozing out of IV sites and her urine color is now reddish brown. Labs: elevated Bun/creat, increased PTT, PT and decreased HCT. What is the diagnosis and how would you manage this patient?

5. Hemolytic reaction Medical emergency Caused by preformed antibodies in recipient Intravascular hemolysis of transfused RBC Presentation : fever , chills, back pain, nausea, vomiting Management: -stop the transfusion -maintain urine output at 100ml/hr or greater with IV fluids or diuretics if necessary

6. Management -clotted samples of patients blood should be delivered to blood bank along with remainder of suspected unit for repeat of cross match -direct and indirect Coombs test -plasma and freshly voided urine should be examined for free Hb COMPLICATIONS: DIC,ARF secondary to ATN

7. Delayed Hemolytic Transfusion Reaction 3-10 days after transfusion Caused by primary or amnestic antibody response to specific RBC antigens on donor RBCs Positive Coombs test s/s: low grade fever, falling Hb, icterus, Management: -none in absence of rapid hemolysis -treat as acute hemolytic reaction if severe

8. Case scenario 1 A 35-year-old woman was hospitalized for anemia 2/2 sickle cell disease, she is receiving 2 units of PRBC. After her 1 st unit of blood she developed a temp of 38.3 °C (101.0°F). She has no other symptoms. On exam she appears anxious but her vital signs are stable with Bp 120/70mmHg, HR 80bpm 18cpm Pox 98% 0n RA She has no skin rash and her urine color is amber What are your differential diagnosis and how would you manage this pxt?

9. Non hemolytic febrile transfusion reaction Cause by cytokines released from white cells s/s: fever, chills Treatment: tylenol Decreased incidence from leukoreduced products

10. Allergic reactions Caused by plasma proteins that elicit an Ig E mediated response s/s: urticaria, hypotension, bronchospasm Treatment depends on the presentation. Mild urticaria treated with diphenhydramine. Severe anaphylaxis is an emergency, treated with epinephrine

12. Volume overload Presents with signs of overload especially in patients with cardiovascular compromise Treated by slowing the rate of transfusion and judicious use of diuretics

13. Transfusion related acute lung injury Occurs with 4hrs of transfusion Caused by anti human leukocyte antigen (HLA) or anti granulocyte antibody in the donor’s serum directed to recipient’s white blood cell s/s:dyspnea, hypotension , fever, chills, hypoxemia Management: -stop transfusion -report blood bank -Supportive: oxygen, PEEP

14. Criteria for TRALI Acute onset of lung injury Measured PA occlusion pressure ≤18 mm Hg or a lack of clinical evidence of left atrial hypertension (ie, no circulatory overload) Bilateral pulmonary infiltrates seen on frontal chest radiograph Hypoxemia: PaO2/FIO2 <300 mm Hg, or O2 saturation ≤90 percent on room air Within 6hrs of transfusion

16. Transfusion related graft versus host disease Caused due to infusion of immunocompetent T lymphocytes in immunocompromised pts s/s:rash,elevated liver function test, severe pancytopenia Irradiation of blood products prevents this.

17. Clinical Presentation Skin : Swollen, erythroderma and bullae formation- most common GI : Diarrhea and abdominal cramps Liver: Elevated LFT and Hyperbilirubinemia Heme : Bone marrow aplasia, persistent thrombocytopenia Skin manifestation of GVHD Generalized swelling, erythroderma and bullous formation