Transfusion reactions and massive transfusion: Case

Immediate management of the reaction

The transfusion is stopped at once and the intravenous line is kept open with normal saline, the airway, the breathing and the circulation are checked, and oxygen is given. The identity of the child, the wristband and the unit label are checked against the paperwork at the bedside, and the blood bank confirmation that the unit was collected for another child of the same surname identifies the root cause as a clerical error, the commonest cause of the ABO mismatch. The unit, the giving set and fresh blood samples are returned to the blood bank with a report, blood is taken for a full blood count, a group and antibody screen, a coagulation screen, a direct antiglobulin test and urea and electrolytes, and the urine is dipped for haemoglobin. The boy is managed in a high-dependency or intensive care setting, because the intravascular haemolysis threatens the renal failure and the disseminated intravascular coagulation. [3][11]

The boy is resuscitated with generous intravenous fluids to maintain the urine output and the renal perfusion, the blood pressure is supported with fluids and vasopressors as the shock demands, and the coagulopathy is treated with blood components as guided by the coagulation tests. The direct antiglobulin test confirms that antibody or complement has coated the transfused red cells, the repeat group and antibody screen identifies the ABO mismatch, and the fall in haemoglobin with the rise in lactate dehydrogenase and bilirubin and the haemoglobinuria confirm the intravascular haemolysis. The mechanism is the binding of the preformed immunoglobulin M antibody to the transfused A or B antigen, the complement activation and the destruction of the red cells within the blood vessel. [3][4]

The TACO and TRALI distinction

If the boy becomes breathless after a later transfusion, the distinction of TACO from TRALI is made at the bedside from the volume history, the blood pressure and the jugular venous pressure. TACO presents with a raised jugular venous pressure, hypertension and bilateral crackles in a child given blood rapidly or in large volume, and it is treated by stopping the transfusion, oxygen and a loop diuretic such as furosemide. TRALI presents with hypoxaemia and bilateral infiltrates but no overload, often with a low blood pressure, after a plasma-rich product from a donor with anti-leucocyte antibodies, and it is treated by stopping the transfusion and respiratory support and no diuretic. The candidate who states that a diuretic helps the TACO child and harms the TRALI child has the heart of the distinction. [5][4]

The massive transfusion protocol for the trauma child

A separate shocked, bleeding child in the emergency department needs the massive transfusion protocol activated without delay. Red cells, fresh frozen plasma and platelets are delivered in a balanced ratio that approaches one unit of red cells to one unit of plasma to one pool of platelets, so that the dilutional coagulopathy is prevented as the bleeding is controlled. Tranexamic acid is given early, within the first three hours of injury, and the blood is warmed throughout to prevent the hypothermia that impairs the coagulation and the platelet function. The child is monitored for the hypocalcaemia of citrate toxicity, with the ionised calcium checked and replaced, and for the hyperkalaemia of the stored unit, with the freshest unit chosen for the large transfusion. The protocol is run with the laboratory, the transfusion service and the surgical and critical care teams, and the child is kept warm, coagulopathy-free and perfused through the control of the haemorrhage. [9][11]