Case discussion

CASE 1
Patient A is a 60-year-old woman who is RBC transfusiondependent. She receives 2 units of RBCs without any problems. Later that evening, she notes feeling tired and passes cola coloured urine. Her temperature is 1010 F. Her investigation results are as follows: Pre- transfusion serum Post- transfusion serum Pre and post DAT (direct antiglobulin or Coomb test) Pre- transfusion urine Post- transfusion urine Bilirubin Total Direct : negative : normal : Hb + : 3.9 mg/dl : 0.5 mg/dl : normal : orange

You are on duty. How would you work up this patients problem?

CASE 2
KMC Hospital receives patient B a young man with polytrauma. He is taken to the OT to repair vascular damage, and receives only crystalloids for fluid support. Subsequently, a unit of RBCs is started, when he develops sudden wheezing, gasping, clutches at his throat and turns blue.

The anaesthesiologist makes a diagnosis of anaphylaxis, starts

epinephrine I.M. and intubates the patient. A second unit of RBCs is transfused, and now the patient goes into shock with no detectable blood pressure.

How would you approach this case?

CASE 3
Patient C is a 60-year-old man with adenocarcinoma stomach. He is transfused 3 units of RBCs pre-operatively. At the end of the second unit, he has dyspnoea, diaphoresis and chest pain. He is intubated and transferred to the ICU. His pulse rate is 120/mt, blood pressure is 180/110. CXR shows bilateral pulmonary oedema. What is your diagnosis? How would you manage this case?

CASE 4
Patient D, a Brigadier in the Indian Army, was admitted for a coronary by-pass. Post-operatively, he was transfused 9 units of packed cells, 6 units fresh frozen plasma and 54 units of platelets. His blood group was AB POSITIVE. His platelet donors were from his old regiment. During transfusion, he developed chills, dyspnoea, flank pain, hypotension and tachycardia, his urine output decreased with pink-red urine. The staff nurse calls you and wants to know what to do.

CASE 5
Patient E is a 64-year-old woman who underwent a hysterectomy 2 weeks ago. During the surgery she received 2 units of RBCs. Her post-op course was uncomplicated and she was discharged five days later.

Two weeks after the surgery, she complains of fever, nausea, vomiting and abdominal pain. She is jaundiced, and has a diffuse erythematous rash. Her laboratory results are as follows:

Hb Total bilirubin Direct AST ALT LDH Hepatitis B, C

: 8 g/dl : 6.3 mg/dl : 5.6 mg/dl : 1200 U/L : 3200 U/L : 4300 U/L : negative

The patient develops diarrhoea, coagulopathy, acute renal failure requiring dialysis, worsening pancytopenia and despite aggressive medical management, she dies 4 days later.

What is your diagnosis? How would you prevent the development of this transfusion reaction?