Suspected acute haemolytic transfusion reaction after a wrong-unit issue
At 14:20, a 34-year-old woman with postpartum haemorrhage is receiving her second unit of packed red cells. Her blood group is A RhD positive; the unit label also says A RhD positive. Ten minutes into the transfusion she complains of chills, lower back pain and nausea. Temperature rises from 37.0 to 38.9°C, heart rate 118/min, blood pressure falls from 110/70 to 88/50 mmHg, and her urine in the catheter bag is dark red. The transfusion is stopped after 50 mL. The nurse asks the laboratory technician whether this is a mild febrile reaction and whether the remaining unit can be restarted after paracetamol. The laboratory has no blood bank physician on site. What immediate actions, laboratory investigations and reporting steps are required?
1. Classify the reaction and list the immediate bedside and laboratory actions. Which findings point away from a simple febrile non-haemolytic reaction?
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Classification. Fever, chills, back pain, hypotension and dark urine 10 minutes into a transfusion strongly suggest an acute haemolytic transfusion reaction, most likely ABO incompatibility from a wrong unit or wrong patient identification. A simple febrile non-haemolytic reaction does not usually cause hypotension, back pain or haemoglobinuria.
Immediate actions. Stop the transfusion at once and keep the IV line open with crystalloid. Call the clinician, check the patient's identity and the unit label against the wristband, and check vital signs. Send the bag and tubing, the unused unit, post-transfusion EDTA and clotted samples, and the first urine sample to the laboratory. Perform DAT, repeat ABO/Rh, antibody screen and crossmatch, and inspect plasma for haemolysis. Consider blood cultures if bacterial contamination is possible. Do not restart the unit.
2. The unit was issued for another patient with the same surname and the bedside identity check was signed by a nurse who did not compare the wristband. What root causes and corrective actions should be documented, and what should be reported to the national haemovigilance system?
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Root cause. The wrong unit was issued for another patient with the same surname, and the bedside check was signed without comparing the wristband. This is a patient-identification failure at collection, issue and administration, not a single person's mistake.
Corrective action. Document a serious adverse event and start a root-cause analysis. Review the request form, sample labelling, blood-bank issue, transport and bedside check. Require two-patient identifiers, label tubes at the bedside, and use a two-person bedside check with a signed record. Retrain staff, audit compliance, and consider colour-coded wristbands or barcode scanning. Report to the national haemovigilance system within the required timeframe. Perform look-back for the other patient and trace the unit. The aim is system change, not blame.
3. The patient's repeat Hb is 5.9 g/dL, platelet count 78 ×10^9/L, INR 1.6, fibrinogen 1.1 g/L, and she is still bleeding. How should transfusion support be prioritized while the reaction investigation continues?
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Priority. The patient is still bleeding with Hb 5.9 g/dL, platelets 78 ×10^9/L, INR 1.6 and fibrinogen 1.1 g/L. She needs urgent resuscitation and blood products, but the reaction investigation must continue in parallel. Use crystalloid while awaiting crossmatch; if she is unstable, use group-specific A RhD-positive units or O RhD-negative units according to the emergency-release protocol, with senior clinician authorization. Give FFP for coagulopathy and cryoprecipitate or fibrinogen concentrate to raise fibrinogen, and platelets if count falls below 50 ×10^9/L with ongoing bleeding. Avoid restarting the implicated unit. Recheck Hb, coagulation, fibrinogen, calcium and urine output. Document every product and inform the blood bank so that compatible units are prioritized.