58-year-old with back pain, dark urine, and hypotension
A 58-year-old woman with myelofibrosis is hospitalized for fatigue and exertional dyspnea with hemoglobin 6.4 g/dL. Twenty minutes into her first unit of packed red blood cells, she develops shaking chills, severe low back pain, nausea, and dark urine. Temperature is 38.7 C, blood pressure is 86/52 mm Hg, pulse is 118/min. Examination shows diffuse oozing from venipuncture sites. Which of the following is the most appropriate next step in management?
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Post-Call Recovery Reads
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A
Explanation
Clinical Pearl:
Fever, back pain, hypotension, hemoglobinuria, and bleeding during a transfusion point to acute hemolytic transfusion reaction, a medical emergency that requires immediate cessation of transfusion and blood bank evaluation. Severe cases can trigger DIC and acute kidney injury.
Explanation:
This patient has an acute hemolytic transfusion reaction, most often due to ABO incompatibility, suggested by rapid onset of fever, rigors, flank or back pain, hypotension, dark urine, and bleeding from venipuncture sites from secondary DIC. The immediate standard of care is to stop the transfusion at once, keep the IV line open with normal saline, notify the blood bank, and send the unit and fresh patient samples for repeat crossmatch and direct antiglobulin testing while treating shock, coagulopathy, and renal injury supportively. Slowing the transfusion with acetaminophen is appropriate for a mild febrile nonhemolytic reaction, which does not cause hemoglobinuria, hypotension, or DIC. Epinephrine is used for anaphylactic transfusion reactions, which present with wheezing, urticaria, or angioedema rather than dark urine and back pain. Furosemide would fit transfusion-associated circulatory overload, which causes hypertension, pulmonary edema, and elevated jugular venous pressure, not bleeding and hemolysis. Bacterial contamination can cause fever and shock, but the prominent hemoglobinuria, back pain, and oozing make hemolysis with DIC the uniquely best diagnosis and the transfusion must still be stopped and investigated immediately.
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