Bored of Transfusions, Tacos, and 'TRALIs' - Review

eden2

You are in the middle of a busy shift where you just had enough time scarf down some tacos in between seeing patients of all sorts that seem to be bleeding, anemic, and requiring transfusions (when it rains, it pours, right?). You’ve started transfusions on 4 patients and then dash off to see new patients. Suddenly the nurse comes to you concerned:

She says that your first transfusion patient has a fever and she is just one hour into the transfusion. You go see the patient she looks excellent and is comfortable, with a new temp of 100.5. What should you do?

Febrile Non-Hemolytic transfusion Reaction – This is due to patient’s antibodies against donor leukocytes and cytokines in the blood product that are released during preparation.
Presents as low-grade fever without other significant vital sign changes; there may be myalgia, headache, and/or rigors.
Treatment: acetaminophen; continue transfusion if reaction is mild / patient is comfortable

What about a situation where the above patient becomes febrile but then also becomes hypotensive, coagulopathic, with severe back pain and hematuria?

Acute Hemolytic transfusion reaction – This is often due to ABO incompatibility. The immune reaction results in hemolysis leading to renal failure, DIC, shock, and organ failure. Mortality is high.
Work-up: Coombs test, renal function, coagulation status. Also send another type and screen and notify the bloodbank.
Treatment: Immediately stop transfusion and provide aggressive supportive care – intravenous fluids, vasopressor if needed; monitor urine output
Despite the need to stop this problematic transfusion, ensure the appropriate match with bloodbank. Many patients will now need transfusion even more given the hemolysis and DIC.

Just when you stabilize that last guy, you pass by your patient getting transfused for a vaginal bleed. She says she feels 'very itchy' and you notice diffuse uticaria. Vital signs are normal. What's the deal with this one?

Simple Allergic Reaction – This is due to an immune response to proteins in the transfusion. This is pretty common, occurring in 1-2% of all transfusions.
Give anti-histamines and stop the transfusion to evaluate, but after treatment, if no respiratory compromise you can restart it and monitor.
While simple allergic reactions are common and usually self-limited, patients can develop anaphylaxis from transfusions, including bronchospasm, angioedema, and anaphylactic shock.
Treat this as you would any anaphylaxis: epinephrine, anti-histamines, steroids, and supportive care.

The 66 year-old man getting transfused for diverticulosis becomes acutely short of breath. He is hypertensive, tachycardic, hypoxic, and dyspnic with diffuse rales. What's the reaction and what should you do?

TACO! Transfusion Associated Circulatory Overload

Presents like CHF exacerbation, which it is- too much volume, often in patients with history of CHF or severe chronic compensated anemia.
Treat like a pulmonary edema/volume overload – BiPAP, nitroglycerin, furosemide, etc.
Prevention: Transfuse slowly, as slow as 1mL/kg/hr, and give furosemide afterward if they are at risk of overload.

Just when you think you're out of the woods at the end of your bloody mess of a shift, your last transfusion patient becomes dyspneic and hypoxemic with diffuse rales and tachycardia. While you are now an expert at TACOs and think this looks similar, you notice she has a BP of 80/40... What complication is this and how will you handle it?

Transfusion-Related Acute Lung Injury (TRALI) – This likely is an immune-mediated reaction more often seen in platelet or FFP transfusions.
Presentation similar to ARDS/noncardiogenic pulmonary edema with bilateral pulmonary infiltrates on CXR. Be careful to distinguish this from TACO as the treatment is different- don’t give furosemide to these folks!
Treatment: Stop the transfusion and give supportive care

What is the key difference between Stevens Johnson Syndrome and Erythema Multiforme? What similarities do they share?

Speacial bonus question! Provide the correct answer in the comments and you’ll get the glory of photoshop fame on next week’s post. This week’s most excellent winner is Dr. Eden Kim – now a taco master!

References

Tintinalli’s Emergency Medicine, 7th Ed. Coil CJ, Santen SA. Chapter 233: transfusion therapy.

Hippo EM Board Review

Special thanks to Dr. Willis