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Acute Hemolytic Reactions
Acute Hemolytic Reactions
Ask a patient who is about to get a transfusion what he is most afraid of and it's probably safe to say that most would mention something along the lines of "getting AIDS" or maybe even "getting hepatitis". Ask the clinician taking care of the patient the same question and your answer might be similar. Ask the Blood Bank physician responsible for the transfusion what he is afraid of, though, and you would get a list as long as your arm, probably topped off by an Acute Hemolytic Transfusion Reaction. (In case you hadn't noticed already, we Blood Bankers spend a lot of time worrying!)
Over the last ten to twenty years, we've gotten much better at preventing transfusion-transmitted infections (through new tests and better donor screening), developed better and more sensitive antibody detection techniques (gel testing, solid phase testing), even seen the impossible happen (hockey teams in Phoenix and Dallas, for crying out loud!), but we haven't done so great (in my opinion) at preventing acute hemolytic transfusion reactions. HTRs account for the vast majority of transfusion-related fatalities, and the sad part is that most of them are entirely preventable! According to a 1997 paper by DeChristopher and Anderson (AJCP 1997;107(Suppl1):S2-S11), acute hemolysis from ABO incompatibility occurs in 1 to 6,000 to 1 in 33,000 transfusions, and is fatal in about 1 in 500,000. Granted, some of these can't be reasonably prevented, and that number does represent improvement over the 1 in 200,000 transfusion risk reported in 1990 by Sazama, but we should not be satisfied.
Etiology
Unfortunately, the majority of Acute HTRs are explained by one very simple and blunt sentence: Someone screwed up! It is really a sad reality that even today, in 1999, the way that we harm folks the most in transfusion is through someone making a silly mistake. Before you start clucking your tongue at the nurses, by the way, you should know that about 1/3 of these mistakes occur in the Blood Bank, according to the classic study by Sazama summarizing transfusion-related deaths reported to the FDA (TRANSFUSION 1990;30:583-590).
What kind of mistakes am I referring to? You name it. Anything from mixing up specimen labels to incorrectly labeled samples to issuing the wrong unit for the wrong patient to transfusing the right unit to the wrong patient can potentially give you hemolysis, most commonly due to an ABO mismatch. Statistically, the most common place where the process breaks down is at the point of actual administration (57%, according to the above study).
Lest we be incomplete, I should remind you that things other than identification or administration error and ABO mismatch can cause acute HTRs. Other blood group incompatibilities (most notably with Rh antibodies like D, E, and c, and Kell antibodies), faulty blood warmers, infusing blood with a hypotonic solution like 0.45% normal saline, and a variety of other mechanical problems can potentially cause acute hemolysis. Fortunately, though, the "other" methods of acute hemolysis usually do not have the devastating consequences typical of an ABO mismatch.
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Mr. Jan B. Wade
Blood Management Consultant
Enhance Outcomes - Control Cost
For Information Call - 360 296-1807
Email
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