Transfusion reaction-textbook? You tell me

[Momto3RN, RN]

Had a male pt in his 70's with peritonitis s/p lap chole. Alert, oriented but stoic, the type that will never tell you if he's uncomfortable.

So his crit was 20 and I got the anticipated order for PRBCS, two units. The doc wanted each unit infused over an hour and a half. That would mean around 200cc/hr. I wasn't terribly comfortable with that so I started out at 100cc/hr. Fortunately, there was no hx of cardiac/renal problems. (I typically start at 75 then increase if no complications.) VS were fine before the tx and a half hour into it. By then I had bumped up to 125cc/hr and since I was getting behind on time, I bumped it to 140cc/hr about two hours into the infusion, to be somewhat compliant with what the doc had ordered.

He did say he was cold just after I had started it but temp was fine and he didn't have any aches/pain. He thought it was from just having been exposed while being cleaned up. Still, the little bell went off in my head but I thought, I 'll just watch him. Well, two and a half hours after the blood started, he spiked a temp of 39.2 (101.2F) and a BP of 180/64. I checked on him (as I had frequently) and he was shivering!!! Still denied any pain/aches. I stopped the infusion though the bag was pretty much empty.

This is where I second guess myself, which I do frequently!! Should I have stopped the infusion when he said he was cold despite normal VSS? Why would his temp go so high so late into the infusion and was it the blood or the occasional spike r/t his diagnosis, which had happened the previous shift?

I'm assuming his bp jumped d/t to the increased rate. But with a crit of 20, he really needed the blood!!! Our docs don't typically premedicate with Tyl and Benadryl but maybe I should suggest that in the future!!

This was the first reaction I've seen. Sometimes I feel I'm a better nurse in the classroom vs. the unit!!!!

I appreciate your input!!:imbar

[Virgo_RN, BSN, RN]

If his VS were stable, I wouldn't have stopped the infusion just then either. I'd probably have gotten him a warm blanket and simply monitored until I some something concrete telling me to stop the blood, which is what you did.

[iluvivt, BSN, RN]

PT had classic s/sx of non-hemolytic febrile reaction. This is caused by pts Human Leukocyte antigens reacting with pts antibodies. You will see pt c/o chills,fever greater than 1 degree C or more HA,n/v,CP,malaise, non-productive cough and sometimes rigors. All thses symptoms are self-limiting. Nursing interventions include to stop transfusion keep NS going at KVO,Notify MD.monitoe VS,ask MD for tylenol,benadrl,zantac. You no not need to send the blood back to the blood bank and can even resume the infusion slowly and increase monitoring. The best thing to do is to usr leukocyte-reduced cells next time. Some hospitals only dispense leukocyte-reduced cels. You can also do this at the bedside by adding a special filter at the hang time. Find out what your hospital does so you know how to monitor future transfusions. I would have done the same thing you did b/c the pt only initailly presented with feelin cold. Pts often complain of this with cold blood anyway,especially during the first part of the infusion. Once the fever kicks, in you pretty much know that it is this type of reaction. This reaction is common in pts with a hx of multiple transfusions,multiple pregnancies and those with high HLA antibody titers. Good for you for advancing your knowledge base and I hope this explains it better. Mary

[Momto3RN, RN]

Thanks for the replies!!

[vampiregirl, BSN, RN]

More blood banks are going to leukoreduced blood products, due to the increased likelyhood of reactions. As far as I know, the FDA is encouraging and supporting leukoreduced products, but there is not any regulations as of yet.

The most common reaction attributed to non-leukoreduced blood is the febrile reaction, but in some cases TRALI (transfusion related acute lung injury) reactions have also been due to the luekocytes in the tranfused blood reacting with the anti-HLA antibodies in the recipients plasma.

[iluvivt, BSN, RN]

Sorry about my typos,it was late at noc when I responed. Our hospital infuses only leukocyte-reduced cells. Nurses should know what their hospital blood bank is dispensing so when the patient does have a reaction they can exclude one relating to HLA.