Was this a blood transfusion reaction?

[blahblahblah172]

Long post, bear with me, I would really appreciate some input..

I just received an email from my work asking for an interview regarding a safety event I was involved in recently, after thinking what it could be about specifically, I'm wondering if it was transfusion related... I have not yet had the interview...

My patient came up with an H&H of 6.1&something (GI bleed), and severe sepsis. He was hypotensive to begin with (90's/60's) with a HR 90's-100's sinus tach. I gave him one unit of blood w/o complications. Gave second unit of blood, pt began to feel mildly SOB, (blood almost done, like maybe 50mls left). Spo2 still high 90's on 3L NC, HR increased to low 100's to 110's. PT also became chilled/shivering, remained afebrile. The MD was notified and he and I both agreed that the severe sepsis was the cause of these symptoms rather than a transfusion reaction as the second unit was basically finished (by the time I was off the phone it was already done, so stopping it really wouldn't have made much difference?) I told him "in any other situation I would turn the transfusion off, but..." He was like "no, no, no just let it finish, this is just the sepsis..."

The line has flushed, pt continues to become more SOB, and more tachycardic, up to 130's -140's, BP remained stable, remained afebrile. Also increased RR. I notified the MD again with an update, he says "just give him time." I really felt at this point like something was going on, I'm thinking 'give him time to what, get worse??' Anyway I at least get an ABG order out of the conversation. The pt continues to deteriorate, requiring 8L oxymask now to maintain SPo2 >90%. I called the MD again, basically said you need to come up here and assess him. He, does, stat CXR and ABG obtained. (by the way, lung sounds remained clear per myself and MD's auscultation) Long story short within 25min of the MD coming to the floor the pt progressed to an spo2 of 80% despite being on a NRB at 15L, and the patient was intubated. Criticore cath showed core temp of 105 (not even 30 min ago he had been afebrile per oral temp reading.)

Now, at the time, sepsis induced ARDS seemed the most likely scenario, especially when we've seen that before many times. Not only was this the MD's thinking, but it was mine as well. thinking back, should I have stopped the transfusion? If it was a reaction, would it have made a difference as it was already almost all transfused? I suppose to not turn it off was per MD orders and nursing judgment, I really didn't feel it was necessary at the time...

Having this interview for the 'safety event' has prompted me to think that maybe this is a follow up on the blood transfusion. Everything I have ever been told about blood transfusion reactions is that reactions will mostly happen in the first 15 minutes. Well based on some research I've done since the event, this pt could have had TRALI (transfusion reaction associated lung injury), which can happen during or 6 hours after the transfusion. He fits the profile for sepsis induced ARDS, and for TRALI. Why have I never heard about this? I literally have always thought that after the first 15 minutes your pretty much golden, But it seems this really only applies to a hemolytic reaction.

Anyway I sort of have that sick feeling now with this interview coming up and hoping I did all the right things. If nothing else it's a learning opportunity.

What are your thoughts? Have you had anything like this happen before?

[BonnieSc]

It does sound like a possible transfusion-related event--it's certainly worth the hospital looking into it. My hospital did a big transfusion education push a few years ago after a couple of different incidents. It was pretty clear, as we discussed the education amongst ourselves, that the vast majority of us who had not been involved in such an incident had been lucky, rather than knowledgeable and effective. We had all gotten somewhat complacent after giving many transfusions without incident, and most of us didn't remember learning some of these details about transfusions in the first place. There were cases where vital signs were either skipped or were done, were "off", and were not reported--okay, that's poor practice. But there was a lot that we just didn't know (including TRALI, as you mention).

While probably policy would say to stop the infusion, practically you're probably right that by that time it wouldn't have affected the outcome one way or another. I have a couple of times had doctors want me to keep the infusion running and I've said simply that I can't, according to policy. (We have a great team in our transfusion services that I rely on for advice more than I do the patients' physicians.)

My one question is: do you have a rapid response team at your hospital? I know not everywhere does, and at one hospital where I worked it was basically the same as calling a code; you wouldn't call it until circumstances were dire. In your story I probably would have called the team at the point where HR increased to 130 and RR increased as well. It's rare that we put anyone on a mask without calling for rapid response. But maybe you don't have those resources.

Good luck with the interview. Answer the questions simply, and avoid being defensive (which I think you have done a good job of here). If they ask you why you didn't stop the transfusion, explain your line of reasoning. You might want to look up your hospital's transfusion policy for a refresher before you go--if it's like mine, you might say something about how at the time your reasoning was____, though now you realize the policy says _____. I think that and whether you should have called for more backup are the main things they might question you about.

[blahblahblah172]

Thank you for your great response!

We are able to call a Rapid Response, however I work at a small rural hospital, our Acute care unit being only 9 beds. There is one RT and one hospitalist on at night, so me, the other 1 or 2 nurses on the floor, and the RT and MD are basically the "RRT". I think we tend to do a lot more interventions here prior to calling a RR that at other places just due to resources. However I imagine if I couldn't have gotten the MD to the floor when I asked I would have called one, just to force some help up there

Thank you for your advice!