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?

[offlabel]

The blood bank will be able to tell you if this was a transfusion reaction or not with the battery of tests that they do on the banked unit and the patient's serum and urine. Beyond that, there is no way at all to tease out what happened to your patient in the setting of severe sepsis you describe.

Any hand wringing and regret has to wait for the blood bank's results. TRALI is far more rare than acute lung injury within sepsis, so ruling that in or out, in my mind is a pretty tall order. TRALI has been estimated to be more common in plasma containing transfusions (FFP, PLT) than PRBC's.

My money is on the sepsis.

[Susie2310]

I assumed from your post that you received the patient from another unit or the ER. Since the patient had severe sepsis (and GI bleeding), prior to your receiving them I am assuming they received IV fluid resuscitation with crystalloid fluids prior to your starting the blood transfusion? Is that what happened? How much fluids were given?

[Lev, MSN, RN, NP]

How fast were you giving the blood? This could have been volume overload and subsequent respiratory distress.

[Lev, MSN, RN, NP]

Or the patient aspirated.

[Lev, MSN, RN, NP]

Just be open to feedback and share your thoughts about what happened openly. These meetings are not punitive.

[Susie2310]

What IV antibiotics had the patient received?

[spacemonkey15]

It sounds more like this patient's deterioration was down to sepsis, you took relevant action each time you were concerned about changes in your patient and consulted a doctor, it sounds like appropriate decisions were made each time.

[Been there,done that, ASN, RN]

Is the physician going to be present in this "interview"? Because you kept him informed and HE called the shots. Thinking the interview is similar to a mortality and morbidity learning event.

The patient circled the drain, you did a great job. Now...THIS is huge.... I would want you to be my nurse.

Deep breaths, let us know how it went.

[canoehead, BSN, RN]

I was wondering how long you infused the unit over? If it was 3 hours or more, probably the last 15min worth of infusion didn't make a difference. If you were giving it faster, like over an hour, even with orders, I would suggest stopping the blood and seeing which way the patient was going would have been prudent. A 30 minute pause, with rapid deterioration, would make me want to stop the transfusion altogether. BUT I'm not saying you did anything wrong, you notified the MD, and got an order to continue. Please tell me that order is documented somewhere, to cover your butt.

[Wile E Coyote, ASN, RN]

To my knowledge, the only clear way to distinguish blood reaction vs. sepsis would be by further lab testing, like already mentioned.

I also think you handled that damn well, and encourage you to go into this meeting with confidence.

[CCU BSN RN]

I'm going to nix TRALI in favor of TACO! Patient probably came from ER or EMS at some point, so we can assume he got at least 2L of fluid boluses prior to arrival to you, factor in 2 units of blood along with volume from antibiotics and/or other meds and I'd put my money on significant volume overload. How did the CXR look? Probably not normal if he ended up intubated shortly thereafter. Did he get any lasix at any point? Have any known heart failure?

My take home for the next time this happens is that it's really easy to send a blood sample to the lab to check for a transfusion reaction, and if your patient is deteriorating, you're going to be sending a bunch of blood anyway, so you're not even adding an extra task. Just tell the doc "I know it's probably the Sepsis/etc. but can we send blood to check for a transfusion reaction just to cover our bases?". They'll usually be happy to do it, but they may not know how to put the order in.