Acute Pain Transfusion Reaction
A 34-year-old woman with a diagnosis of hemophagocytic lymphohistocytosis (HLH) received a double umbilical cord blood transplantation following a myeloablative chemotherapy preparative regimen with busulfan and cyclophosphamide. HLH is a rare, potentially fatal hematologic disorder characterized by the overactivation of histocytes and T lymphocytes, leading to organ infiltration and acute illness. On day 25 post-transplantation, the patient required a platelet transfusion for a platelet count of 6,000 per ml (normal range = 150,000–450,000 per ml). The patient's blood type prior to the cord blood transplantation was B positive and, although both umbilical cord blood donors were O positive, the patient was still B positive per blood bank testing on that day. Although the recipient of an allogenic stem cell transplantation will eventually become the blood type of the donor, the time for this process to occur varies for each person. That process must be monitored by the blood bank for the purpose of cross-matching blood products to decrease hemolysis as much as possible. The patient was premedicated with the facility's standard for platelet transfusions: acetaminophen 650 mg and diphenhydramine 25 mg about 30 minutes prior to the platelet transfusion.
Baseline vital signs were heart rate, 108 bpm; blood pressure, 135/96; temperature, 97.2°F; respirations, 12; and O2 saturation, 98%. The unit and patient identification was confirmed by a second RN for accuracy. The platelet transfusion was given through the patient's Port-a-Cath® via y-type, leukopoor-filtered tubing primed with 0.9% normal saline. An apheresed, leukocyte-reduced, cytomegalovirus (CMV)-negative, O-positive unit was transfused. Vital signs remained unremarkable throughout the 15-minute infusion. The patient was talkative and showed no visible signs or symptoms of a transfusion reaction.
About five minutes after transfusion completion, the patient called staff into her room and was visibly distressed, reporting excruciating pain in all of her joints, particularly the large joints of the hips and lower back. Erythema was noted in the face and neck. Vital signs were taken with blood pressure, 163/106; heart rate, 131 bpm; temperature, 97.9°F; and O2 saturation, 97%. Blood pressure and heart rate remained consistently elevated during this 15-minute post-transfusion reaction and the patient remained afebrile. Meperidine 75 mg was given via IV push as well as a 1 mg IV bolus of hydromorphone. The patient was already receiving hydromorphone through a patient-controlled analgesia pump for severe mucositis at the time of the event. After about 15 minutes, the patient's vital signs returned to baseline and the severe, acute pain episode subsided, with complete resolution of lingering joint pain after several more hours. A complete post-transfusion analysis was conducted per hospital policy, beginning with bedside confirmation of correct product and patient identification. Blood samples and urine specimens were obtained. A direct antiglobulin test (DAT) also was performed showing 2+ reactivity. A positive DAT indicates that some degree of hemolysis of red blood cells has occurred and is measured on a range of minimally reactive to 4+ reactivity.
Introduction
A 34-year-old woman with a diagnosis of hemophagocytic lymphohistocytosis (HLH) received a double umbilical cord blood transplantation following a myeloablative chemotherapy preparative regimen with busulfan and cyclophosphamide. HLH is a rare, potentially fatal hematologic disorder characterized by the overactivation of histocytes and T lymphocytes, leading to organ infiltration and acute illness. On day 25 post-transplantation, the patient required a platelet transfusion for a platelet count of 6,000 per ml (normal range = 150,000–450,000 per ml). The patient's blood type prior to the cord blood transplantation was B positive and, although both umbilical cord blood donors were O positive, the patient was still B positive per blood bank testing on that day. Although the recipient of an allogenic stem cell transplantation will eventually become the blood type of the donor, the time for this process to occur varies for each person. That process must be monitored by the blood bank for the purpose of cross-matching blood products to decrease hemolysis as much as possible. The patient was premedicated with the facility's standard for platelet transfusions: acetaminophen 650 mg and diphenhydramine 25 mg about 30 minutes prior to the platelet transfusion.
Baseline vital signs were heart rate, 108 bpm; blood pressure, 135/96; temperature, 97.2°F; respirations, 12; and O2 saturation, 98%. The unit and patient identification was confirmed by a second RN for accuracy. The platelet transfusion was given through the patient's Port-a-Cath® via y-type, leukopoor-filtered tubing primed with 0.9% normal saline. An apheresed, leukocyte-reduced, cytomegalovirus (CMV)-negative, O-positive unit was transfused. Vital signs remained unremarkable throughout the 15-minute infusion. The patient was talkative and showed no visible signs or symptoms of a transfusion reaction.
About five minutes after transfusion completion, the patient called staff into her room and was visibly distressed, reporting excruciating pain in all of her joints, particularly the large joints of the hips and lower back. Erythema was noted in the face and neck. Vital signs were taken with blood pressure, 163/106; heart rate, 131 bpm; temperature, 97.9°F; and O2 saturation, 97%. Blood pressure and heart rate remained consistently elevated during this 15-minute post-transfusion reaction and the patient remained afebrile. Meperidine 75 mg was given via IV push as well as a 1 mg IV bolus of hydromorphone. The patient was already receiving hydromorphone through a patient-controlled analgesia pump for severe mucositis at the time of the event. After about 15 minutes, the patient's vital signs returned to baseline and the severe, acute pain episode subsided, with complete resolution of lingering joint pain after several more hours. A complete post-transfusion analysis was conducted per hospital policy, beginning with bedside confirmation of correct product and patient identification. Blood samples and urine specimens were obtained. A direct antiglobulin test (DAT) also was performed showing 2+ reactivity. A positive DAT indicates that some degree of hemolysis of red blood cells has occurred and is measured on a range of minimally reactive to 4+ reactivity.