Record number:
1082
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
Case studies presented
Time to detection:
<6 hours
Alerting signals, symptoms, evidence of occurrence:
Two cases. First patient was transfused with 2 units of group B RBCs in AS-1. Shortly after completion of the second unit, she became acutely short of breath with erythema and hypotension. A chest X-ray showed bilateral pulmonary edema and O2 saturation was 67% on 3 L of O2. Second patient admitted for trauma and because of evidence of bleeding, a decision was made to transfuse 3 units of RBCs before extubation. The pretransfusion Hb was 6.9 g/dL. Three units of group B RBCs in AS-1 were transfused. Pulmonary function deteriorated rapidly after the third unit with bilateral pulmonary edema on chest X-ray and the plans to extubate were abandoned. The posttransfusion Hb was 8.3 g/dL.
Demonstration of imputability or root cause:
Both RBC units were stored in AS-1 and were from female donors who had anti-HLA Class II antibodies of high strength against cognate antigens in the recipients. Anti-DR4 was identified in both cases.
Keywords:
Suggest references:
Weber, L.L., Roberts, L.D. and Sweeney, J.D. (2014). Residual plasma in red blood cells and transfusion-related acute lung injury. Transfusion 54(10): 2425-30.