CASE STUDY 1 A 45-year old white man was admitted to the hospital with gastrointestinal bleeding from recurrent peptic ulcer disease. The patient had been transfused 4 months earlier for the same symptoms. His hemoglobin upon admission was 7.0 gm/dl. Four units of blood were ordered and crossmatched, were found to be compatible, and were transfused.

CASE STUDY 1 Five days after the transfusion the patient appeared pale and mildly jaundiced, and had a fever of  F (39  C). A CBC and blood cultures were ordered by the physician. The patient’s 5-day posttransfusion hemoglobin was 5.0 g/dl and hematocrit was 15%.

CASE STUDY 1 Spherocytes were present on the peripheral blood smear. Because of the low hemoglobin, the physician ordered 2 units of blood. Five days after the transfusion 2 more units of blood were crossmatched and found to be incompatible.

CASE STUDY 1 The antibody screen was positive at this time. Five days previously the antibody screen test result had been negative. No clerical errors were revealed.

CASE STUDY 1 Repeat ABO and Rh typing on pretransfusion and posttransfusion reaction specimens confirmed original results. Repeat crossmatch test on pretransfusion and posttransfusion patient specimens with donor units revealed no incompatibility.

CASE STUDY 1 The pretransfusion DAT result was negative, but the posttransfusion DAT result was positive owing to IgG sensitization. Panels completed on the patient’s serum and eluate revealed the following antibody identification: Serum: Anti-Jka by enzyme technique Eluate: Anti-Jka by enzyme technique

CASE STUDY 1 Results of the patient’s blood culture, Gram stain, and culture of the donor unit were all negative.

What is the diagnosis? A.Acute hemolytic reaction B.Allergic reaction C.Alloimmunization D.Delayed hemoytic reaction E.Febrile nonhemolytic reaction

CASE STUDY 2 A 55 –year old man was hospitalized to have abdominal surgery for carcinoma. The patient had no previous history of transfusion.

CASE STUDY 2 The patient’s admission hemoglobin was 10.0 g/dl. Two units of RBCs were ordered for the surgery. The patient was group O positive.

CASE STUDY 2 The antibody screen result was negative. Two units of RBCs were crossmatched and found compatible.

CASE STUDY 2 During surgery, following receipt of the first unit of RBCs, the patient experienced oozing at the surgical site. The patient’s blood pressure fell from a pretransfusion level of 120/70 mm Hg to 80/40 mm Hg after the transfusion.

CASE STUDY 2 The transfusion was immediately stopped, and the hypotension treated. A new blood sample was sent to the blood bank requesting four more units of RBCs immediately.

CASE STUDY 2 Repeat grouping of the patient’s pretransfusion blood specimen confirmed the blood group as originally designated O positive.

CASE STUDY 2 The posttransfusion specimen revealed mixed-field agglutination when tested with anti-A and anti-B antisera.

CASE STUDY 2 Clerical checks were performed both in the blood bank and in the operating room. Upon completion of the clerical checks, it was determined that the surgical nurse had selected the wrong unit of blood for this patient.

CASE STUDY 2 Two patients were undergoing surgery who had similar names. The unit had been selected from the operating room refrigerator by name only, and had not been checked to include hospital identification number prior to transfusion.

CASE STUDY 2 It was additionally determined that two people had not checked the unit before transfusion, as the hospital policy required. Investigation eliminated that any other patient was at risk for a similar incident at that time. The unit inadvertently transfused was determined to be group A positive.

CASE STUDY 2 The postreaction DAT result was negative indicating rapid destruction of the incompatible transfused RBCs. The pretransfusion and posttransfusion antibody screen test results were negative.

CASE STUDY 2 The crossmatch on the pretransfusion specimens with the original group O donor unit revealed no incompatibility. Hemoglobinemia and hemoglobinuria was present with free hemoglobin demonstrated in the first posttransfusion urine specimen.

CASE STUDY 2 The patient developed a hemorrhagic coagulopathy with afibrinogenemia. The patient’s platelets became decreased with a concomitant increase in fibrin- fibrinogen degradation products.

CASE STUDY 2 Shortly thereafter the patient became anuric, producing only 50 ml of urine in 12 hours. The patient’s condition deteriorated despite attempts to control the hemorrhagic process. Autopsy findings 4 days posttransfusion revealed hemoglobin casts in the renal tubules of the patient’s kidneys.

What is the diagnosis? A.Acute hemolytic reaction B.Allergic reaction C.Alloimmunization D.Delayed hemoytic reaction E.Febrile nonhemolytic reaction

Case Study 3 A 45- year old woman was admitted to the hospital for a hysterectomy. The patient had been pregnant four times previously with no history of transfusions. She was taking no medications.

Case Study 3 The patient’s admission CBC revealed low hemoglobin of 8.0 g/dl. The physician ordered a unit of RBCs to be given before surgery to correct her anemia in time for an elective hysterectomy.

Case Study 3 A unit of group O Rh-positive RBCs was crossmatched and found compatible. The patient’s antibody screen test result was negative.

Case Study 3 A transfusion of group O Rh-positive compatible RBCs was begun at 1:45 pm and given through a standard 170  m blood infusion set. After receiving approximately half of the RBCs, the patient experienced chills and had a temperature elevation to 103  F from a pretransfusion temperature of 99  F (39.4  C) She had a severe headache, felt anxious and uncomfortable. The blood transfusion was stopped and the patient’s physician notified. A transfusion reaction investigation was initiated.

Case Study 3 No clerical mistakes or omissions were detected. Donor and patient identification was verified.

Case Study 3 Examination of the patient’s pretransfusion and posttransfusion blood and urine specimens revealed no visible hemolysis. The DAT result on the posttransfusion blood specimen was negative. No RBC alloantibodies were detected in the serum of patient or donor.

Case Study 3 Repeat blood typing and crossmatch tests on the pretransfusion and posttransfusion specimens and donor unit confirmed the original test results. No incompatibility was demonstrated. Results of the serum bilirubin test 5 hours after the transfusion were normal. A negative culture and Gram stain ruled out bacterial contamination.

What is the diagnosis? A.Acute hemolytic reaction B.Allergic reaction C.Alloimmunization D.Delayed hemoytic reaction E.Febrile nonhemolytic reaction

Case Study 4 A 38-year old man arrived at the hospital emergency room complaining of abdominal pain. A CBC was ordered. His hemoglobin was 7.0 g/dl.

Case Study 4 The physician determined evidence of bleeding and ordered 2 units of RBCs immediately. The patient had no history of prior transfusion and was taking no medication. Two units of RBCs were crossmatched and found compatible. The patient’s antibody screen test result was negative.

Case Study 4 One compatible donor unit was released to the emergency room.

Case Study 4 After proper identification of the unit of RBCs with the patient by two people, vital signs were checked and recorded, and the transfusion was initiated. Thirty minutes after the transfusion had begun, the patient experienced a slight rash and itching. No other associated adverse effects were noted.

What is the diagnosis? A.Acute hemolytic reaction B.Allergic reaction C.Alloimmunization D.Delayed hemoytic reaction E.Febrile nonhemolytic reaction

CASE STUDY 5 A 65- year old white male sustained severe injuries in a highway accident five months ago, just before the December holidays.

CASE STUDY 5 The patient was group O, Rh-negative. He was transfused with two units of O, Rh- negative blood followed by two units of O, Rh D-positive blood.

CASE STUDY 5 Five months after the accident, the patient is admitted to the hospital and is scheduled for follow-up shoulder surgery. Two units of RBCs are requested to be available during the surgery. A tube of blood was drawn from the patient and sent along with the proper paperwork to the blood bank.

CASE STUDY 5 There were no abnormal hematology or chemistry findings.

CASE STUDY 5 The initial tube of blood that was drawn was not collected properly. It did not have a patient name or any other identification on it. It was promptly discarded by the blood bank tech. Another properly labeled tube was collected.

CASE STUDY 5 The patient forward types as O Rh D- negative. Results of the antibody screen demonstrate Anti-D. No clerical errors were revealed.

What is the diagnosis? A.Acute hemolytic reaction B.Allergic reaction C.Alloimmunization D.Delayed hemoytic reaction E.Febrile nonhemolytic reaction

CASE STUDY 6 An 18-year old African-American female with sickle cell anemia is seen in the emergency room with a swollen and painful knee injury.

CASE STUDY 6 The patient had received several prior transfusions, the last about 4 months ago. Two units of blood were requested. A tube of blood for the type, screen and crossmatch along with the proper paperwork was sent to the blood bank.

CASE STUDY 6 The patient’s hemoglobin was 6.5 g/dl and the hematocrit was 19%. Chemistry results were within normal range.

CASE STUDY 6 The patient typed as a group A Rh-positive. However, one of the three screen cells is positive. Anti-E is identified from the panel cells.

CASE STUDY 6 However, one of the three screen cells is positive and the antibody is shown to be Anti-E.

What is the diagnosis? A.Acute hemolytic reaction B.Allergic reaction C.Alloimmunization D.Delayed hemoytic reaction E.Febrile nonhemolytic reaction