Case 1:

Premature neonate: 29 week gestation, BW=900Gr Intubated for respiratory dystress and Surfactant prescribed Then extubated Non-invasive ventilation for three days Ampicillin & Amikacin started after lab exam

At the 2nd day; breast milk started 2ml q3h and the feeding incresed from the 8th day to reach 90 ml/Kg in 14th day of life. In this period, Intra venous alimentation with vitamins, lipid and amino acids administered with central venous catheter .

In 14th days recurrent apnea present that do not response to stimulation   WBC: 2,600/ μL PMN:15%, Lymp: 82%, Eos: 3% Hb: 8.8 g/dL, Hct: 25%, RBC: 3,200,000/μL Plat:27,000/ μL

ABG: pH:7.01, PCO2: 65 mmHg, PO2: 67 mmHg HCO3: 7 BE: -12

Mechanical ventilation restarted(Duopap) Antibiotics change to Vancomycin and cefotaxime Dopamine started 10μg/kg due to decrease mean blood pressure below 25 mmHg

Abdominal tenderness in RLQ Diameter of abdomen increase 3 cm from the day before Abdomen X-ray: Distention of loops without any air in sub mocusa

What is your plan for patient?   WBC: 2,600/ μL PMN:15%, Lymp: 82%, Eos: 3% HB: 8.8 g/dL, Hct: 25%, RBC: 3,200,000/μL Plat:27,000/ μL

Case 2:

A 22 years old woman with Intermediate Thalassemia She was on Hydroxy urea (HU)and hemoglubin level more than 10 gr/L She stopped HU for pregnancy Hb level dropped below 8 gr/L Several transfusion was done

After pregnancy, hemoglobin levels did not increase with transfusion Antibody screening: anti-E, anti-JK, anti S and auto-antibody Low dose prednisone started Transfusion every 14 days with complete match blood

Fetus was IUGR Gy-Ob decide to terminate pregnancy on 32nd week of pregnancy The 1,800 gr girl was delivered and admitted in NICU In 15th day of birth , neonatologist decide to discharge the patient The Hb level is 8.5 gr/L

What do you do for Hb=8.5?

Unfortunately the neonatologist did not know history of mother and transfused packed cell and the patient died due to severe hemolysis

Case 3:

Case study Blood transfusion

History A 17day old preterm twin, who was already jaundiced, had a neonatal blood transfusion through a 24 gauge peripheral cannula. The baby had lower than expected rise in Hb, an unexpected rise in bilirubin from 6.9 /L two days pretansfuion to 22.2 /L within 24 hours of transfusion, and evidence of schistocytes, red cell fragments and polychromasia on the film. The baby also develop transient signs of increased work of breathing a few hours post transfusion.

What went wrong? Evidence of hemolysis ? Related to cannula Breathlessness related to transfusion

Why? There is evidence of haemolysis but it is not clear why. The text does not mention the formation of a new allo-antibody. It would be unusually for a cannula of that size to cause mechanical haemolysis.

What should have happened? A full investigation to look for an allo-antibody or another cause for the haemolysis.

cause The reporters considered that this might have been mechanical hemolysis related to the small bore cannula as they could not identify another cause for the probable hemolysis, but this size cannula is routinely used for neonates including for transfusion so this is less likely than an underlying hemolysis causing the anemia requiring transfusion .

Case 4:

Case 4 A 22 day old boy receiving extracorporeal membrane oxygenation therapy (ECMO) whose own group was A Rh D positive was transfused with group O RhD positive platelets (the only group available at the time). He was bleeding and the transfusion was urgent. The child developed a positive direct antiglobulin test, and anti-A was found in the eluate when referred to the Blood Service reference laboratory.

What went wrong? Patient given transfusion of platelets that were incompatible.

Why? It is an emergency and in this situation the decision was the correct one. Platelets are far less likely to cause an immediate life threatening ABO haemolysis that red cells. He may have died without the platelets.

Consequences to the patient/clinician? Potentially the patient could have had a haemolytic transfusion reaction.

Causes There were no adverse clinical sequelae related to this Alloimmunisation The formation of anti-A and a positive DAT is not sufficient to make the diagnosis of haemolysis.

What went wrong? Patient given transfusion of platelets that were incompatible.