Status:
Ready to upload
Record number:
2298
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
Increasingly rare, death from an ABO hemolytic transfusion reaction is required by the federal government to be reported to the US FDA. From 2011 to 2016 there were only 16 deaths reported from ABO-incompatible transfusions.
Time to detection:
According to the article, it took 4 days to discover the adverse event due to blood transfusion. The patient received a group B blood transfusion on hospital Day 7 and experienced a severe transfusion reaction, however the patient’s blood type was not confirmed as B until Day 4.
Alerting signals, symptoms, evidence of occurrence:
The patient became acutely febrile and oliguric. He developed a severe acidosis prompting a return trip to the OR on Day 8 for suspected bleeding. No bleeding was found, but his omentum was ischemic and his liver was very pale. On this date his bilirubin was 17.5 mg/dL despite being normal on Day 3. Liver function tests were not serially followed as there was no routine clinical reason to do so. The patient progressed to liver failure and despite maximal support he died on Day 8 within 14 hours of his fever spike.
Demonstration of imputability or root cause:
The tests performed to confirm that this was a case of hemolysis included:
*Forward and back typing: The initial sample was typed as weak B+ using automated technology, indicating the presence of weak B antigens on the patient's red blood cells (RBC). The back type confirmed the presence of anti-B antibodies in the patient's plasma, matching the forward type and identifying the patient's blood as ABO group B.
*Crossmatch: A second sample drawn 20 minutes later confirmed the ABO group B typing obtained from the initial sample. Subsequent crossmatches also confirmed the patient's ABO group B status.
*Molecular typing: After the patient's demise, two separate samples were obtained and sent for ABO typing by molecular methods, both confirming the patient's ABO blood group O status.
*Test for bilirubin level.
Imputability grade:
3 Definite/Certain/Proven
Groups audience:
Keywords:
References:
Suggest new keywords:
ABO-incompatible transfusions
Massive Transfusion Protocol (MTP)
Reference attachment:
Suggest references:
Davis CS, Milia D, Gottschall JL, Weigelt JA. Massive transfusion associated with a hemolytic transfusion reaction: necessary precautions for prevention. Transfusion. 2019 Aug;59(8):2532-2535. doi: 10.1111/trf.15405. Epub 2019 Jun 26. PMID: 31241167.
Note:
I recommend the second review for this article to come from the Process group.
First revision by the Clinical Complications group - second review by the Process group (EP)
Expert comments for publication:
This case report highlights several essential lessons. Double- and triple-checking blood typing is paramount, especially in urgent situations. Blood typing should occur as early as possible in a patient's care, with universal donor blood (O-negative) used in emergencies where the blood type is unknown. Clinicians must remain vigilant for early signs of transfusion reactions and recognize that these reactions might present atypically. Patients with recent transfusions require close monitoring. This case underscores the need for systemic improvements, including enhanced protocols and technology to minimize blood typing errors. Openly discussing communication failures and training clinicians to recognize atypical transfusion reactions are important.