Critical Care physician Northeast georgia medical center, United States
Introduction: We present a case of anaphylaxis after blood transfusion with washed packed red blood cells (pRBCs).
Description: 87-year female with history of mechanical valve on coumadin presented to Intensive Care Unit (ICU) twice in a month with low hemoglobin (Hb). First time, patient had melena and Hb of 4.9. She had a history of transfusion reactions after requiring >100 pRBCs from a complicated thoracentesis resulting in liver injury. Red Cross supplied the most compatible pRBCs. Post transfusion patient developed wheezing. The Hb did rise appropriately. Post transfusion workup showed five rare antibodies, positive Direct Antibody Test, normal serum Immunoglobulin (Ig)A, low haptoglobin and elevated bilirubin. Esophagoduodenoscopy showed jejunal arteriovenous malformations that were thought to be the culprit. She was discharged but presented two weeks later with Hb of 5.9. Transfusion of least incompatible pRBC was reattempted after pretreatment with steroids and antihistamine but had to be stopped due to wheezing. After discussion with hematologist, lab values from previous admission and current reaction were attributed to be allergy rather than hemolysis. Patient was given 3 options: transfusion of least incompatible blood or washed RBCs or desensitization with pRBCs under non-emergent conditions. Given reactions with least incompatible blood, transfusion of washed pRBCs was agreed upon. After 45ml of slow transfusion of 5-times washed pRBCs and despite pretreatment with steroids, antihistamine and furosemide, the patient developed shortness of breath and wheezing, and transfusion was halted. The patient was counseled and presented two treatment options: continued acceptance of least incompatible pRBC with risk of anaphylaxis and death or declining transfusion and accepting risk of mortality from bleeding. The patient opted against future blood transfusion. She was discharged home with hospice.
Discussion: Washed pRBCs are indicated for patients who have had allergic transfusion reactions especially with immunoglobulin A deficiency. Our patient had normal IgA. Currently no known case has been reported of a similar nature and this highlights the need to explore avenues of treatment for allergic transfusion reactions to washed pRBCs.
