Acute haemolysis, DIC and renal failure after transfusion of uncross-matched blood during trauma resuscitation: illustrative case and literature review

Impact of Lactate on Disseminated Intravascular Coagulation in Patients with Severe Trauma

Introduction

The association between elevated lactate levels and the development of disseminated intravascular coagulation (DIC) in patients with severe trauma remains unclear. Hence, this study aimed to explore the association between lactate and the development of DIC in patients with severe trauma.

Methods

This prospective cohort study was conducted on consecutive patients with severe trauma who were hospitalized in the intensive care unit from January 2020 to January 2023. The primary outcome measured was the occurrence of DIC in patients in the emergency department or posthospitalization. Logistic regression analysis evaluating the risk values for lactate and DIC, the receiver operating characteristic (ROC) curve, and decision curve analysis (DCA) examinations studying the predictive efficiency of lactate for DIC. The Kaplan-Meier survival curve was used to assess patient survival. Sensitivity robustness analysis included modified Poisson regression, E-value, subgroup analysis, and numerical variable transformation analysis.

Results

Logistic regression analysis corrected for confounding factors showed that lactate was a risk factor for DIC in patients with severe trauma (adjusted odds ratio [OR]: 1.374, 95% confidence interval [CI]: 1.206-1.566). Lactate predicted DIC risk with a 0.8513 area under the ROC curve (95% CI: 0.7827-0.9199), 4.8 cutoff value, 0.8333 sensitivity, and 0.8014 specificity. DCA showed the correlation between lactate and DIC. The mortality rate of patients with a high risk of DIC was significantly higher than that of patients with a low risk (log-rank test, P < 0.001). The modified Poisson regression showed that lactate was a risk factor for DIC (risk ratio: 1.188, 95% CI: 1.140-1.237). E-value was 1.645, and the lower limit of 95% CI was 1.495. The logistic regression analysis after subgroup analysis and transformation of numerical variables showed that lactate remained a risk factor for DIC.

Conclusions

Elevated lactate is closely associated with the occurrence of DIC in patients with severe trauma. Lactate seems to be a good predictive factor for DIC manifestation in patients with severe trauma.

A Rare Case of Hemolytic Transfusion Reaction in a Premature Infant Caused by a Passive Anti-Jka Antibody

Hemolytic transfusion reaction (HTR) is an important type of transfusion-associated reaction and usually occurs after alloimmunization to red blood cell antigens. The HTRs caused by passively transferred Kidd blood group antibodies are not well documented. Here, we report about a premature infant who developed HTR owing to a passive anti-Jka antibody transfer following fresh frozen plasma transfusion. Anti-Jka antibody was detected in the infant’s plasma and was also found in the donor plasma with a titer of 1:128. We reported this case to the local blood center, and they subsequently began testing for irregular antibodies of donor plasma, which is recommended but not mandated in China. This case reveals an unusual cause of HTR and emphasizes a possible need to screen donor plasma for antibodies to minimize risks to recipients.

Adverse transfusion reactions and what we can do

INTRODUCTION

Transfusions of blood and blood components have inherent risks and the ensuing adverse reactions. It is very important to understand the adverse reactions of blood transfusion comprehensively for ensuring the safety of any future transfusions.

AREAS COVERED

According to the time of onset, adverse reactions of blood transfusion are divided into immediate and delayed transfusion reactions. In acute transfusion reactions, timely identification and immediate cessation of transfusion is critical. Vigilance is required to distinguish delayed responses or reactions that present non-specific signs and symptoms. In this review, we present the progress of mechanism, clinical characteristics and management of commonly encountered transfusion reactions.

EXPERT OPINION

The incidence of many transfusion-related adverse events is decreasing, but threats to transfusion safety are always emerging. It is particularly important for clinicians and blood transfusion staff to recognize the causes, symptoms and treatment methods of adverse blood transfusion reactions to improve the safety. In the future, at-risk patients will be better identified and can benefit from more closely matched blood components.

Blood Transfusion Reactions-A Comprehensive Review of the Literature including a Swiss Perspective

Blood transfusions have been the cornerstone of life support since the introduction of the ABO classification in the 20th century. The physiologic goal is to restore adequate tissue oxygenation when the demand exceeds the offer. Although it can be a life-saving therapy, blood transfusions can lead to serious adverse effects, and it is essential that physicians remain up to date with the current literature and are aware of the pathophysiology, initial management and risks of each type of transfusion reaction. We aim to provide a structured overview of the pathophysiology, clinical presentation, diagnostic approach and management of acute transfusion reactions based on the literature available in 2022. The numbers of blood transfusions, transfusion reactions and the reporting rate of transfusion reactions differ between countries in Europe. The most frequent transfusion reactions in 2020 were alloimmunizations, febrile non-hemolytic transfusion reactions and allergic transfusion reactions. Transfusion-related acute lung injury, transfusion-associated circulatory overload and septic transfusion reactions were less frequent. Furthermore, the COVID-19 pandemic has challenged the healthcare system with decreasing blood donations and blood supplies, as well as rising concerns within the medical community but also in patients about blood safety and transfusion reactions in COVID-19 patients. The best way to prevent transfusion reactions is to avoid unnecessary blood transfusions and maintain a transfusion-restrictive strategy. Any symptom occurring within 24 h of a blood transfusion should be considered a transfusion reaction and referred to the hemovigilance reporting system. The initial management of blood transfusion reactions requires early identification, immediate interruption of the transfusion, early consultation of the hematologic and ICU departments and fluid resuscitation.

Safety of Uncrossmatched ABO-Compatible RBCs in Alloimmunized Patients with Bleeding: Data from Two Decades: Results of a Systematic Analysis in 6,109 Patients

Introduction: Uncrossmatched ABO-compatible red blood cells (RBCs) are generally recommended in patients with life-threatening massive bleeding. There is little data regarding RBC transfusion when patients are transfused against clinically significant alloantibodies because compatible RBCs are not immediately available. Methods/Patients: All patients reviewed in this study (n = 6,109) required emergency blood transfusion and were treated at the Charité – Universitätsmedizin Berlin between 2001 and 2015. Primary uncrossmatched O Rh(D)-positive or -negative RBC units were immediately transfused prior to complete regulatory serological testing including determination of ABO group, Rhesus antigens, antibody screening, and crossmatching. Results: Without any significant change in the protocol of emergency transfusion of RBCs, a total of 63,373 RBC units were transfused in 6,109 patients. Antibody screening was positive in 413 patients (6.8%), and 19 of these patients received RBC units against clinically significant alloantibodies. None of these patients appeared to have developed significant hemolysis, and only one patient with anti-D seems to have developed signs of insignificant hemolysis following the transfusion of three Rh(D)-positive units. One patient who had anti-Jka received unselected units and did not develop a hemolytic transfusion reaction. Conclusion: Transfusion of uncrossmatched ABO-compatible RBCs against alloantibodies is highly safe in patients with life-threatening hemorrhage.

Rapidly freeze-dried human red blood cells for pre-transfusion alloantibody testing reagents

Prior to transfusion of red blood cells (RBCs), recipients must be tested for the presence of alloantibodies to avoid immune complications. Liquid-preserved reagent RBCs with known blood group antigen phenotypes are used for testing. However, these reagents have practical constraints, including limited shelf-life and require constant refrigeration. To address these issues, we explore the effects of rapid freeze-drying conditions with trehalose cryoprotectant (0.1-1 M concentrations) on human RBCs and storage of freeze-dried RBCs (FDRBCs) at room temperature (RT) for up to 12 months. We report that rapid freeze-drying of RBCs for 2.5 hr with 0.5 M trehalose achieves recoverable cells with near-normal morphological shape, although size-reduced. The FDRBCs are metabolically active and functional in antibody-agglutination tests by the column agglutination test (CAT) for ABO and Rhesus-D blood group antigens. Expression of the Duffy blood group protein (CD234) decreases by 50% after freeze-drying RBCs. The initial recovery rate is ≤25%; however, 43% of these FDRBCs are still recoverable after RT storage for 12 months. In this proof-of-principle study, we show that rapid freeze-drying can stabilize RBCs. Further refinements to improve the recovery rate and preservation of antigenic epitopes will make FDRBCs a practical alternative source of reagent RBCs for pre-transfusion alloantibody identification.

Red cell use in trauma

PURPOSE OF REVIEW

Red cell transfusions are commonly used in management of hemorrhage in trauma patients. The appropriate indications and criteria for transfusion are still debated. Here, we summarize the recent findings on the use of red cell transfusion in trauma setting.

RECENT FINDINGS

Recent evidence continues to support the long-established link between allogeneic transfusion and worse clinical outcomes, reinstating the importance of more judicious use of allogeneic blood and careful consideration of benefits versus risks when making transfusion decisions. Studies support restrictive transfusion strategies (often based on hemoglobin thresholds of 7-8 g/dl) in most patient populations, although some argue more caution in specific populations (e.g. patients with traumatic brain injury) and more studies are needed to determine if these patients benefit from less restrictive transfusion strategies. It should be remembered that anemia remains an independent risk factor for worse outcomes and red cell transfusion does not constitute a lasting treatment. Anemia should be properly assessed and managed based on the cause and using hematinic medications as indicated.

SUMMARY

Although the debate on hemoglobin thresholds for transfusion continues, clinicians should not overlook proper management of the underlying issue (anemia).