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Stem
A 68-year-old man with a history of ischaemic heart failure (ejection fraction 35 percent) is admitted with melaena from a bleeding duodenal ulcer, successfully treated endoscopically. His haemoglobin is 73 g/L; he is haemodynamically stable. The team has prescribed two units of red cells to be given back-to-back over the next four hours.
A 25-year-old woman with known severe IgA deficiency is transfused one unit of red cells for autoimmune haemolysis. Ten minutes into the transfusion she develops widespread urticaria, lip swelling, stridor and a blood pressure of 78/40.
Questions
a) For the 68-year-old man, state whether the transfusion prescription is appropriate and justify your answer. What should be changed? (3 marks)
b) Outline three measures to prevent transfusion-associated circulatory overload (TACO) in this patient. (2 marks)
c) For the 25-year-old woman, what is the reaction, what is the immediate management, and what special blood products are required in future? (3 marks)
d) State the universal first steps taken for ANY transfusion reaction. (2 marks)
Model answers
a) The prescription is not fully appropriate. He is haemodynamically stable with a haemoglobin of 73 g/L — above the restrictive threshold of 70 g/L — so observation rather than routine transfusion is reasonable under the AABB 2023 guidelines. A restrictive strategy (transfuse at Hb under 70) is at least as safe as a liberal strategy. If transfusion is nonetheless clinically indicated, two units back-to-back should NOT be given: give one unit, then reassess the Hb and symptoms before deciding on a second.
b) (1) Transfuse slowly — one unit at a time over up to 4 hours; (2) give prophylactic IV furosemide between units and monitor fluid balance and weight; (3) nurse upright with oxygen, watch for dyspnoea, raised JVP and crackles, and stop if overloaded. These measures specifically target TACO in a patient with cardiac failure.
c) This is anaphylaxis, most likely from IgA deficiency with anti-IgA antibodies reacting to IgA in donor plasma. Immediate management: STOP the transfusion, maintain IV access, give IM adrenaline (0.5 mg), high-flow oxygen, airway support and IV fluid resuscitation. After recovery, investigate with a serum IgA level and anti-IgA antibodies; future transfusions must use washed or IgA-deficient products.
d) STOP the transfusion immediately; maintain IV access with normal saline; assess ABCDE and vital signs; keep the donor unit and giving set; take fresh patient samples (clotted, EDTA, urine) and return the unit and samples to the blood bank; and report the reaction.