A detection of unexpected blood antibody at the time of transfusion was needed, during the operation -A case report-
A 30-year-old male patient was brought to our hospital with the chief complaint of abdominal pain following a traffic accident. The patient's consciousness was clear, but his vital signs showed hypotension (66/43 mmHg), tachycardia (heart rate 109 beats per minute), and hyperventilation, indicating hypovolemic shock. Blood testing performed in the emergency room revealed hemoglobin (Hb) 8.6 g/dl and hematocrit (Hct) 26.3%. The abdominal computed tomography (CT) showed pancreatic head injury and active bleeding, and an emergency exploratory laparotomy was performed under the diagnosis of hemoperitoneum. The patient had no particular medical history except for taking medication for rheumatic heart disease 17 years earlier, and he had never undergone surgery.\nPreoperative blood testing performed in the emergency room showed a negative result on the unexpected antibody screening test. Due to intraoperative blood loss, 11 pints of packed red blood cells and 5 pints of fresh frozen plasma were administered. A complete blood count performed immediately after the operation showed Hb 10.4 g/dl. Two additional pints of packed red blood cells were transfused one hour after the end of the operation since the Hb level was measured to be 8.1 g/dl. Including this transfusion, a total of five additional pints of packed red blood cells were transfused by the third postoperative day. The patient's body temperature was maintained over 37.5℃ following the operation.\nOn the eighth day following the first operation, panperitonitis caused by duodenal perforation was found, and a second exploratory laparotomy was thus performed. Preoperative blood tests showed that Hb, Hct, and platelets (PLT) were in the normal range, but that the white blood cell (WBC) level had increased to 213,000/µl. Other blood tests revealed no abnormal findings. An unexpected antibody screening test was not performed at this time. On the first day after the operation, the patient's Hb had decreased to 8.9 g/dl, and thus two pints of packed red blood cells were transfused. Following the transfusion, fever, with a body temperature of 37.8℃, was found, with accompanying chills. On the second postoperative day, bleeding continued at the suture site and through the surgical drain, and the Hb was found to be 9.0 g/dl. One pint of packed red blood cells was transfused, but bleeding continued to be observed. On the seventh postoperative day, three pints of packed red blood cells were transfused when the patient had a Hb of 8.2 g/dl with a measured body temperature over 38.2℃. After this transfusion, the Hb was 9.2 g/dl, blood urea nitrogen (BUN) 8 mg/dl and creatinine (Cr) 0.8 mg/dl. Jaundice or hemoglobinuria that might suggest a blood transfusion reaction was not found.\nSixty days after the first operation, a third exploratory laparotomy was performed for a chief complaint of duodenal perforation and large intestine omental laceration. The patient's vital signs at that time were blood pressure 130/80 mmHg, heart rate 80/min, tidal rate 20/min, and body temperature 37.0℃. Blood tests showed normal findings, but a preoperative unexpected antibody screening test was not performed. During the operation, at about one and a half hours after the induction of general anesthesia, massive bleeding was found, accompanied by tachycardia, with a heart rate of 110 beats per minute or higher. At one hour and 50 minutes after the start of the operation, the diastolic blood pressure had dropped below 50 mmHg, and tachycardia, with a heart rate of 130 beats per minute or higher, was found. A volume expander (colloid) was therefore intravenously injected.\nThe patient's vital signs then stabilized to some extent, but the intraperitoneal bleeding continued, and the decision was made to perform a transfusion. The arterial blood gas analysis performed at that time showed Hb 8.0 g/dl, Hct 29%, and pH 7.41. Crossmatching performed as the blood sample was taken and sent to the test room showed a positive antigen-antibody reaction. The unexpected antibody screening test that was performed because no appropriate blood was found repeatedly showed a positive result.\nDue to these findings, it was impossible to perform a transfusion promptly, and thus both the need for rapid transfusion and the probability of reactions due to the transfusion of incompatible blood had to be taken into account at the same time. While testing was continued, the patient's systolic blood pressure was kept at 80-100 mmHg, but tachycardia persisted, with a heart rate of 130 beats per minute or higher, and the diastolic blood pressure remained at 50 mmHg, with continued bleeding observed.\nA discussion was held among the surgeon, the laboratory medicine expert, and the anesthesiologist. The crossmatching testing was continued, and an antigen-antibody reaction over 2+ was found repeatedly. Meanwhile, we found weakly positive blood with an antigen-antibody reaction of 1+ in the 11th sample.\nAlthough an emergency blood transfusion was required, crossmatching had to be performed between the patient's blood and the blood to be transfused, a procedure which required two hours to find the most appropriate blood. At about five hours after the start of the operation, transfusion of five pints of packed red blood cells was begun. The patient's vital signs then stabilized, with the mean arterial pressure higher than 90 mmHg and the diastolic blood pressure higher than 70 mmHg. The arterial blood gas analysis at the start of the blood transfusion showed Hb 6.2 g/dl, Hct 19.6%, and pH 7.34.\nThe operation continued for about six additional hours, and the total blood loss was estimated to be 4000 ml. After transferring the patient to the intensive care unit (ICU), three pints of packed red blood cells and five pints of fresh frozen plasma were additionally transfused, and thus a total of eight pints of packed red blood cells were administered on the day of the operation.\nDuring the postoperative follow-up, we found no symptoms that suggested delayed serological transfusion reaction (DSTR) or delayed hemolytic transfusion reaction. The patient was discharged after 100 days without any sequelae. The warm autoantibody adsorption test performed by the ZZAP method 90 days after the last blood transfusion verified that the unexpected antibody found in the patient was an autoantibody.