Post-partum sequential occurrence of two diverse transfusion reactions (transfusion associated circulatory overload and transfusion related acute lung injury)
A 29-year-old female suffered post-partum hemorrhage following a normal vaginal delivery after, which she was referred to our institute on the second post-partum day. She had no co morbidities. On admission to the high dependency unit, she was in shock (blood pressure [BP] 80/50 mm Hg), had tachycardia (pulse rate 120/min), was restless and had severe pallor. Her baseline hemogram results were — hemoglobin 4 g/dl, Leucocyte count of 7800/ml and platelet count of 88 × 103/ml. Abdominal ultrasound was suggestive of placenta accreta. Immediate resuscitation commenced under anesthetist's supervision and packed red blood cells (PRBC's), fresh frozen plasma (FFP), platelet concentrates, and cryoprecipitate were arranged. Under ultrasound guidance and local anesthesia left internal jugular vein (for central line) and left radial artery (for arterial line) were cannulated. When conservative measures such as blood product transfusion (2 units PRBC and FFP each), uterine massage, administration of oxytocin, methylergometrine, prostaglandin and balloon tamponade failed to control the hemorrhage, the patient was rushed to the operation theater for an emergency hysterectomy. During the surgery, the patient lost around 1500 ml of blood for which she was transfused 3 units each of PRBC, FFP and platelets along with 1500 ml of hydroxyethyl starch over 3 h. Intraoperative central venous pressure (CVP) was maintained between 8 mm Hg and 10 mm Hg. She also required ionotropic support (dopamine at the rate of 8 μg/kg/min) transiently. At the conclusion of surgery, arterial blood gases (ABG) showed metabolic acidosis. (pH: 7.20, P/F ratio: 310, HCO3: 12, BE: −6.5), but ionotropic support could be tapered off. The patient was shifted to the intensive care unit (ICU) for elective mechanical ventilation. Within an hour of ICU admission, the patient developed an elevated CVP (14 mm Hg), jugular venous distension, and bilateral crepitations. Urgent work-up revealed hypoxemia (PO2: 70 mm Hg on FiO2 of 0.4) and cardiomegaly and lung congestion on chest X-ray []. Ultrasound chest showed B lines []. Electrocardiography and Troponin T levels were within normal limits. Echocardiography carried out promptly, showed a dilated left ventricle (left ventricular end diastolic diameter: 6 cm) with an ejection fraction of 50%. Plasma B-type natriuretic peptide (BNP) levels was measured, which was found elevated (255 pg/dL). A presumptive diagnosis of TACO was made and ventilator support was augmented by increasing the oxygen concentration (FiO2: 0.6), Positive End Expiratory Pressure (PEEP) (8 cm H2O), and pressure support (17 cm H2O). Diuretic therapy (furosemide 40 mg intravenous loading dose followed by 20 mg intravenously 8 h) was also initiated. Repeat chest X-ray after 24 h showed a reduction in cardiomegaly and clearing of congestion. Subsequently, her condition resolved and she could be extubated on the 2nd day of ICU stay. The next 2 days were uneventful with the patient receiving supportive therapy and making a gradual recovery. Her investigations and clinical features were within normal limits during this period. On the 3rd day from the event, oozing was observed from her central line insertion site, which prompted an emergency coagulogram. Her investigations revealed a platelet count of 115 × 103/ml, prothrombin time of 13 s, fibrinogen level of 252 mg/dl and an elevated activated partial thromboplastin time of 46 s. For correction of the same, she received 4 units of FFP over the next 5 h. Within 2 h of the last transfusion, she developed breathlessness, tachypnea and bilateral crepitations at the lung bases. At this point, the CVP measured was 5 mm Hg. Considering an allergic reaction, she was immediately administered steroids and antihistaminics, but was not relieved. An urgent chest X-ray revealed new onset bilateral pulmonary infiltrates []. ABG showed hypoxemia (PaO2 of 58.5 on FiO2-.35). A plasma sample for BNP was sent, which resulted in a value of 80 pg/dL. Echocardiography showed an ejection fraction of 55% without any valvular defects (left ventricular end diastolic diameter: 4.8 cm). Computed tomography angiography ruled out embolic phenomenon. As no other causes of acute lung injury (ALI) could be elicited, TRALI was considered a diagnosis of exclusion and the sample was sent back to the blood bank informing about the event with requisitioning for donor human leucocyte antigen (HLA) antibody testing. Ventilatory support was initiated (non-invasive ventilation) with the following settings: Mode Continous Positive Airway Pressure (CPAP), pressure support-16 cm H2O, PEEP-8 cm H2O and FiO2-0.5. After receiving ventilator support, the patient became comfortable. Repeat ABG's showed an improving trend and the ventilator support could be discontinued by the next 24 h. After this episode, further complications were not observed and the patient was discharged from the ICU on the 7th day of her surgery. A week later, the result of donor plasma came out to be positive for HLA antibody.