1. Case presentation Present by R1 黃信豪

2. Brief history (1) This 49 y/o male patient denied any systemic disease except HBV related HCC. Hepatectomy was performed on 89-10-06. Post-operative bile leakage happened and biloma was found, so choledochotomy with T-tube insertion was performed on 90-01-25.

3. Brief history (2) Recurrent HCC over sup. lat. aspect of r ’ t lobe and inf. aspect of r ’ t lobe were found during regular echo f/u. Abdominal CT also proved the echo finding. So the patient admitted in the ward, and awaited for operation on 91- 02-25.

4. Brief history (3) Past history: 1. Denied any systemic disease 2. No known allergy 3. Intra-operative transfusion with PRBC and FFP, but no transfusion reaction was noted. 4. No specific family history

5. Brief history (4) Induction of anesthesia with Robinul 0.3mg, Pentothal 250mg, SCC 80mg, Fentanyl 100μg, Pavulon 4mg, Atracurium 15mg 7.5 endo-tracheal tube with cuff inserted, and fixed at 23 cm. Right hand arterial line and 12*12*16 CVP were set up after intubation.

6. Brief history (5) Anesthesia was maintained with desflurane and O 2. Atracurium was also given intra-op. During the operation, the patient ’ s vital sign was smooth and stable. The BP was around 120/70 mmHg, and HR was around 75. HAES 1500ml with N/S and L/R 2000ml was given intra-op.

7. Brief history (6) Blood loss about 300ml, and FFP 6u was given. After transfusing, suddenly BP dropped and tachycardia were noted in 20 min. Neosynesin 0.1mg IV was given, but the BP was still low. Another hand A-line setting up was suggested. When opening the cloth covering the patient ’ s hane, skin rash with urticaria-like change was found.

8. Brief History (7) Allergy due to FFP transfusion was suspected, Vena 1amp, Ephedrine 16mg and Solu-medrol 2 vial were given immediately. Vitacal 2 amp and Jusolin 5 amp were given due to PH 7.344-7.301, Ca 0.97 Laxis ½ amp was given due to small amount urine output, but no bloody or tea-color urine was found.

9. Brief history (8) After the treatment, the BP cameback to 110/50 mmHg in 20 minutes. The skin rash and urticarial-like change also relieved. The patient was then sent to SICU for post-op care after the operation.

10. Brief history (9) In SICU, the patient ’ s BP was around 140/70 mmHg, normal ECG with sinus rhythm,and SpO 2 100%. The patient ’ s consciousness recovered within one hour. Under the stable vital sign, the patient was extubated at 10:00 am on 2/26, and transferred to 9B-21-01 at 10:30am.

11. Discussion

12. What happened during the operation? Suddenly onset hypotension with tachycardia cause by: 1. Cardiogenic shock ?- no ECG finding 2. Massive bleeding ?- no major bleeding sorce 3. Pulmonary embolism ?- no ETCO 2 was noted 4. Drug induce-tracurium ? 5. Transfusion reactions!

13. The incidence of transfusion reaction According to Henderson RA.and Pinder L. report: 1) 0.73% for per unit of RBC 2) 0.1% for per unit of plasma 3) 0.04% for per unit of platelets 4) 0.01% for per unit of stable plasma protein

14. The symptom and sign of transfusion reaction 1. Fever – the most common symptom 2. Inflammatory reaction – chills, rigors … 3. Allergic reaction – urticaria, pruritis … 4. Other reaction – hemolysis, sepsis …

15. The factors induce transfusion reaction (1) about donor ’ s blood 1. Leukocytes – Graft-versus-host reaction 2. Cytokines level – increasing in 48-72 hrs after the blood was collected. 3. Virus or bacteria 4. antibodies

16. The factors induce transfusion reaction (2) About recipient 1. ABO or Rh incompatible. 2. Allergy history. 3. Multiple transfusion history

17. classification of blood transfusion Immune complication Infectious complications Others – coagulopathy, citrate toxicity, hypothermia …..

18. Immune complication of blood transfusion Hemolytic reactions Non-hemolytic immune reactions 1. Febrile reactions 2. Urticarial reactions 3. Anaphylactic reactions 4. Non-cardiogenic pulmonary edema 5. Graft-versus-host disease 6. Posttransfusion purpura 7. Immune suppression

19. The treatment of the immune complication(1) Hemolytic reaction: A. Acute hemolytic reaction: 1) Stop transfusion, and check PLT count, PT and PTT. 2) On foley, and check the hemoglobin in urine. 3) Osmotic diuresis should be initiated with mannitol and intravenous fluids.

20. The treatment of the immune complication(2) 1) Low dose dopamine for preserve renal blood flow 2) FFP and PLT are indicated if rapid blood loss. B. Delayed hemolytic reaction: 1) Primarily supportive care

21. The treatment of the immune complication(3) Non-hemolytic reaction: 1. Febrile reactions – 20-40 mm filter to trap WBC and PLT. 2. Urticarial reactions – antihistaminic drugs are needed. 3. Anaphylactic reactions – epinephrine, fluids, corticosteroids, and antihistaminic drugs.

22. The treatment of the immune complication(4) 4. Noncardiogenic pulmonary edema – supportive therapy. 5. Graft-Versus-Host reaction – leukocyte filter, irradiation (1500-3000 cGy) 6. Post-transfusion purpura – plasmapheresis is recommended.

23. The management of transfusion reaction 1. Stop the transfusion and maintain IV access. 2. Perform clerical check of labels, forms and patient identification. 3. Report reaction to physician and blood bank personnel. 4. Draw a post-transfusion sample and urine sample and send it along with the unused product to the blood bank.

24. Thank you for your attention!