Tachycardia and fever after packed red cell (PRC) infusion: A case report

ABSTRACT

A 56-year-old female patient with a body weight of 60 kg was brought to the hospital with hematemesis and received one unit of packed red cells (PRCs) for this condition. After 30 min, the patient experienced tachycardia of 120 beats/min and an increased body temperature of 102°F. The patient had no relevant medical history of allergy or similar episodes in the past. The patient was not suffering from any coagulopathies or sickle cell anaemia, which is a prevalent condition in the region. The patient was receiving the PRC for the first time. After this event, the infusion was stopped and immediately injection meropenem, pantoprazole and ondansetron IV were administered. The patient’s condition normalised after 6 h. No re-challenge was given after the recovery of the patient. Suspected ADR was analysed according to the World Health organization (WHO) causality assessment scale and the causality was “Possible”. Meticulous monitoring and prompt therapy were provided. The patient was discharged after observing for 24 h. The adverse drug reaction was possibly caused due to the PRCs.

Introduction

The red blood cells (RBCs), which are separated for the purpose of blood transfusion, are known as packed red cells (PRCs) or packed cells. A single unit may increase the level of haemoglobin up to 1 g/dL.[1,2,3] Patients with severe blood loss or who are receiving treatment for cancer in the form of chemotherapy PRC can be administered intravenously.[4] RBC transfusion is routinely performed. RBC transfusion is dependent on the clinical condition of a patient.[5] Reactions may occur in 1 to 2% of patients. While transfusion of RBCs, the overall patient’s condition shall be taken into consideration rather than haemoglobin only.[6]

Patient Information

The patient was a 56-year-old female who came to the hospital for a check-up of hematemesis. The cause of hematemesis was investigated. There were no signs of oesophageal or gastric varices but the presence of gastric ulcers was seen. There was no significantly relevant medical, family and psycho-social history. There was no past history of blood transfusion.

Clinical Findings

On physical examination (PE), important clinical findings were

• Blood pressure 120/80 mmHg

• Temperature 37.8°C

• Pulse rate 100 beats/min

• Pallor was present

• No icterus

• Cardiovascular system (CVS), central nervous system (CNS) and respiratory system (RS) did not show any abnormalities on physical examination

• There was no pedal oedema

• Jugular venous pressure was not raised

Diagnostic Assessment

Following blood investigations were performed

• Complete blood count (CBC): RBC-2.92 million cells/mL

• Haemoglobin-7 g/dL

• Whole blood count (WBCs)-3.4 billion cells/L

• Platelets-157 billion/L

• LFT-indirect bilirubin 0.9 mg/dL, bilirubin total 0.3 mg/dL, serum glutamic-oxaloacetic transaminase (SGOT) 30 units/L, serum glutamic pyruvic transaminase (SGPT) 11 units/L

• KFT-serum uric acid 3.6 mg/dL, blood urea nitrogen 9 mg/dL, serum creatinine 0.7 mg/dL, blood urea nitrogen/creatinine ratio 9:1

• Serum calcium 130 mmol/L.

The only significant finding in the case of diagnostic assessment was a significantly decreased haemoglobin content.

Therapeutic Intervention

Because the patient was anaemic and was also suffering from hematemesis, it was decided to administer 1 Unit PRCs. The PRC was acquired from Jawaharlal Nehru Medical College (JNMC) Blood Bank and was administered with all the precautions following the standard protocol. Within 15 to 20 min of the start of the infusion, the patient complained of heaviness in the chest and a headache. The infusion was stopped when the heart rate was recorded as 120 beats/min, confirming tachycardia. The temperature was also raised to 102° F. The patient also complained of a vomiting sensation and had one episode of vomiting without hematemesis. Administration of therapeutic intervention for adverse drug events:

Injection pantoprazole 2 mL once

Injection ondansetron 2 mL once

Tab paracetamol 60 mg stat and SOS.

Follow-up and Outcomes

The patient recovered from adverse drug event (ADE) after prompt treatment within 8 h, there was no rechallenge given. The patient was further observed for the next 24 h for the recurrence of any adverse drug reactions or hematemesis. There was no recurrence of hematemesis or any adverse drug reactions reported. The patient was discharged with the prescription of the haematinic syrup and asked for a monthly follow-up or return if the patient encountered any adverse drug reaction or episodes of hematemesis.

Discussion

Transfusion reactions range in frequency from relatively common (mild allergic and febrile non-hemolytic reactions) to rare (anaphylaxis, acute hemolytic and sepsis). The severity and incidence vary depending on the type of transfusion reaction, the prevalence of disease in the donor population, and the extent of follow-up care the patient receives. This reaction, which was of mild grade and subsided quickly with proper medications, was labelled as a mild allergic reaction due to hypersensitivity to a foreign protein in the donor product. This allergic reaction to the components of PRCs may be attributed to the genetic makeup of the individual.[7,8,9,10] Plasma component factor in causing adverse drug reaction was also noted in the Suryatapa et al. study.[11] Immune-mediated reaction to blood transfusions such as chills, rigors and tachycardia is also mentioned in the Raval et al. study.[12] Xiuping et al.[13] study also mentions the same finding as mentioned in this study that individual differences of the patient too can cause adverse transfusion reactions.

Conclusion

This type of reaction is a rare occurrence in patients receiving the PRC.

Genetic profiling of the patient and its correlation with such adverse drug reactions may help to predict these types of reactions in the future. Until such facilities are available, proper monitoring of the patient during the PRC can help in reducing the incidences of adverse drug reactions in the patients receiving PRC.

Summary: (Key Points)

• Packed cells in a single unit may increase the level of haemoglobin up to 1 g/dL.

• Immune-mediated reactions to blood transfusion such as chills, rigors and tachycardia.

• Transfusion reactions range in frequency from relatively common to rare.

• Genetic profiling of the patient.

• Proper monitoring of the patient during the PRC transfusion.

Take home message

• Proper monitoring of the transfusion can avoid transfusion reactions.

Novelty/New Knowledge

• A previous genetic profiling and detailed history of the previous transfusion events can help a lot in managing the patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.