Acute non-immunologic hemolytic transfusion reaction due to intravenous dextrose infusion

Acute hemolytic transfusion reactions (AHTR) occur during or within 24 hours after the completion of transfusion. They could be immunologic or non-immunologic.[1] It may not be easy to differentiate between the two but the cause can be ascertained by careful evaluation of clinical history, signs, symptoms, and laboratory investigations.

One unit packed red blood cells (PRBC) of O+ group was issued for a 27-year-old female patient for inevitable abortion. Blood was transfused the same day; uneventful. Next day the patient’s relatives noted yellow coloration of skin. The doctor suspecting AHTR sent the patient’s post transfusion blood sample and empty blood bag with the remarks ‘hemolytic reaction, indirect hyperbilirubinemia, fall in Hb.’

Clerical check in the laboratory revealed no identification error. The visual check of the blood samples revealed that the patient’s pre-transfusion serum was normal but the post-transfusion serum/plasma was yellow in colour (evident in the Figures).

Repeat blood group on pre and post transfusion samples of the patient and donor were all O+. Screening test for unexpected antibodies [Figure 1]. Direct antiglobulin test [Figure 2] and autocontrol [Figure 3] on both pre and post transfusion samples of the patient were negative. Repeat cross-match of both pre and post transfusion specimens and donor blood from the bag were compatible [Figure 4]. All these tests were done by column agglutination technique (CAT).

Figure 1.

Antibody screen: Pre and post transfusion: Both negative

Figure 2.

Direct antiglobulin test: Pre and post transfusion: Both negative

Figure 3.

Auto control: Pre and post transfusion: Both negative

Figure 4.

Cross-match: Pre and post transfusion: Both negative

We contacted the patient’s physician to know her clinical status. The patient was stable and remained asymptomatic during and after the transfusion. She did not experience fever, chill, rigor, backache, hypotension or any other sign that may accompany an immune hemolytic transfusion reaction or infusion of bacterially contaminated blood. No medication was added to the unit or tubing, no blood warmer or infusion pump was used but after completion of the blood transfusion 5% dextrose was given through the same set.

These clinical and laboratory findings: Uneventful blood transfusion, no ABO and Rh discrepancy, no un-expected alloantibodies and negative direct antiglobulin test (DAT), rule out immune hemolysis. Dextrose is known to cause clumping and/or hemolysis of red cells[2] and apparently seems to be the only cause to induce hemolysis in this case.

In a study conducted in Post Graduate Institute of Medical Education and Research (PGIMER) Chandigarh, incidence of AHTR was found to be 0.23 per 1,000 red cells transfused, which is higher than most reported studies and improper storage of blood in the refrigerator of wards was a more common cause than immunological incompatibilities.[3] Non immune hemolysis can be prevented by strict adherence to standard practices for processing, storage, transport, and transfusing blood components.[4] The blood banks must look beyond their boundaries to solve a case of AHTR. Both, the blood bank and the clinical teams, are responsible to meet this challenge. Every patient has right to receive safe blood infusion, which can only be achieved by “doing ordinary things extra ordinarily well”.