Acute Hemolytic Reactions
PRESENTATION: The very old (and very unfunny) joke goes: "Where does a 500 pound gorilla sit?"
Answer: "Wherever he wants!" I warned you that it wasn't funny, didn't I?
For our purposes, we could modify that to say that our 500 pound gorilla, the Acute HTR, can present any way it darn well pleases.
The "classic" descriptions in medicine, isn't seen all that often in real life. Unfortunately, many people believe that the "classic" presentation is the only presentation. More on that in a minute. Anyway, here's what the books describe:
- Temperature increase +/- chills
- Back or flank pain
- Vague feeling of "unease"
- Hypotension/shock
- Increased bleeding (especially under anesthesia)
The problem with lists like the one above is that people (especially clinicians) start falling into the trap that they can reliably diagnose these reactions based on the presence or absence of all of the above things. Here's the truth: It does not matter if you are God's gift to medicine; in the early stages, you cannot reliably distinguish the signs and symptoms of an acute HTR from a benign nonhemolytic reaction! The reason is simple: Most acute hemolytic reactions begin with just fever and or chills, a presentation which could be one of several benign reactions. Once an acute HTR is fully developed, and the patient is crashing with DIC and shock, my grandmother could make the diagnosis! (she's pretty smart, by the way, but she wasn't the inspiration for the TV show "ER", if you know what I'm saying).
Early diagnosis and treatment is the key to these reactions, so as I've said before, have a very high index of suspicion for acute hemolysis and if in doubt, work it up!
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