Acute Hemolytic Reactions
TREATMENT AND PROGNOSIS: The theory of treatment of an Acute HTR is something that most Blood Bank Directors are well-versed on.
The reality, however, may be somewhat different. Most of us have never treated a true, honest to goodness, crash-and-burn acute hemolytic reaction (and hope NEVER to do so, by the way), so it is of critical importance to be good and ready with sound advice for your clinicians when one of these bad boys actually happens.
I'll repeat the theme one more time, then I'll stop for awhile: The best time to diagnose an acute HTR is early and the best time to treat one is early; the earlier the better, in fact. Waiting costs precious time that the patient might not have. The treatment will revolve around four things: Pressure/volume support, renal function support, DIC treatment, and removal of incompatible blood.
- If the patient is hypotensive, intravenous fluids and pressors are necessary, but be careful not to overload a volume sensitive patient. Traditionally, we have taught that people with Acute HTRs should be treated with enough volume and diuretics to keep the urine output over 100 ml/hour. The goal of this is twofold: supporting volume and supporting renal function.
- As mentioned before, Acute Tubular Necrosis (ATN) is the primary form of renal pathology in these patients, and prevention involves not only volume but diuretics like IV furosemide or mannitol, with consideration of low dose dopamine (1-5 micrograms/Kg/minute) to dilate renal vasculature.
- Treatment of DIC is no less controversial in this setting than it is anywhere else. The age-old mantra is as follows: "To treat DIC, TREAT THE CAUSE!" While it's hard to argue with this, it's just not always possible. Most people fall into one of two camps on this: Heparin vs. Blood Products. The idea behind the use of heparin is that, since DIC is a consumptive process that involves activation of both the clotting and lysis pathways, the use of heparin may stop the cycle. Heparin is also reported to directly inhibit complement activity, which may slow the hemolytic process, as well. Here's the problem, though: If someone is in DIC and is bleeding out with significant coagulopathy or thrombocytopenia, it is hard to argue with the need for components. Some people believe that giving more components just adds "fuel to the fire" and continues the cycle of clotting and lysis. Personally, my experience is that the use of heparin is often discussed in DIC, but I have seldom actually seen it used.
- Finally, some people have advocated early exchange transfusion to limit the amount of incompatible blood left in the patient's circulation. This is because of the fact that the greater the amount of incompatible blood that is hemolyzed, the worse the patient's ultimate prognosis. There have been some studies to show that rapid exchange transfusion with antigen-negative blood does, in fact, improve prognosis in ABO-incompatible transfusion reactions.
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