What is the management for a patient with a mismatched blood transfusion?

Management of Mismatched Blood Transfusion

If a mismatched blood transfusion is suspected or confirmed, immediately stop the transfusion, maintain IV access with normal saline, notify the blood bank and physician urgently, and initiate acute transfusion reaction protocols while closely monitoring vital signs and renal function. 1

Immediate Actions

Stop the Transfusion Immediately

• Discontinue the transfusion as soon as any signs of a reaction are detected (tachycardia, rash, breathlessness, hypotension, fever, or hemolysis). 1
• Keep the IV line open with normal saline to maintain vascular access for emergency medications and fluid resuscitation. 2, 3
• Do not discard the blood product or administration set—these must be returned to the blood bank for investigation. 1

Urgent Notifications

• Contact the transfusion laboratory immediately to report the suspected mismatched transfusion. 1
• Notify the responsible physician and activate the transfusion reaction protocol per institutional policy. 2
• Document the exact time the transfusion was stopped and the volume of blood transfused. 1

Clinical Assessment and Monitoring

Vital Signs Monitoring

• Measure heart rate, blood pressure, temperature, and respiratory rate immediately and continue frequent monitoring (every 15 minutes initially). 1
• Assess for signs of acute hemolytic transfusion reaction: fever, chills, back pain, chest pain, dark urine (hemoglobinuria), hypotension, and disseminated intravascular coagulation. 2, 3

Laboratory Investigations

• Send urgent blood samples: complete blood count, direct antiglobulin test (DAT/Coombs), repeat type and crossmatch, coagulation studies (PT, aPTT, fibrinogen), renal function (creatinine, BUN), lactate dehydrogenase (LDH), indirect bilirubin, and haptoglobin. 1, 2, 3
• Collect a fresh urine sample to assess for hemoglobinuria. 2, 3
• Return the blood product unit and administration set to the blood bank for clerical check and serological investigation. 1
• Compare the patient's identification with the blood component label to identify the source of error. 1, 4

Supportive Management

Hemodynamic Support

• Maintain adequate blood pressure and tissue perfusion with IV crystalloid fluids. 1
• In severe hypotension, consider vasopressor support while aggressively treating the underlying hemolysis. 1
• Avoid vasopressors in the initial resuscitation phase if possible, prioritizing volume replacement. 1

Renal Protection

• Maintain aggressive hydration to preserve renal function and prevent acute tubular necrosis from hemoglobinuria. 2, 3
• Target urine output >100 mL/hour initially, then maintain >30 mL/hour. 1
• Consider diuretics (furosemide) if fluid overload develops, but only after adequate volume resuscitation. 2
• Monitor for acute kidney injury with serial creatinine measurements. 3

Pharmacological Interventions

• Administer antihistamines (diphenhydramine) for allergic-type symptoms such as urticaria or pruritus. 1
• Consider corticosteroids (hydrocortisone or methylprednisolone) for moderate to severe reactions. 1
• For life-threatening anaphylaxis: give intramuscular or intravenous epinephrine immediately (0.3-0.5 mg IM for adults). 1

Management of Coagulopathy

• If disseminated intravascular coagulation (DIC) develops, treat aggressively with fresh frozen plasma, cryoprecipitate, and platelets as guided by laboratory results. 1
• Target fibrinogen >1.0 g/L, PT/aPTT <1.5 times control, and platelet count >50 × 10⁹/L (or >100 × 10⁹/L if ongoing bleeding). 1

Prevention of Future Errors

Root Cause Analysis

• The most common cause of mismatched transfusions is failure of bedside identity verification—errors in patient identification or sample labeling account for the majority of cases. 1, 4
• Conduct a thorough investigation to identify whether the error occurred during phlebotomy (wrong blood in tube), laboratory testing, or bedside administration. 4

Critical Safety Checks

• Always verify four core identifiers (first name, last name, date of birth, patient identification number) on the patient's wristband against the blood component label before any transfusion. 1
• Implement two-sample verification systems where the patient's blood type is confirmed on a second sample collected at a different time. 5, 4
• Use electronic identification verification systems or mechanical barrier systems when available to prevent patient misidentification. 5

Special Considerations

RhD Negative Women of Childbearing Age

• If an RhD negative woman receives RhD positive blood, administer high-dose anti-D immunoglobulin immediately to prevent RhD alloimmunization and future hemolytic disease of the fetus and newborn. 6
• Follow up with flow cytometry to monitor clearance of RhD positive red blood cells and antibody screening at regular intervals. 6

Ongoing Hemorrhage

• Diagnosis of transfusion reactions during active bleeding is challenging because hemodynamic instability may be attributed to blood loss rather than the reaction. 1
• Double-check all documentation for administration errors and proceed with laboratory investigation while continuing resuscitation with correctly matched blood products. 1

Common Pitfalls to Avoid

• Never assume vital sign changes are solely due to the patient's underlying condition—always consider transfusion reaction when changes occur during or shortly after transfusion. 1, 2
• Do not delay stopping the transfusion while waiting for laboratory confirmation—clinical suspicion alone warrants immediate cessation. 1, 3
• Avoid using derived fibrinogen levels in massive transfusion scenarios; always request Clauss fibrinogen for accurate assessment. 1
• Remember that hemoglobin concentration may remain falsely elevated immediately after acute blood loss due to inadequate fluid resuscitation. 1