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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 6  |  Issue : 4  |  Page : 239-242

A successful treatment of rhesus positive transfusion in traumatic brain injury patient with rhesus negative: A case report


Department of Anesthesiology and Intensive Care, Dr. Soetomo General Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia

Date of Submission24-May-2022
Date of Decision31-Jul-2022
Date of Acceptance03-Aug-2022
Date of Web Publication31-Oct-2022

Correspondence Address:
Dewi Rosita Hendriana
Department of Anesthesiology and Intensive Care, Dr. Soetomo General Hospital, Faculty of Medicine, Universitas Airlangga, Campus A, Jl. Mayjen Prof. Dr. Moestopo 47, Surabaya, East Java
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjoa.bjoa_153_22

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  Abstract 

Management of Traumatic Brain Injury (TBI) aims to prevent secondary brain injury from factors such as hypoxia, hypotension, and anemia. Transfusion is one of the treatments for anemia in patient with TBI. However, unexpected side effects might occur as a result of transfusion, especially transfusion using different rhesus (Rh). Herein, we reported a 33-years-old male Rh(-) patient who suffered from TBI and anemia, receiving a different Rh transfusion due to stock unavailability and emergency condition. A Focused Abdominal Scan for Trauma (FAST) examination did not discover any fluid in the abdominal cavity. Head CT-scan found intracerebral hemorrhage (ICH) in the right frontotemporal. Legs x-ray found inter trochanter fracture on the right femur. Open reduction and internal fixation (ORIF) plating surgery was conducted to manage the intertrochanter fracture. This patient received 4 bags of blood product type B with Rh(+). After undergoing intensive observation and several more surgeries, the patient survived. In an emergency, patient with Rh(-) who requires blood transfusion but is faced with stock unavailability should considered using Rh(+) blood transfusion to prevent worsening of their condition. Blood product transfusions with different rhesus must be given with the utmost caution and close monitoring to avoid triggering a transfusion reactions.

Keywords: Anemia, rhesus negative, rhesus positive, transfusion traumatic brain injury


How to cite this article:
Maulydia M, Hendriana DR. A successful treatment of rhesus positive transfusion in traumatic brain injury patient with rhesus negative: A case report. Bali J Anaesthesiol 2022;6:239-42

How to cite this URL:
Maulydia M, Hendriana DR. A successful treatment of rhesus positive transfusion in traumatic brain injury patient with rhesus negative: A case report. Bali J Anaesthesiol [serial online] 2022 [cited 2022 Nov 26];6:239-42. Available from: https://www.bjoaonline.com/text.asp?2022/6/4/239/359925




  Introduction Top


Traumatic brain injury (TBI) has continue to grow as one of the biggest cause of mortality and morbidity among all trauma-related injuries.[1] The incidences of TBI due to traffic accidents are most prominent in Southeast Asia at 56%.[1] Prevalence of head injury nationally has increased from 8.2 in 2013 to 11.9% in 2018.[2]

Management of TBI aims to prevent secondary brain injury from factors such as hypoxia, hypotension, and anemia.[3] Anemia can disturb cerebral oxygenation in TBI patient and worsen their outcome, especially when hemoglobin (Hb) <9 g/dL. This is due to Hb being the main determinant of oxygen delivery.[4] A study found that 40–50% of patients with TBI usually experienced hematocrit <30% once during their intensive care unit (ICU) admission.[5] Another study found that Hb <8.0 g/dL occurred in 22% of patients with acute TBI.[6] As prevention, blood transfusion can improve cerebral oxygenation and potentially reduce the risk of tissue hypoxia. Transfusion plays an important role in overcoming anemia in TBI patient.[4]


  Case Report Top


33-years-old men fell from 8-meter height. The patient was brought to a rural hospital. Patient was unconscious and experiencing shock. Resuscitation was done and blood pressure gradually improved. Initial examination showed hemoglobin level was 13 g/dL; however, 6 hours later, it dropped to 6.2 g/dL. CT scan examination of the head showed intracranial hemorrhage (ICH) in the right frontotemporal regions. The patient was then referred to a tertiary hospital.

Physical examination found patient was experiencing tachypnea with respiratory rate (RR) of 24x/m. Oxygen through simple mask was given at 5 L/minute which increased oxygen saturation to 100%. Further examination found blood pressure was 125/78 mmHg, pulse was 91x/m and temperature was 36.8o C. Patient responded to external pain stimulus. Patient experienced bloody otorrhea but not bloody rhinorrhea. There were no racoon eyes. Laboratory examination was done as soon as the patient entered the resuscitation room. His laboratory results are presented in [Table 1].
Table 1: Laboratory examination results

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Radiological examination was done, which include Focused Abdominal Scan for Trauma (FAST), head CT scan and legs x-ray. FAST examination did not find any fluid in the abdominal cavity. Head CT scan found ICH in the right frontotemporal. Legs x-ray found inter trochanter fracture on the right femur.

Operation was needed to manage ICH and inter trochanter fracture on the right femur. Patient was then intubated and intravenous (IV) access was placed. Patient was given metamizole 1 g IV to resolve pain and 200 ml mannitol 20%. The patient blood type was B with Rh(-); however, due to stock unavailability, transfusion using blood product type B with Rh(+) was done. After one bag of packed red blood cells (PRBCs) transfusion, operation was conducted. Evacuation of ICH and external fixation of the right femur was done simultaneously. Two more bags of PRBCs Rh(+) was given during surgery. There was no concerning reaction after the transfusion procedure. After the surgery was finished, patient was transferred to the ICU.

First day after surgery, patient remained under sedation and on ventilator. Patient was given crystalloid infusion of 1,000 ml/24h, antibiotic injection of 1 g/12h, analgetic using non-steroidal anti-inflammatory drugs (NSAID) 1 g/8h and antiemetic agent. Mannitol 100 ml/4h was given to maintain intracranial pressure, and phenytoin injection 100 mg/8 h was given to prevent seizures. For diet, patient was given low-dose enteral nutrition.

On the second day, an infusion pump of fentanyl 10 mcg/h was added as an analgesic, together with NSAID. The patient was also given one bag of stored whole blood (SWB) Rh(+) transfusion and albumin 20% 100 ml. On the third day, fentanyl and mannitol was tapered down with mannitol tapered to 100 ml/8h. Ventilator weaning was started. The other therapies were also continued.

On the fourth day, open reduction and internal fixation (ORIF) plating surgery was conducted to resolve intertrochanter fracture. During the surgery, patient received two bags of whole blood (WB) Rh(-) transfusion. After surgery, patient showed stable vital signs and GCS of 3 × 6. Mannitol was further tapered to 100 ml/12h. On the fifth day, due to the patient’s improvement, extubating was performed. After 14 days of treatment in the ICU, the patient was transferred to the ward without any concerning side effect regarding the transfusion.


  Discussion Top


Negative Rh is commonly found in Caucasians (15%), less common in Black communities (8%) and rare in Asians (1%).[7] In 2010, only 1.2 million (<1%) Indonesian have a blood type with Rh(-).[8] This is going to be a problem when patient with Rh(-) are in an emergency, they usually found it difficult to acquired Rh(-) blood products. The presence of anemia can lead to secondary brain injury and is associated with an increased risk of a worse outcome.[9] As prevention, blood transfusion can improve cerebral oxygenation and potentially reduce the risk of tissue hypoxia.[4]The American Society of Anesthesiologists (2015) supports the use of the strategy of restrictive transfusion, which mean transfusion is given when Hb <8 g/dL and hematocrit <25%.[10] This strategy reduce transfusion and without increasing the risk of a severe outcome.

This patient required surgery but had a very low Hb levels, thus transfusion was needed. Due to stock unavailability, there was no available blood product with Rh(-) and patient received blood product with Rh(+). Surgery was carried out immediately afterward to avoid further delay. Blood transfusion with different Rh compared to the type of patient’s Rh is allowed only in emergency situations that require immediate action.[11]

Rhesus positive people have antigen, which pose a danger to people with Rh(-) who lack antigen. Initially, side effects may not occur when blood product with Rh(+) was given to patient with Rh(-); however, the immune system will responds to these antigens by producing antibodies (anti-D). If transfusion is done again after the formation of anti-D, it will attack the red blood cells.[12] Clots, reaction mismatch and hemolysis of blood cells could happen, this could manifest into jaundice and hemoglobinuria. The reaction may be mild, severe, or even fatal.[13]

This patient received 4 bags of blood product type B with Rh(+). 1 bag of PRBCs before surgery, 2 bags of PRBCs during surgery and 1 bag of SWB on 2nd day after surgery while the patient is recovering in the ICU. There was no concerning reaction after transfusion was done. Later, during ORIF surgery, 2 bags of WB group B with Rh(-) were given. No rejection reaction was found. This may be due to two things, either when the Rh(-) transfusions were administered the anti-D weren’t produced yet or the anti-D were already washed out when the Rh(-) transfusions were administered.[14]

In a study conducted on trauma patients, 20% of patients produced anti-D after being given a transfusion with different Rh. Furthermore, it was found that they could produce anti-D as early as 12 days after transfusion.[15] While another study found that anti-D could be produce 14 to 15 days after transfusion.[14] Patients who produced anti-D were transfused with 6 to 36 units of D-mismatched PRBCs.15] The risk of anti-D formation in a blood transfusion using Rh(+) for patient with an unknown blood group is equal to 3–6%.[14]

Transfusion with Rh(+) does not increase the rate of a hemolytic transfusion reaction nor the mortality and morbidity rate of the patient. Our patient survived after 14 days of monitoring in ICU, and there were no clinical signs of transfusion side effects. The risks of transfusion are outweighed by the benefits of rapid recovery when adequate volume of red blood cells is achieved, especially if the patient is experiencing severe bleeding or life-threatening anemia.[15]


  Conclusion Top


In an emergency, when a patient with an Rh(-) requires blood transfusion but fail to acquire the correct Rh; a similar blood group transfusion with a Rh(+) could be considered. Blood product transfusions with different rhesus must be given with the utmost caution and close monitoring to avoid triggering a transfusion reaction.

Acknowledgement

Not Applicable

Financial support and sponsorship

Nil.

Conflicts of interest

The authors declared that there is not any conflict interest in this study.

Author contributions

M & D.R.H have made substantial contributions to the conception; design of the work; the acquisition, analysis, interpretation of data; the creation of new software used in the work; have drafted the work or substantively revised it.

Consent to participate

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

Ethical approval

Not applicable.



 
  References Top

1.
Dewan MC, Rattani A, Gupta S, Baticulon RE, Hung YC, Punchak M, et al. Estimating the global incidence of traumatic brain injury. J Neurosurg2019;130:1080-97.  Back to cited text no. 1
    
2.
Senapathi TGA, Wiryana M, Aribawa IGNM, Ryalino C. Bispectral index value correlates with glasgow coma scale in traumatic brain injury patients. Open Access Emerg Med 2017;9:43-6.  Back to cited text no. 2
    
3.
Jeremitsky E, Omert L, Dunham CM, Protetch J, Rodriguez A. Harbingers of poor outcome the day after severe brain injury: Hypothermia, hypoxia, and hypoperfusion. J Trauma 2003;54:312-9.  Back to cited text no. 3
    
4.
Lelubre C, Bouzat P, Crippa IA, Taccone FS. Anemia management after acute brain injury. Crit Care 2016;20:152.  Back to cited text no. 4
    
5.
Utter GH, Shahlaie K, Zwienenberg-Lee M, Muizelaar JP. Anemia in the setting of traumatic brain injury: The arguments for and against liberal transfusion. J Neurotrauma 2011;28:155-65.  Back to cited text no. 5
    
6.
Schirmer-Mikalsen K, Vik A, Gisvold SE, Skandsen T, Hynne H, Klepstad P. Severe head injury: Control of physiological variables, organ failure and complications in the intensive care unit. Acta Anaesthesiol Scand 2007;51:1194-201.  Back to cited text no. 6
    
7.
Gundrajukuppam DK, Vijaya SB, Rajendran A, Sarella JD. Prevalence of principal rh blood group antigens in blood donors at the blood bank of a tertiary care hospital in southern india. J Clin Diagn Res 2016;10:EC07-10.  Back to cited text no. 7
    
8.
Golassa L, Tsegaye A, Erko B, Mamo H. High rhesus (rh(D)) negative frequency and ethnic-group based Abo blood group distribution in ethiopia. Bmc Res Notes 2017;10:330.  Back to cited text no. 8
    
9.
East JM, Viau-Lapointe J, McCredie VA. Transfusion practices in traumatic brain injury. Curr Opin Anaesthesiol 2018;31:219-26.  Back to cited text no. 9
    
10.
American Society of Anesthesiologists Task Force on Perioperative Blood Management. Practice guidelines for perioperative blood management: An updated report by the american society of anesthesiologists task force on perioperative blood management. Anesthesiology 2015;122:241-75.  Back to cited text no. 10
    
11.
Dean L. Blood Groups and Red Cell Antigens [Internet]. Bethesda (MD): National Center for Biotechnology Information (US); 2005. Chapter 3, Blood transfusions and the immune system. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2265/  Back to cited text no. 11
    
12.
Strobel E. Hemolytic transfusion reactions. Transfus Med Hemother 2008;35:346-53.  Back to cited text no. 12
    
13.
Rh and blood transfusion. Nature1945;156:625-6.  Back to cited text no. 13
    
14.
Frohn C, Dümbgen L, Brand JM, Görg S, Luhm J, Kirchner H. Probability of anti-D development in D- patients receiving D+ rbcs. Transfusion 2003;43:893-8.  Back to cited text no. 14
    
15.
Tchakarov A, Hobbs R, Bai Y. Transfusion of D+ red blood cells to D- individuals in trauma situations. Immunohematology 2014;30:149-52.  Back to cited text no. 15
    



 
 
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