GAP-114
Anaphylactic reaction to platelet transfusion post cardiopulmonary bypass in an infant
Magsino K, Trieu C
UCLA, Los Angeles, CA, US
Introduction:
The treatment of bleeding during cardiac surgery is a major perioperative concern in pediatrics. Thrombocytopenia and thrombocytopathy are common after cardiopulmonary bypass (CPB) due to mechanical destruction of platelets and hemodilution. Although blood transfusion is generally safe, there are risks. These risks include allergic reactions, infection, and volume overload(1).
Case Report:
5 month-old 5.4Kg female with a history of tetralogy of fallot (TOF) and pulmonary stenosis presented for TOF repair. After an uneventful separation from CPB, the platelet count was 47,000. The patient received 20cc of donor directed ABO incompatible platelets prior to notification by blood bank that the patient required ABO compatible platelets given she was less than 10Kg,per institutional policy. Vitals remained stable. No evidence of hemolysis noted. Due to continued bleeding, 55cc of ABO compatible platelets was transfused. Hemodynamic instability with severe sustained hypotension was then noted. Severe bronchospasm with bilateral diffuse wheezing and worsening lung compliance leading to oxygen desaturation was noted. Given reassuring evidence of successful cardiac repair, anaphylactic versus anaphylactoid reaction to ABO compatible platelets was thought to be the etiology due to the timing and constellation of symptoms. The patient remained in labile critical condition for the next 24 hours in the ICU requiring significant cardiopulmonary support despite reassuring cardiac function. With supportive management, the patient recovered and was discharged home on POD 9.
Discussion:
Pediatric cardiac surgeries are associated with a high rate of transfusion of blood products. The CPB machine requires a significant priming volume leading to hemodilution of coagulation factors and platelets. Platelet dysfunction also occurs as a result of platelet contact with the synthetic material of the CPB machine. The patient’s young age and small size, most notably neonates and infants less than 10Kg, can greatly compound the issue of hemodilution due to small blood volumes, immature coagulation system, and reduced platelet aggregation.
Platelet transfusion is associated with a higher rate of transfusion reactions compared to pRBC's and plasma(2). ABO incompatible platelets are routinely given to patients without consequence. This is due to the dilution of donor anti-A or anti-B antibodies in the adult recipient’s relatively large plasma volume, which is not the case in infants(3).While the use of blood products is necessary and routine in pediatric cardiac surgeries, it is important to keep in mind the serious transfusion reactions that can occur. Life-threatening anaphylaxis is rare, but requires urgent detection and supportive care.
References:
1. Hirayama F. Current understanding of allergic transfusion reactions: incidence, pathogenesis, laboratory tests, prevention and treatment.British Journal of Haematology. 2013 Feb; 160(4);
434-444.
2. Guay J. Mediastinal Bleeding After Cardiopulmonary Bypass in Pediatric Patients. Annals of Thoracic Surgery. 1996.Volume 62 , Issue 6 , 1955 – 1960.
3. Sid J. Platelet Transfusion-the Art and Science of Compromise. Transfusion Medicine and Hemotherapy. 2013 June; 40(3)160-171.
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