Discussion on a Case of “Urgent” Blood Transfusion in Clinical Application

Emergency blood transfusion is a critical intervention in lifethreatening situations where time- sensitive decision-making directly impacts patient survival. In the Emergency Department (ED), transfusions are often required before complete serologic testing or crossmatching can be performed, especially in cases of trauma, gastrointestinal bleeding, or obstetric emergencies. The urgency of such interventions mandates protocols that prioritize rapid response over conventional compatibility testing, particularly when the patient’s blood type is unknown. Özgür et al. highlighted that a significant proportion of blood transfusions in the ED are conducted under urgent or extremely urgent conditions, necessitating streamlined protocols for rapid administration [1]. Similarly, Quintana-Díaz et al. emphasized that transfusion in the emergency setting goes beyond mere administration of blood products, involving complex clinical decision- making to balance timeliness, safety, and resource utilization [2]. However, while uncross matched transfusion of type O red blood cells—often RhDpositive— is a commonly accepted practice in extreme emergencies, it carries inherent immunologic risks.

Studies have shown that such transfusions, especially in patients with pre-existing alloantibodies, may lead to haemolytic reactions and other transfusion-related complications if not managed with caution. Shander noted the emerging risks associated with intraoperative and emergency transfusions, underscoring the need for improved transfusion strategies and risk mitigation approaches [3]. Additionally, Maxwell’s analysis in obstetric settings illustrated how the need for transfusion during caesarean sections parallels the urgency seen in trauma care, reinforcing the need for preplanned emergency transfusion pathways [4]. Saverimuttu et al. further warned of the high prevalence of clinically significant red cell antibodies in specific patient groups, raising concerns over the safety of uncross matched transfusion in diverse populations [5]. Given these complexities, it is imperative to establish and evaluate structured protocols—such as “extremely urgent” transfusion plans—for administering uncross matched blood products. These protocols must aim to maximize patient benefit while minimizing immunohematology risk, particularly in settings where conventional pre-transfusion testing is not feasible.

In emergency situations where patients in clinical departments such as respiratory medicine or gastroenterology experience critical conditions requiring urgent transfusion, and their blood type is unknown and crossmatching has not been performed, it is essential to promptly activate the Recommended Scheme for Emergency Rescue Transfusion under Special Circumstances (hereinafter referred to as the “Recommended Scheme”). This protocol mandates the initiation of emergency transfusion within 15 minutes, referred to as “extremely urgent” transfusion. Compared with ordinary emergency transfusion, “extremely urgent” transfusion is characterized by a more critical time constraint, unknown (or unconfirmed) blood type, and the absence of crossmatching. In such situations, a small amount (1–2 units) of type “O” RhD-positive suspended red blood cells is transfused immediately to achieve rapid intervention. Simultaneously, efforts are made to determine the patient’s blood type and complete crossmatching within the shortest possible time to maximize the chances of survival. This paper presents an analysis and discussion of a recent case of “extremely urgent” transfusion that occurred in our hospital.

The patient was a 61-year-old female who presented with acute onset and a short medical history. The chief complaint was multiple traumatic injuries caused by a fall from height, accompanied by hypotension and impaired consciousness.

The patient appeared anaemic, with pale skin and mucous membranes. There was a slight depression in the right frontal region and a laceration approximately 7 cm in length, with some dried blood scabs. Conjunctivae were pale, sclerae showed no jaundice, and the bulbar conjunctivae were mildly edematous. Pupils were unequal in size: the left pupil measured approximately 6 mm in diameter and the right pupil 5 mm, with no light reflex detected. Breath sounds in both lungs were slightly coarse, with a few moist rales; no pleural friction rubs were heard. Cardiac borders were within normal limits, heart rate was 100 beats per minute with a regular rhythm, and no murmurs or pericardial friction rubs were auscultated. The abdomen was flat and soft, with no palpable liver or spleen below the costal margins; shifting dullness was negative, and bowel sounds were absent. Ecchymosis and swelling were observed in the left lumbar region and left lower limb. The skin on the dorsum of the left hand was cyanotic. The extremities were cold, with weak arterial pulsations.

1. Intra-abdominal hemorrhage due to liver and splenic rupture
2. Traumatic haemorrhagic shock
3. Severe haemorrhagic anaemia
4. Right frontotemporal skull fracture with right frontal cerebral contusion and laceration
5. Right frontal epidural hematoma
6. Mild subarachnoid hemorrhage
7. Fracture of the anterior arch and right lateral mass of the atlas
8. Atlantoaxial subluxation
9. Comminated fracture of the distal left femur
10. Metabolic acidosis
11. Electrolyte imbalance

In this case, the emergency department physician submitted an “extremely urgent” request for the transfusion of two units of type “O” RhD-positive suspended red blood cells. Subsequently, upon receiving the patient’s blood specimen, the transfusion department determined the patient’s blood type to be type “A” RhD-positive. Crossmatching results showed major compatibility but minor side agglutination (4+). During the transfusion of the two units of type “O” RhD-positive red blood cells, the patient exhibited no adverse transfusion reactions. Following this, the patient received an additional 4.5 units of type “A” RhD-positive suspended red blood cells. During surgery, the patient was transfused with 20 units of type “A” RhD-positive cryoprecipitate, 6 units of suspended red blood cells, and 1000 mL of plasma.

After postoperative treatment, the patient recovered and was discharged. In this case, the use of type “O” RhD-positive red blood cells as an emergency unmatched transfusion, before confirmation of the patient’s blood type and completion of crossmatching, gained valuable time for treatment. With subsequent blood typing and crossmatching results, the transfusion protocol was promptly adjusted, ultimately leading to the patient’s recovery. Comparative analysis of haematological parameters before and after transfusion showed marked improvement: RBC increased from 1.03 × 10 ¹² /L to 3.23 × 10 ¹² /L; haemoglobin (Hb) increased from 31 g/L to 95 g/L; and haematocrit (Hct) rose from 10.02% to 28.5%. These findings underscore the necessity and effectiveness of implementing the Recommended Scheme in such emergency rescue scenarios.

This study focuses on the implementation and evaluation of “extremely urgent” transfusion protocols in emergency scenarios where time is critically limited and the patient’s blood type is unknown or unconfirmed, and crossmatching has not been performed. Based on the analysis of the presented case and drawing on extensive experience in transfusion practices and standards, the following conclusions are made:
a) The management approach in this “extremely urgent” transfusion case is consistent with the Recommended Scheme for emergency transfusions under special conditions, such as complex blood types, ABO forward and reverse typing discrepancies, and undeterminable blood types. The use of type O RhD-positive suspended red blood cells in such instances is in accordance with recommended standards. Additionally, this case provides supplementary strategies for managing “extremely urgent” transfusions, which are not explicitly addressed in the current guidelines.
b) The successful outcome of this case demonstrates that, in life-threatening emergencies, even heterologous transfusion can effectively alleviate time constraints, allowing for subsequent blood typing and crossmatching, and ultimately improving the patient’s prognosis and recovery rate.
c) During the execution of “extremely urgent” transfusions, utmost caution must be exercised, with emphasis on minimal volume transfusion. Once the transfusion department receives the patient’s blood specimen, prompt blood typing and crossmatching must be performed, and the transfusion plan should be adjusted accordingly. The results must be immediately communicated to the clinical team, who must closely monitor the patient during the transfusion. If any transfusion reaction occurs, the transfusion must be stopped immediately.
d) Although “extremely urgent” transfusions are justified and beneficial in critical situations, the approach carries inherent limitations under current transfusion guidelines. Identifying only the ABO and Rh blood group systems may not account for incompatibilities in other blood group systems, posing significant risks. These include febrile or allergic reactions, or even haemolysis, which may be life-threatening.
e) Given the high risk associated with “extremely urgent” transfusions, their use should be strictly limited and not abused. Transfusion departments and clinical teams must engage in clear communication and adhere to standardized procedures. It is recommended that the hospital transfusion committee establish strict regulations and formal protocols for “extremely urgent” transfusions, providing clear operational guidance for physicians and laboratory staff, and thereby minimizing the risk of transfusion-related medical incidents.

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1. Özgür Y, Akın S, Gecmez G, Aladag N, Keskin O (2018) How Urgent are Blood Transfusions Provided in Emergency Service? Southern Clinics of Istanbul Eurasia 29(3): 180-186.
2. Quintana-Diaz M, Andres-Esteban EM, Sanchez-Serrano J, Martinez-Virto A, Juarez-Vela R, et al. (2020) Transfusions in the Emergency department: More than a blood Rev Clin Esp 220(7): 393-399.
3. Shander A (2004) Emerging Risks and Outcomes of Blood Transfusion in Surgery. Semin Hematol 41(1 Suppl): 117-124.
4. Maxwell CN (1989) Blood Transfusion and Caesarean Australian and New Zealand Journal of Obstetrics and Gynecology 29(2): 121-123.
5. Saverimuttu J, Greenfield T, Rotenko I, Crozier J, Jalaludin B, et al. (2003) Implications for urgent transfusion of uncross matched blood in the emergency department: the prevalence of clinically significant red cell antibodies within different patient Emerg Med 15(3): 239-243.