Authors: Jastanyah A, Niyaz R I, Bokhari A, et al.
Cureus 17(7): e89128. doi:10.7759/cureus.89128
This case report describes a 58-year-old woman undergoing bilateral total knee arthroplasty who inadvertently received an ABO-incompatible blood transfusion intraoperatively under general anesthesia. Despite this, the patient remained hemodynamically stable with no immediate signs of hemolysis. Intensive post-operative monitoring, including ICU observation, serial lab testing, and interdisciplinary consultation, revealed no clinical or laboratory evidence of hemolytic transfusion reaction apart from a gradual drop in hemoglobin and transiently elevated lactate dehydrogenase (LDH) levels. The patient was discharged home in good condition on postoperative day six.
The case highlights how general anesthesia can mask early signs of transfusion reactions, emphasizing the importance of rigorous verification protocols. The incident was traced to human error in patient-blood bag identification. A hospital-wide corrective action was implemented, including adopting barcode scanning for patient and blood bag matching to prevent future errors. Despite the favorable outcome, the report underscores that mismatched transfusions pose serious risks, and multidisciplinary vigilance, rapid response, and systemic safety protocols are crucial for patient safety.
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