Severe hypotensive transfusion reaction in a patient with liver dysfunction: A case report

Massive transfusion protocols (MTPs) are essential for managing substantial intraoperative bleeding. However, transfusion-related complications such as hypotensive transfusion reactions (HyTRs), although uncommon, can be overlooked during emergencies, particularly in patients with hepatic impairment.

A 56-year-old woman with compensated cirrhosis, hepatic metastases, hypertension (on carvedilol), and well-controlled type 2 diabetes presented with progressive lower limb weakness from a compressive extradural spinal lesion. Surgery required activation of an MTP. She received four units each of O-positive packed red blood cells (PRBCs), random donor platelets (RDPs), and Fresh Frozen Plasma (FFP). Haemorrhage was controlled and the patient stabilised; MTP was discontinued. Approximately 5 min after starting the fourth unit of FFP, she developed sudden, profound isolated hypotension without other signs of allergic reaction, hemolysis or volume overload. The transfusion was stopped and vasopressors restarted; blood pressure normalised within 10 min. Alternative causes were systematically excluded. Given the temporal relationship with FFP and underlying hepatic dysfunction, a bradykinin-mediated HyTR was considered. Histopathology later confirmed poorly differentiated pancreaticobiliary adenocarcinoma.

This case highlights the importance of recognising bradykinin-mediated HyTRs during FFP transfusion, especially in patients with liver dysfunction where impaired bradykinin degradation may contribute to accumulation. Prompt recognition, exclusion of alternative causes, and supportive management are crucial for favourable outcomes.