**2. A case review**

A 48-year-old female presented to the emergency room of a busy community hospital with the chief complaint of a syncopal episode. She had a history of heavy menstrual bleeding caused by multiple uterine fibroids. Upon arrival, the patient was actively bleeding per vagina. She was pale, but alert and oriented, was tachycardia at 120 beats per minute, and had orthostatic hypotension.

Her past medical history was significant for a DVT while using combined oral contraceptive pills approximately 20 years before. Her past surgical history included a laparoscopic bilateral tubal ligation. She was scheduled to undergo a hysterectomy later that month secondary to her history of heavy menses and her contraindication to estrogen therapy.

While being evaluated in the emergency room, her initial blood work demonstrated a hemoglobin of 9 g/dL, down from her baseline of 12.5 g/dL. Her gynecologist was consulted who recommended performing the hysterectomy in the acute setting given her ongoing bleeding and contraindication to medical management. The patient agreed and consented for surgery.

On the same day, there was a second patient being admitted for a hysterectomy for endometriosis. The patient was known to have two atypical blood antibodies necessitating cross-matched blood to be prepared. The operating staff and blood bank were in close communication for this patient in an event of a hemorrhage.

The first patient was taken to the operating room where a total laparoscopic hysterectomy was performed. Secondary to the location of her uterine fibroids, the patient sustained a laceration to her right uterine artery upon manipulation of the uterus to better visualize the uterine vessels. During attempts to control this bleeding, a massive blood transfusion (MBT) was initiated using non-cross-matched O negative blood. The gynecologic surgeons were unable to properly visualize and control the source of bleeding and therefore converted to a laparotomy.

Upon arrival of the blood products, the patient was immediately transfused. The surgeons completed the hysterectomy but continued to observe significant and diffuse pelvic bleeding. At this time, a surgeon noted that the blood being transfused was not O negative blood. The anesthesiologist was alerted and he immediately stopped the transfusion. The circulating nurse called the blood bank to notify them of the error. The blood bank personnel had incorrectly assumed that the MBT was initiated for the patient who had tested positive for the antibodies. The operating room staff removed all blood products from the operating room, and new O negative noncross-matched blood was sent. By this time, the patient had developed a state of disseminated intravascular coagulation (DIC). With no identifiable active bleeding source, the patient's pelvic cavity and vagina were packed, and she was transferred to the intensive care unit (ICU).

The patient's ICU course included aggressive resuscitative efforts with multiple blood transfusions and ventilator support due to transfusion-related acute lung injury (TRALI). Once stable, the patient was taken back to the operating room for removal of packing and re-exploration where no active bleeding was noted. Fortunately, the patient recovered from her nearfatal injuries, and she was eventually discharged home with a close outpatient follow-up.
