SHOT Annual Report 2009 - Serious Hazards of Transfusion

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12. Haemolytic Transfusion Reactions (HTR) Definition Haemolytic transfusion reactions are split into two categories: acute and delayed. ■■ Acute reactions are defined as fever and other symptoms/signs of haemolysis within 24 hours of transfusion, confirmed by one or more of: a fall in Hb, rise in LDH, positive DAT and positive crossmatch. ■■ Delayed reactions are defined as fever and other symptoms/signs of haemolysis more than 24 hours after transfusion; confirmed by one or more of: a fall in Hb or failure of increment, rise in bilirubin, positive DAT and positive crossmatch which was not detectable pre transfusion. ■■ Simple serological reactions (development of antibody without positive DAT or evidence of haemolysis) are excluded. DATA SUMMARY Total number of cases 47 Implicated components Mortality/morbidity Red cells 46 Deaths due to transfusion 0 FFP 0 Deaths in which reaction was implicated Platelets 1 Major morbidity 8 Other (specify) 0 Unknown Gender Age Emergency vs. routine and core hours vs. out of core hours Where transfusion took place Male Female Unknown 21 26 0 18 years+ 16 years+ to 18 years 1 year+ to 16 years 28 days+ to 1 year Birth to 28 days Unknown Total 45 0 2 0 0 0 47 Emergency Routine Not known In core hours Out of core hours Not known/applicable 6 37 4 47 ED Theatre ITU/NNU/HDU/Recovery Wards Community Outpatient/day unit Not known 47 Sixty questionnaires were received; 9 were transferred out, 6 to the IBCT and 3 to ATR; 4 were withdrawn. This section describes the findings from 47 cases: 8 acute and 39 delayed reactions. Patients There were 21 male and 26 female patients, with an age range from 4 to 94 years old. Two patients were under 18 years of age: 2 patients with sickle cell disease (SCD), aged 4 and 7, each of whom suffered a DHTR with anti-Jk b and anti-S implicated respectively. The latter may have been preventable with better communication between hospitals, but probably also included an element of hyperhaemolysis. 98 12. Haemolytic Transfusion Reactions (HTR)
Figure 13 Number of cases of HTR reviewed since 1996 60 55 50 47 47 43 40 39 34 Number of reports 30 20 23 25 30 24 25 28 23 10 0 1996–97 1997–98 1998–99 1999–00 2000–01 2001–02 (15 months) 2003 2004 2005 2006 2007 2008 2009 Year of report Mortality, Morbidity, and Imputability Acute haemolytic transfusion reactions (AHTR) n = 8 There were no deaths caused, or contributed to, by these transfusion reactions. There were 3 cases of major morbidity; one patient (A4) required ITU admission, while the other 2 (A7, A8) showed signs of deteriorating renal function. Four reactions were reported as definitely related to the transfusion (imputability 3), 3 probably related (imputability 2), and 1 possibly related (imputability 1). Delayed haemolytic transfusion reactions (DHTR) n = 39 There were 2 patients in this group who died from underlying disease, not related to the transfusion reaction. There were 5 cases of major morbidity. One patient (D10) required dialysis, but made a full recovery. One patient with SCD (D34) required ITU admission following a severe episode of hyperhaemolysis. The other 3 cases showed signs of deteriorating renal function, but did not require dialysis. Of the remaining 32 cases, 23 patients suffered minor morbidity and 9 had no clinical signs or symptoms. One patient did not even develop a positive DAT, but the case is included in this chapter because of its unusual nature (D39). From 2010, the Dendrite database will accept reports of simple antibody formation without a positive DAT or any other signs or symptoms. Case D39 Development of multiple red cell antibodies following platelet transfusion An elderly patient with MDS received a total of 25 adult doses of platelets but no red cells, over a period of approximately a year, and developed anti-c, -E and -A 1 , followed by anti-K, -S, -Fy b , and -Jk b . There were no clinical or laboratory signs of a haemolytic reaction. The patient finally developed platelet antibodies (anti-HPA-2a) in addition to his red cell antibodies. 12. Haemolytic Transfusion Reactions (HTR) 99
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Annual Report 2009 Affiliated to th
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Requests for further information sh
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1. Foreword The Serious Hazards of
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2. SHOT - The UK Haemovigilance Sch
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3. Participation in Haemovigilance
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Figure 2 Number of reports sent per
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For the first time this year, SHOT
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4. SHOT 2009-2010 UK Transfusion La
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Update on 2008 recommendations Last
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Numbers of components issued In 200
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Table 10 Cumulative mortality/morbi
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Acute transfusion reaction (ATR) Th
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6. Key Messages and Main Recommenda
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Recommendation All pulmonary compli
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2005 Appropriate use of blood compo
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7. Incorrect Blood Component Transf
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Table 12 Summary of IBCT cases Type
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Major morbidity There were 2 cases
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Wrong blood components transfused t
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Learning points ■■ All componen
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Table 15 Number of staff involved i
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All of the errors in this group wer
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Trust and sometimes in separate Tru
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IBCT events originating in the hosp
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multiple group O components; 1 grou
Page 51 and 52: Learning points ■■ ■■ Where
Page 53 and 54: Three interpretation errors occurre
Page 55 and 56: IT must be used to its full potenti
Page 57 and 58: Case 8 When the laboratory knows of
Page 59 and 60: ■■ All staff must take full pro
Page 61 and 62: 7.1 Errors Relating to IT Systems (
Page 63 and 64: to laboratory B. The clinical reque
Page 65 and 66: Improving Laboratory Standards (bas
Page 67 and 68: 7.2 Right Blood Right Patient (RBRP
Page 69 and 70: COMMENTARY Each year SHOT emphasise
Page 71 and 72: Core hours vs. out of hours and Whe
Page 73 and 74: Broad breakdown of where primary er
Page 75 and 76: Case 6 Dilute (possible drip arm) s
Page 77 and 78: Case 10 Over-transfusion following
Page 79 and 80: 9. Handling and Storage Errors (HSE
Page 81 and 82: Excessive time to complete administ
Page 83 and 84: etween removing the component from
Page 85 and 86: 10. Adverse Events Relating to Anti
Page 87 and 88: Omission or late administration of
Page 89 and 90: Anti-D Ig given to the wrong patien
Page 91 and 92: RECOMMENDATIONS New recommendations
Page 93 and 94: Case 1 Possible fatal reaction A ma
Page 95 and 96: adequate resources both for monitor
Page 97 and 98: Figure 12 Reaction by component typ
Page 99 and 100: Bacterial culture of patient and un
Page 101: Previous recommendations that are s
Page 105 and 106: Antibody only detectable in eluate
Page 107 and 108: Table 39 Serology, laboratory signs
Page 109 and 110: Table 40 DHTRs - New specificities
Page 111 and 112: 13. Transfusion-Related Acute Lung
Page 113 and 114: Classification of cases according t
Page 115 and 116: Comparative data on implicated comp
Page 117 and 118: Case Histories TRALI probable Case
Page 119 and 120: RECOMMENDATIONS New recommendations
Page 121 and 122: Table 42 Cases classified according
Page 123 and 124: Clinical details and transfused flu
Page 125 and 126: Cases in which RBC transfusion was
Page 127 and 128: exchange in patients with TTP. 43 I
Page 129 and 130: 15. Transfusion-Associated Dyspnoea
Page 131 and 132: 16. Post-Transfusion Purpura (PTP)
Page 133 and 134: ■■ The requirement to irradiate
Page 135 and 136: Two incidents (both bacterial, desc
Page 137 and 138: Viral and parasitic TTIs Since 1996
Page 139 and 140: The most likely source of the organ
Page 141 and 142: 19. Autologous Transfusion Definiti
Page 143 and 144: RECOMMENDATIONS There are no new re
Page 145 and 146: Introduction and overall trends In
Page 147 and 148: incident group O D negative units w
Page 149 and 150: Table 47 Types of reactions for eac
Page 151 and 152: always require notification by clin
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21. Near Miss Reporting Definition
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29 UK Resuscitation Council Emergen
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24. Acknowledgements The Steering G
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SHOT Annual Report 2009 - Serious Hazards of Transfusion

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