SHOT Annual Report 2009 - Serious Hazards of Transfusion

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Case A8 A patient with known anti-E and a non-specific cold antibody received 3 units of red cells compatible by NISS IAT. At the end of the third unit the patient developed fever, dark urine and jaundice. There was a rise in bilirubin, and a 2.0 g/dL fall in Hb. Anti-E and weak anti-C w were identified in the post-transfusion sample, and retrospectively in the pre-transfusion sample using DiaMed and PEG IAT. An eluate revealed weak anti-C w and the first unit was confirmed as C w positive. However, the patient had a positive DAT before transfusion (IgG coating), was on high dose antibiotics, and had hypersplenism. The haemolysis continued for some time after the transfusion, and the patient required no further transfusion post splenectomy. The reporter concluded that the haemolysis was unlikely to have been due to the anti-C w . HLA antibodies apparent cause of AHTR Case A5 Having been transfused 100 mL for symptomatic anaemia, a patient suffered nausea, vomiting, rigors, fever, abdominal and knee pain, tachycardia and hypotension. Her O 2 saturation fell to 90%. She required resuscitation with O 2 and fluids. Immediate symptoms were followed by signs of haemolysis. Pre- and post-transfusion antibody screens were negative and blood was issued electronically. Although the DAT was positive (IgG coating) on both the pre- and posttransfusion samples, an eluate was non-reactive. Anti-C and a pan-reactive autoantibody were detected using a 2 stage enzyme; a retrospective IAT crossmatch was initially incompatible, but the antibody was not identified. Three weeks later a further incompatible unit was found. Further testing showed the patient’s plasma to be positive against HLA A28, B7 and B17 (Bg c , Bg a , Bg b , respectively). The implicated donor was typed as HLA-B57 (a subgroup of B17); the serological incompatibility was not confirmed by IBGRL, but a CDC crossmatch was positive. Although the serological picture is not clear, this appears to be an acute haemolytic transfusion reaction due to Bg antibodies. Learning points ■■ ■■ ■■ The patient’s clinical condition can obscure the diagnosis of an acute haemolytic reaction. Testing an eluate is an important part of investigating an HTR. Presence of an alloantibody does not prove cause and effect. Serological findings – DHTR n = 39 Kidd (Jk) and Rh alloantibodies were the most common, present in 18/39 and 19/39 (46 and 49%) cases respectively, either singly or in combination with other specificities. Table 39 shows details of the serology, laboratory signs and time interval by case, and Table 40 shows the specificity of new antibodies detected post transfusion, by blood group system. 102 12. Haemolytic Transfusion Reactions (HTR)
Table 39 Serology, laboratory signs and timing of reaction Case no. New antibody(ies) in plasma Antibodies in eluate Comments 1 K Not performed Hb↓ bilirubin↑; dark urine 7 2 C None Hb↓ bilirubin↑ creatinine↑ 8 3 Jk a Not performed bilirubin↑ 17 4 K, c Not performed Hb↓ bilirubin↑ dyspnoea, hypotension 13 5 Jk a Jk a No signs or symptoms 14 6 Jk a , K, warm auto Jk a Hb↓ 3 7 Jk b No specificity Hb↓ bilirubin↑; fever during transfusion; known anti-K 10 8 K Not performed No signs or symptoms; died unrelated 7 9 C, E, auto-D E Hb↓ bilirubin↑. Normal D gene confirmed – presumably auto anti-D 13 10 Jk a , E Not performed Hb↓ bilirubin↑↑; dyspnoea, hypotension, fever 10 Days post transfusion 11 E E No signs or symptoms; prob. primary response 10 weeks 12 Jk a None bilirubin↑, poor Hb increment 16–18 13 D Not performed bilirubin↑ 5–8 14 Jk a Not performed Hb↓ bilirubin↑ 17 15 c Not performed Hb↓ 14 16 C Not performed no Hb increment. Known anti-Jk a ?26 17 c c Hb↓ Hburia (?UTI) 4 18 Lu a Jk a No signs or symptoms 54 19 Jk b None Hb↓ bilirubin↑ creatinine↑; known anti-c 7 20 Jk a Jk a Hb↓ 22 21 Fy a Not performed Hb↓ bilirubin↑ 6 22 Jk a Jk a Hb↓ 10 23 C, E None No Hb increment ?? 24 Jk a Not performed No signs or symptoms 10 25 Jk b Jk b Hb↓ bilirubin↑ 23 26 Jk a , C w , auto Jk a + panagg Hb↓ bilirubin↑ 6 27 c Not performed Hb↓ bilirubin↑ LDH↑; known anti-E 17 28 E+K K No signs or symptoms 16 29 Jk a Jk a Hb↓ 8 30 None None Hb↓ Hburia, methaem 7 31 E E bilirubin↑ creatinine↑ 2–3 32 S (detected previously elsewhere) Not performed Hb↓↓ bilirubin↑; known anti-M (+S); also ?hyperhaemolysis 1–2 33 K K No signs or symptoms 74 34 Fy a , Fy3, S Not performed Hb↓↓ dark urine, LDH↓, ?hyperhaemolysis 7 35 S, Jk b S+Jk b No signs or symptoms. Known anti-E 12–14 36 Fy3 Inconclusive Hb↓↓ bilirubin↑↑ dark urine. Known anti-Fy a +Jk b +M. SCD 2 37 Jk b Jk b M Hb↓↓ bilirubin↑↑ Hburia 8 38 D D No signs or symptoms 28 39 E, c, A 1 , K, S, Fy b , Jk b None No signs or symptoms; platelet transfusions only ? 2 months 12. Haemolytic Transfusion Reactions (HTR) 103
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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
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Learning points ■■ ■■ Where
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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 and 102: Previous recommendations that are s
Page 103 and 104: Figure 13 Number of cases of HTR re
Page 105: Antibody only detectable in eluate
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
Page 153 and 154: 21. Near Miss Reporting Definition
Page 155 and 156: 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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