SHOT Annual Report 2009 - Serious Hazards of Transfusion

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Serological techniques used – DHTRs only Antibody screening was undertaken using a variety of automated systems, broadly representative of those used routinely in the UK. Of those answering the question, 19 undertook an IAT crossmatch (7 of these had a positive antibody screen), 3 an immediate spin, and 14 electronic issue. Use of eluates In 24/39 (62%) of cases an eluate was made from the patient’s post-transfusion red cells and tested for antibody. This is similar to last year (63%). Of these eluates, 17 were performed in reference laboratories and 6 in-house (one unknown). In 16 cases (67%) a specific antibody(ies) was identified. In 1 case (D18), anti-Jk a was detectable only in the eluate. Retrospective testing findings Retrospective testing of the pre-transfusion sample was undertaken in house in 7 (18%) cases: the same results were obtained in all 7 cases. However, in 4/7, no different or additional testing was undertaken, and none was confirmed by a reference centre. In most cases the pre-transfusion sample had been discarded, even though in 2 cases the reaction occurred within 3 days of transfusion. DHTR cases Case D34 Major morbidity in patient with sickle cell disease A female patient with SCD and a history of transfusion but no alloantibodies had an 8 unit red cell exchange. Seven days later she returned to the ED with several signs of severe haemolysis, her Hb having fallen from 10.4 g/dL to 4.2 g/dL. The reporter queries an element of hyperhaemolysis as well as DHTR. The DAT was strongly positive with IgG coating, and anti-Fy a , -Fy3 and -S were identified in the plasma, but no eluate was performed. The patient required ITU admission but made a full recovery. As a result of this reaction, the hospital is changing its transfusion policy for patients with SCD, to give Fy(a-) red cells to Fy(a-) individuals. Case D32 A 7-year-old patient with SCD and a historical record of anti-M, not currently detectable, was transfused with 2 units of M negative red cells (Rh and K matched). The Hb fell from 8.6 g/dL immediately post transfusion to 4.1 g/dL 48 hours later, 1 g/dL lower than the pre-transfusion Hb of 5.1 g/dL. Other signs of haemolysis were dark urine, and rising bilirubin and LDH. The patient was transferred to a second hospital which the patient had attended 2 months earlier, when anti-S had been identified in addition to anti-M. One of the units transfused had been S positive, and the patient was found to have a positive DAT, though an eluate was non-reactive. Anti-S and anti-M became detectable 3 days post transfusion. This appears to be a case of HTR due to anti-S combined with hyperhaemolysis. Learning points ■■ ‘ New’ patients with sickle cell disease are likely to have been tested and possibly transfused elsewhere. They are at higher than average risk of developing red cell antibodies and hospitals should actively seek a transfusion and antibody history. ■■ Where care is shared between hospitals there should be a system for communicating important serological information between sites. Case D30 No specificity identified A woman required an emergency transfusion of 5 units of red cells and 2 units FFP at delivery. Nine days later her DAT was weakly positive, Hb had fallen by 3 g/dL, haptoglobins became undetectable and LDH was raised. The blood service identified weak anti-C by enzyme techniques only and obtained a strong reaction with a single panel cell, but were unable to identify a specificity. The patient had received a massive transfusion at delivery several years earlier. 104 12. Haemolytic Transfusion Reactions (HTR)
Table 40 DHTRs – New specificities by blood group system Antibody specificity by blood group system No. cases Sole new antibody Kidd Jk a 12 Jk b 6 8 4 Rh C E c D C w Auto anti-D 4 7 5 2 1 1 2 2 3 2 Kell K 7 3 Duffy Fy a Fy b Fy3 2 1 2 1 1 MNSs S M 4 1 1 Other Lu a 1 A 1 1 COMMENTARY ■■ ■■ ■■ ■■ Antibodies not commonly associated with haemolytic transfusion reactions were identified in several patients following AHTRs. It is likely in some cases that these antibodies were not responsible for the reaction. Patients with sickle cell disease are once again prominent in both AHTR and DHTR cases. These patients are particularly vulnerable to haemolytic reactions as they have a higher incidence of sensitisation, are prone to episodes of hyperhaemolysis and have clinical symptoms which can mask HTRs. In addition they often move between different treatment centres. As the result of a serious DHTR, one centre has changed its policy to routinely provide Fy(a-) blood to Fy(a-) patients with SCD. HLA antibodies (Bg) were apparently the cause of a severe AHTR. Although Bg antibodies are usually benign, there have been a few associated cases of HTR reported in the literature. 35,36 In 3 cases (one acute, and 2 delayed), an antibody specificity was identified in an eluate made from the patient’s post-transfusion red cells which had not been detected in the plasma. This highlights the vital role played by this test in the investigation of an HTR. 12. Haemolytic Transfusion Reactions (HTR) 105
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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
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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 and 106: Antibody only detectable in eluate
Page 107: Table 39 Serology, laboratory signs
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
Page 157: 24. Acknowledgements The Steering G
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SHOT Annual Report 2009 - Serious Hazards of Transfusion

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