SHOT Annual Report 2009 - Serious Hazards of Transfusion

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RECOMMENDATIONS There are no new recommendations this year; however, previous recommendations remain relevant and those in the table below are pertinent to this year’s report. The second, recommending a national register of patients with antibodies, is now redirected to the newly formed IT subgroup of the NBTC and its counterparts in Scotland, Wales and Northern Ireland. Previous recommendations relevant to this year’s report Year first made Recommendation Target Progress 2008 Prior to transfusion, an antibody history and a transfusion history should be actively sought for previously unknown patients with sickle cell disease. This must include contacting the local blood service reference laboratory as well as any other hospitals the patient has attended. Hospital blood transfusion laboratories The Shared Care document is now nationally available and can be used for patients with sickle cell disease. www.sicklecellsociety.org/pdf/ CareBook.pdf 2008 A national register of patients with antibodies, linked between the red cell reference laboratories, should be considered. UK blood services For 2010 this task is directed to the newly formed IT subgroup of the NBTC. 2005 All cases of suspected AHTR and DHTR should be appropriately investigated, and ideally referred to a reference laboratory. Referring hospitals should make it clear to reference laboratories that they are investigating an HTR to ensure that timely, appropriate tests are undertaken. Clinical details should be completed on the request forms and the donation numbers of the units transfused should be included, so that their phenotype can be determined. Hospital blood transfusion laboratories, Blood Service reference laboratories and the NBTC Transfusion Laboratory Managers Working Group BCSH guidelines for investigation and management of transfusion reactions are in progress. 2005 Reference laboratories should ensure that investigation of DHTRs includes testing an eluate made from the patient’s red cells when the DAT is positive. Blood Service reference laboratories Eluates were undertaken in 63% of cases this year and last year, compared with 35% in 2006 and 50% in 2005, suggesting sustained progress. 2001/02 Consideration should be given to issuing antibody cards or similar information to all patients with clinically significant red cell antibodies. These should be accompanied by patient information leaflets, explaining the significance of the antibody and impressing that the card should be shown in the event of a hospital admission or being crossmatched for surgery. Laboratories should be informed when patients carrying antibody cards are admitted. The CMO’s NBTC and its counterparts in Scotland, Wales and Northern Ireland This recommendation was made in the BCSH Guidelines (BCSH 2004). 106 12. Haemolytic Transfusion Reactions (HTR)
13. Transfusion-Related Acute Lung Injury (TRALI) Definition Transfusion-related acute lung injury (TRALI) is defined as acute dyspnoea with hypoxia and bilateral pulmonary infiltrates during or within 6 hours of transfusion, not due to circulatory overload or other likely causes. DATA SUMMARY Total number of cases 21 Implicated components Mortality/morbidity Highly likely/probable 9 Red cells 2 Deaths due to transfusion 0 Possible/unlikely 12 FFP 2 Deaths in which reaction was implicated Platelets 3 Major morbidity 18 Red cells and cryo 1 2 Unknown 13 Gender Age Emergency vs. routine and core hours vs. out of core hours Where transfusion took place Male Female Unknown 9 12 0 18 years+ 16 years+ to 18 years 1 year+ to 16 years 28 days+ to 1 year Birth to 28 days Unknown Total 19 2 0 0 0 0 21 Emergency Routine Not known In core hours Out of core hours Not known/applicable 21 21 ED Theatre ITU/NNU/HDU/Recovery Wards Community Outpatient/day unit Not known 21 In all, 32 questionnaires were received in 2009: 7 were transferred to other categories – 5 to TACO, 1 to TAD and 1 to ATR – and 4 were withdrawn, leaving 21 reports in this section. Two of the 4 withdrawn cases were withdrawn by the hospital reporter. One occurred before transfusion and the other was found to have bronchopneumonia. The other 2 cases were withdrawn by the analyst because they did not meet the SHOT definition for TRALI: ■■ 1 reaction occurred more than 6 hours after transfusion (12 to 24 hours) and there had been no change in respiratory status. ■■ 1 patient with severe alcoholic liver disease developed worsening respiratory function before transfusion began. This patient had been treated with palliative care because of poor prognosis. Twenty-one cases were analysed and the assessed probability of TRALI is shown in Figure 15. Two patients died, 1 had probable TRALI after RBC (Case 1, page 113) and the other had possible TRALI after RBC and FFP (Case 3). All other patients recovered fully from the event. Seven of 21 analysed cases concerned late reporting of incidents which had occurred in 2008. 13. Transfusion-Related Acute Lung Injury (TRALI) 107
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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
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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 and 108: Table 39 Serology, laboratory signs
Page 109: Table 40 DHTRs - New specificities
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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