SHOT Annual Report 2009 - Serious Hazards of Transfusion

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Figure 15 Summary of cases Assessment of TRALI Cases There is no diagnostic test for TRALI and it is easily confused with other causes of acute lung injury, circulatory overload or infection. More than one cause may have contributed to the respiratory impairment in many cases and TRALI may co-exist with other conditions. The likelihood of TRALI has been assessed in each case. Clinical factors which influence this assessment of cases include: time from transfusion to respiratory deterioration; radiological features; possibility of infection; other risk factors for ALI/ARDS; evidence of circulatory overload and/or impairment of cardiac function; pre-existing cardiac, pulmonary, renal or other disease; fluid balance in the previous 24 to 48 hours and response to diuretics. Serological results are also taken into account. Cases are still included in this report if it is thought that both TRALI and another risk factor such as cardiac failure contributed to the clinical events. Two intensive care specialists and a transfusion medicine expert (TRALI expert panel) have initially assessed the cases concerning NHSBT components (17 of 21 cases) before laboratory investigation has commenced. NIBTS are now also referring cases to the intensive care specialists for assessment. A transfusion medicine specialist, who has previously reviewed SHOT TRALI cases for the past 6 years, has subsequently assessed all cases including the results of TRALI investigations. Complete results of investigations were not available in 4 cases; 1 of these was not investigated because the TRALI expert panel considered that the clinical picture was much more likely to be due to alternative reasons. As in previous years, cases were divided into 4 groups (as shown in Figure 15): highly likely – where there was a convincing clinical picture and positive serology probable – where there was either a less convincing history and positive serology or a good history and less convincing or absent serology possible – where either the clinical picture or serology was compatible with TRALI, but other causes could not be excluded unlikely – where the picture and serology were not supportive of the diagnosis 108 13. Transfusion-Related Acute Lung Injury (TRALI)
Classification of cases according to Canadian Consensus Criteria 37,38 All 21 analysed reports and the 4 withdrawn cases were also classified using the Canadian Consensus Criteria. This gave the following results: ■■ ■■ ■■ TRALI 5 Possible TRALI 12 Outside criteria 8 The cases which were outside the consensus criteria had features of cardiac failure (6), bronchopneumonia (1) and delayed event with pneumonia (1). Website tables Data extracted from individual TRALI questionnaires and laboratory results are tabulated on the SHOT website www.shot-uk.org. ■■ ■■ ■■ TRALI Table 1 – Patient and component details and patient characteristics TRALI Table 2 – Clinical characteristics and radiological features of cases reported as TRALI TRALI Table 3 – Treatment, outcomes, investigation results and likelihood of case being TRALI. Age Patient ages ranged from 16 to 85 years with a median age of 50. Two patients were aged less than 18 years (one was aged 16 and the other 17; both cases were classified as probable TRALI). Clinical specialty This year the most frequent specialty was surgery (7 cases) followed by haematology/oncology (6), general medicine (5) and obstetrics and gynaecology (3). Analysis of cumulative figures since 1996 from 257 reports of suspected TRALI has shown that haematology/oncology combined has provided the highest number of reports of suspected TRALI (89, 35%) and surgery the second highest (83, 32%). General medicine was reported as the specialty in 30 cases (12%). Denominator data are not available. Clinical features Clinical presentation All cases, by definition, had been dyspnoeic and hypoxic with CXR features of acute lung injury. Eighteen patients were treated in ITU; of these 5 were already on ITU before the event. Ten patients required mechanical ventilation continuing between 1 and 22 days (median 3 days). Fever and/or rigors were present in 3 patients, absent in 16 and not recorded in 2. Hypotension was part of the event in 8 cases, absent in 12 and not recorded in 1. Patient outcomes Two patients died; 1 case was probably related to TRALI (Case 1) and the other possibly related to TRALI (Case 3). Nineteen patients made a full recovery from the event. Laboratory results All cases were referred to the BTS and 20 were subsequently investigated at reference laboratories. TRALI investigations were incomplete in 3 of the referred cases. 13. Transfusion-Related Acute Lung Injury (TRALI) 109
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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
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■■ 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 and 110: Table 40 DHTRs - New specificities
Page 111: 13. Transfusion-Related Acute Lung
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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