SHOT Annual Report 2009 - Serious Hazards of Transfusion

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Donor antibodies Concordant donor HLA antibodies were found in donors of components transfused within 6 hours of the event in 8 cases (5 HLA class I only, 2 both HLA class I and class II, and 1 with HLA class II only). No case had proven concordant granulocyte antibodies but 1 recipient of massive transfusion received cryoprecipitate containing HNA-3a antibodies in addition to components from 4 other donors with concordant HLA class I antibodies. In this case, a sample from the patient was not obtained for crossmatch to assess concordance of the HNA-3a antibody but the frequency of HNA-3a is 99% in Europeans making it highly likely that it would have been concordant. All donors found to have concordant leucocyte antibodies were female. Males with a history of transfusion were investigated but none was identified with concordant antibodies. Untransfused males were generally investigated only if all other donors had been investigated and excluded and no other likely cause for respiratory deterioration was present. All individuals who have been transfused since 1980 have been excluded from donation in the UK since 2004. Patient antibodies Testing for HLA and HNA antibodies in patients is no longer routinely performed because all components except granulocytes are now leucodepleted in the UK. Such testing is now confined to recipients of granulocytes (apheresis or buffy coat). Components All implicated components with proven concordant donor leucocyte antibodies were donated by females. Platelet pools were implicated in 3 cases; in each of these the implicated donor had contributed only a buffy coat to the unit. Two cases followed female FFP and 3 followed RBC OA. All cases which occurred following relatively little transfused plasma (buffy coats and RBC OA) also had other factors which may have caused or contributed to the events. The reported risk of TRALI in 2009 following transfusion of components with concordant donor leucocyte antibodies was 1 in 6884 issued units of female FFP and 0 cases following male FFP, 1 in 88,771 units of platelets, 1 in 121,555 units of cryoprecipitate, and 1 in 736,384 RBC. Table 41 Cases with concordant donor antibodies – specificities and implicated components ANTIBODY SPECIFICITY/IES COMPONENT/S * OTHER RISK FACTORS HLA class I HLA-B8 FFP None HLA class I HLA-B45 Platelet pool (buffy coat only)* Possible left ventricular failure HLA class I HLA-B35 RBC OA Sepsis HLA class I HLA-A26, B60 Platelet pool (buffy coat only)* 2.1 L positive fluid balance HLA class I HLA-B44, Cw7 RBC OA x 3, cryoprecipitate x 2 Multiple trauma, shock, pulmonary contusions, rib fractures, massive transfusion HLA class I and class II HLA-B60, DR13, DR52, DQ6 RBC OA Ischaemic heart disease, pitting oedema to below knee before transfusion HLA class I and class II HLA-A2, DR13, DR52, DQ6 FFP None HLA class II HLA-DR53 Platelet pool (buffy coat only)* Signs of cardiac failure * Platelet pools are produced by pooling components from 4 donors. One donor (preferentially male) contributes a whole unit of plasma (nominally 300 mL) and a buffy coat (platelets suspended in approximately 30 mL of plasma), and 3 other donors (either gender) each contribute a buffy coat. 110 13. Transfusion-Related Acute Lung Injury (TRALI)
Comparative data on implicated components since 2003 TRALI cases associated with concordant leucocyte antibodies have been analysed by implicated component from 2003 to 2009. Results are shown in Figure 16. Disappointingly, a further 2 cases of TRALI have been reported this year following implicated female donor FFP (one was actually transfused in 2008 and the other in 2009). Figure 16 Cases of TRALI with concordant donor antibody in FFP or platelet components 2003–2009 9 8 7 Key FFP Platelets 6 5 Number of cases 4 3 2 1 0 2003 2004 2005 2006 2007 2008 2009 Year of report Annual reports and deaths 1996–2009 The annual number of reports of suspected TRALI and deaths at least possibly due to TRALI each year from 1996 to 2009 are shown in Figures 17 and 18. Annual reports of TRALI and deaths due to TRALI continue to show a reduction compared with 2003; preferential male plasma policies were introduced in late 2003. Owing to the time taken to complete TRALI investigations on donors, some cases are reported in the calendar year following the one in which the transfusion reaction occurred. Figure 17 shows the annual number of reports based upon the date of receipt of the completed SHOT questionnaire. 13. Transfusion-Related Acute Lung Injury (TRALI) 111
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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
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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 and 112: 13. Transfusion-Related Acute Lung
Page 113: Classification of cases according t
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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