SHOT Annual Report 2009 - Serious Hazards of Transfusion

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Figure 17 Deaths at least possibly due to TRALI and number of suspected TRALI reports by year 40 Number of deaths against reports 35 30 25 20 15 10 Key Number of deaths Suspected TRALI 5 0 1996–97 1997–98 1998–99 1999–00 2000–01 2001–02 (15 months) 2003 Year of report 2004 2005 2006 2007 2008 2009 Figure 18 presents the annual numbers of completed reports analysed by year of transfusion instead of year of report. Figure 18 TRALI by year of transfusion n = 257 40 35 30 32 36 Number of reports 25 20 15 14 15 21 19 21 16 19 16 18 14 10 11 5 5 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year of transfusion 112 13. Transfusion-Related Acute Lung Injury (TRALI)
Case Histories TRALI probable Case 1 Probable TRALI following transfusion of RBC OA to treat symptomatic tumour anaemia A man had disseminated rectal cancer plus severe coronary artery disease, left ventricular hypertrophy, and bilateral peripheral oedema extending to just below his knees. He was transfused with 3 RBC OA units. Six hours later during transfusion of the third unit he developed chills, rigors, breathlessness, wheeze, and his JVP was raised. He died an hour later. At postmortem he had severe pulmonary oedema with no evidence of MI or PE. Lung histology showed increased numbers of neutrophils in the interstitial fluid. Investigations revealed that the female RBC donor of the third unit had multiple HLA class I and class II antibodies concordant with patient HLA-B60, DR13, DR52 and DQ6. The implicated blood pack was also cultured for bacteria and grew Enterobacter species, Pantoea species and Enterococcus faecalis but, because the blood pack had been unspigoted, these findings were considered most likely to have been due to contamination (as discussed in the SHOT Annual Report 2008, page 128). This case was assessed as probable TRALI because cardiac failure may also have contributed to the pulmonary oedema. TRALI highly likely Case 2 TRALI follows receipt of female FFP during treatment of TTP A patient received 4 units FFP and was being transferred to another hospital between 2 and 6 hours later when she suddenly developed respiratory distress. The ambulance diverted to the nearest hospital where the patient became increasingly hypoxic and hypotensive. Her chest was described as ‘bubbly’ and her CXR as ‘bilateral white-out’. She suffered cardio-respiratory arrest from which she was successfully resuscitated but required mechanical ventilation for 2 days. She made a full recovery from this event. One female donor was found to have multiple HLA class I antibodies including HLA B8 antibodies concordant with this patient. This case was assessed as highly likely to be TRALI. TRALI possible Case 3 Middle-aged woman developed possible TRALI after transfusion to treat variceal bleeding This patient had cirrhosis, portal hypertension and a large gastric varix. She was admitted with Hb 3.7 g/dL following upper GI bleeding. She received 4 packs of RBC over the next 3 days for continued GI bleeding. Six days after admission she bled further and E. coli was cultured from her urine. She had repeat endoscopy and injection of a bleeding gastric varix. Terlipressin was commenced and she was transfused with 1 unit of male RBC OA which was discontinued due to a febrile reaction. Five hours later transfusion was recommenced. After 1 male FFP and 2 male RBC she developed a drop in O 2 saturation from 100% to 94% and was started on O 2 support 4 L/min with improvement. She then received 1 male FFP and 2 female RBC OA units. Her respiratory rate gradually increased and CXR around 9 hours after the initial drop in O 2 level was reported as ‘suboptimal inspiration... but there is strong impression of bilateral airspace shadowing compatible with consolidation’. Terlipressin was discontinued with some symptomatic improvement. A few hours later she had cardiopulmonary arrest and resuscitation was unsuccessful. Postmortem examination found pulmonary oedema and early stage ARDS but no evidence of MI. The 2 female RBC donors were tested: the male donors were excluded from investigation. One female donor had HLA class II antibodies with concordance at HLA-DR51 and DQ6 but this donation had not been commenced until 2 hours after the patient’s respiratory deterioration had already begun. The other female donor did not have concordant HLA or HNA antibodies. This case was assessed as possible TRALI due to the timing of events and the presence of other risk factors for respiratory deterioration. 13. Transfusion-Related Acute Lung Injury (TRALI) 113
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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 (
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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 and 114: Classification of cases according t
Page 115: Comparative data on implicated comp
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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