SHOT Annual Report 2009 - Serious Hazards of Transfusion

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COMMENTARY ■■ ■■ ■■ ■■ ■■ Observed rates of TRALI remain lower than in 2003 when TRALI risk reduction strategies were first initiated. Two deaths occurred, 1 probably caused by TRALI and 1 possibly related. Female donors were implicated in all cases where concordant donor antibody was found (8 cases, 12 components). Disappointingly, 2 cases of highly likely TRALI have been reported again this year following transfusion of female FFP containing concordant donor HLA antibodies. One of these was transfused in 2008. This reinforces the absolute requirement to achieve 100% use of male plasma for FFP across the UK. In 2009 the Welsh Blood Service, Northern Ireland Blood Transfusion Service and Scottish National Blood Transfusion Service produced 100% FFP and plasma for platelet pools from male donors. NHSBT produced 97% of FFP and 95% plasma for platelet pools from male donors in 2009 and has confirmed that no female FFP has been issued from NHSBT since early February 2010. 39 ■■ The use of SD-FFP is recommended for the treatment of TTP rather than standard FFP. ■■ Three cases followed transfusion of platelet pools. In each case the implicated donor contributed only a buffy coat to the pool. Each patient also had other risk factors for respiratory deterioration; 2 had evidence of cardiac failure and 1 had a markedly positive fluid balance. 114 13. Transfusion-Related Acute Lung Injury (TRALI)
RECOMMENDATIONS New recommendations There are no new recommendations this year. Recommendations still active from previous years Year first made Recommendation Target Progress 2008 UK blood services that have not yet achieved 100% male FFP and plasma to platelet pools must make this a priority. Exchange of male FFP for previously issued female FFP should be undertaken whenever feasible. NHSBT 2006 UK blood services should continue to investigate and apply methods to reduce the continuing risk of TRALI associated with apheresis donations, reducing the number of female donors on the panel, and testing those remaining for HLA antibodies. This year only 1 case involved an apheresis donor with a concordant antibody but this recommendation remains relevant. UK blood services ‘Amendments and Corrections’ to the BCSH guidelines ‘Transfusion Guidelines for neonates and older children’ clarifies these recommendations. 2005 Hospital staff should continue to be aware of TRALI and report possible cases to the local Blood Centre to facilitate investigation. Detailed clinical information is needed to allow accurate clinical assessment of these cases. Blood samples (clotted and EDTA) from affected patients should be sent promptly for laboratory investigation. Continued education of all relevant staff about this condition is encouraged. HTTs This recommendation was made in the BCSH Guidelines (BCSH 2004). 2005 Cases should be evaluated early by the consultant(s) involved and prompt discussion with the Blood Service is helpful. A team approach including the haematologist and chest physician and/or ITU consultant is recommended. Clinical users of blood and consultant haematologists with responsibility for transfusion BCSH guidelines for investigation and management of transfusion reactions are in progress. 2005 Case 3 from the 2005 report emphasises the importance of avoiding transfusing whole blood. Blood services, clinical users of blood and consultant haematologists with responsibility for transfusion 13. Transfusion-Related Acute Lung Injury (TRALI) 115
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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
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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 and 116: Comparative data on implicated comp
Page 117: Case Histories TRALI probable Case
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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