SHOT Annual Report 2009 - Serious Hazards of Transfusion

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Previous recommendations still relevant Year first made Recommendation Target Progress 2008 Increased recognition of TACO by clinicians and reporting to SHOT is needed, to raise awareness and increase focus on this important and in many cases potentially avoidable complication of blood transfusion. HTT The number of cases of TACO have increased; however, it almost certainly remains under-reported. 2008 Education and training aimed at the recognition and avoidance of TACO is required for doctors across all specialties, and nurses at both national and local levels. Education and training of junior doctors, to ensure appropriate decision making as regards transfusion of blood components/ products and appropriate prescription, remains a key priority. NBTC This year’s report highlights the need for a national initiative to address these issues. 2008 Doctors should ensure careful clinical assessment of each patient to whom transfusion of components is being considered, to ensure that the proposed transfusion is appropriate. The minimum volume of blood components required should be prescribed to be transfused at an appropriate rate, in accordance with BCSH guidelines on blood administration. HTT, BCSH a) The new BCSH guidelines on the administration of blood components have addressed issues related to the rate of transfusion. 19 b) The BCSH guidelines do not address clinical assessment prior to transfusion, which could be addressed in a national initiative led by NBTC (see above recommendation). 2008 If it is necessary to transfuse RBC to a patient with chronic anaemia, the risk of precipitating congestive cardiac failure may be minimised by administering a diuretic. The decision to give a diuretic must be based on clinical assessment of the patient. HTT, BCSH As b) above 2008 Nursing staff should record the rate of transfusion and fluid balance in patients receiving blood components and act on signs suggestive of TACO. Transfusions should be administered at times, and in locations, permitting careful observation of patients throughout the transfusion and upon completion. Out-of-hours transfusions should be avoided unless appropriate facilities are available. BCSH guidelines on blood administration in preparation should address these issues. HTT, BCSH The new BCSH guidelines on the administration of blood components have addressed these issues, and also advise that patients discharged home after a transfusion should be counselled with systems available to ensure that patients have 24 hour access to clinical advice. 19 124 14. Transfusion-Associated Circulatory Overload (TACO)
15. Transfusion-Associated Dyspnoea (TAD) Definition The category TAD has been introduced by the ISBT. TAD is characterised by respiratory distress within 24 hours of transfusion that does not meet the criteria of TRALI, TACO or allergic reaction. Respiratory distress should not be explained by the patient’s underlying condition or any other known cause. 14 This will allow haemovigilance systems to classify all reported pulmonary reactions without the need for exceptions or inappropriate assignment. DATA SUMMARY Total number of cases 4 Implicated components Mortality/morbidity Red cells 4 Deaths due to transfusion 0 FFP 0 Deaths in which reaction was implicated Platelets 0 Major morbidity 0 0 Gender Age Emergency vs. routine and core hours vs. out of core hours Where transfusion took place Male Female Unknown 0 4 0 18 years+ 16 years+ to 18 years 1 year+ to 16 years 28 days+ to 1 year Birth to 28 days Unknown Total 4 4 Emergency Routine Not known In core hours Out of core hours Not known/applicable 4 4 ED Theatre ITU/NNU/HDU/Recovery Wards Community Other (haematology day care) Not known 2 2 Two reports of TAD were received (Case 1 and Case 2); 2 more cases were transferred in – 1 from the ATR section (Case 3) and 1 from the TRALI section (Case 4) – and all 4 are reported in this chapter. Mortality and major morbidity n = 0 Minor morbidity n = 4 One of the 4 patients required CPAP as a result of the reaction. Table 44 Diagnosis/Indication for transfusion, components/products transfused and fluid balance Case no. Age Sex Diagnosis/Indication for transfusion RBC Units FFP mL Other Rate of transfusion Fluid balance 24 hrs mL 1 F81 Anaemia 1+ - - 1 unit /2 hrs NS Possible 2 F74 Myeloma, chemo < 1 - - NS NS Possible Probability of TAD 3 F84 4 F65 Ca bowel, acute hepatic failure, Hb fall from 8.5 to 6.2 g/dL Ca lung, COPD, ?pneumonia, Hb 8.2 g/dL 1+ - - NS NS Possible 2 - - NS NR Possible 15. Transfusion-Associated Dyspnoea (TAD) 125
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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
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7.2 Right Blood Right Patient (RBRP
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COMMENTARY Each year SHOT emphasise
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Core hours vs. out of hours and Whe
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Broad breakdown of where primary er
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Case 6 Dilute (possible drip arm) s
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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 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: exchange in patients with TTP. 43 I
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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