SHOT Annual Report 2009 - Serious Hazards of Transfusion

Case studies
In all 4 cases a key feature was respiratory distress. None of the 4 cases met the criteria for TACO or TRALI, and did not
have classical features of an allergic reaction. They were therefore categorised as (possible) cases of TAD. In cases 1, 2
and 3 the symptoms occurred within 2 hours of the transfusion, and in Case 4 within 12–24 hours.
Case 1
An 81-year-old woman with anaemia was written up for a 2 unit RBC transfusion – each unit over 2 hours. Ten minutes
into the second unit she developed SOB with a rise in her respiratory rate from 16 to 40 per minute. Her O 2
saturation
remained normal at 96%. The reaction was associated with vomiting and flushing. The transfusion was stopped and
her symptoms resolved.
Case 2
A 74-year-old woman with myeloma on chemotherapy was prescribed a 2 unit RBC transfusion. She had been
hypertensive, BP 197/114, prior to transfusion. Ninety minutes into the first unit she developed SOB, with a fall in her
O 2
saturation to 88%. The transfusion was stopped, she was treated with IV furosemide and GTN and admitted to the
ward. Her symptoms resolved over the next 48 hours.
Case 3
An elderly woman with acute hepatic failure dropped her Hb from 8.5 to 6.2 g/dL over 48 hours, and an RBC transfusion
was commenced. Twenty minutes into the second unit she developed dyspnoea associated with a rise in RR from 14 to
32 pm and a fall in O 2
saturation from 94% to 91%. Her pulse rose from 120 to 135 bpm and her BP fell from 122/82
to 99/65. The transfusion was stopped and her symptoms resolved.
Case 4
A 65-year-old woman with lung malignancy and COPD had an Hb of 8.2 g/dL and was transfused 2 units of RBC.
Twelve to 24 hours later she became SOB and was brought back to the hospital by ambulance. Fluid balance was not
documented, but clinically there was no fluid overload and she was possibly a bit dry. Pulse was raised at 111 bpm
and BP low at 96/58. A CXR showed bilateral interstitial changes which had not been present 24 hours previously. She
had hypoalbuminaemia. She was treated with antibiotic therapy, O 2
and CPAP, and a diuretic 36 hours later, when she
developed pulmonary oedema. Her symptoms resolved.
COMMENTARY
■■
■■
TAD appears to be a clinically heterogeneous entity and perhaps includes cases with more than one
physiological mechanism. More information about this group of complications is required to enable a
systematic approach to the investigation and management of pulmonary complications of transfusion (see
Key Messages and Recommendations, page 21).
TAD appears to be able to occur during or up to 24 hours after transfusion, highlighting the need for appropriate
monitoring during administration of blood components, as detailed in the new BCSH guidelines. 19
RECOMMENDATIONS
There are no new recommendations.
Previous recommendation still relevant
Year first
made
2008
Recommendation Target Progress
All pulmonary reactions to transfusion should be reported
to SHOT. Accurate information on the diverse spectrum of
pulmonary complications of transfusion will inform a systematic
approach to their appropriate investigation and management.
HTTs
TAD reporting has not increased appreciably
over the past year; however, it is hoped
that growing awareness about this new
category will result in more reports.
126 15. Transfusion-Associated Dyspnoea (TAD)