SHOT Annual Report 2009 - Serious Hazards of Transfusion

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17. Transfusion-Associated Graft-versus-Host Disease (TA-GvHD) Definition Transfusion-associated graft-versus-host disease is a generally fatal immunological complication of transfusion practice, involving the engraftment and clonal expansion of viable donor lymphocytes contained in blood components in a susceptible host. TA-GvHD is characterised by fever, rash, liver dysfunction, diarrhoea, pancytopenia and bone marrow hypoplasia occurring less than 30 days following transfusion. The diagnosis is usually supported by skin/bone marrow biopsy appearance and/or the identification of donor-derived cells, chromosomes or deoxyribose nucleic acid (DNA) in the patient’s blood and/or affected tissues. No new case of TA-GvHD was reported in 2009. Figure 20 Number of cases of TA-GvHD reported to SHOT each year 5 4 Number of cases 3 2 1 0 1996–97 1997–98 1998–99 1999–00 2000–01 2001–02 (15 months) 2003 2004 2005 2006 2007 2008 2009 Year of report COMMENTARY ■■ ■■ ■■ ■■ No report of TA-GvHD has been received during the last 8 years. A total of 13 cases of TA-GvHD have been reported to SHOT since 1996, all of which were fatal. Two cases have followed transfusion of leucodepleted components. One case occurred before the introduction of leucodepletion of all cellular components (except granulocytes/buffy coats), which took place in late 1999. This followed transfusion of a leucodepleted component to a patient and was reported in 1998–99. Another case occurred since the introduction of universal leucodepletion which was reported in 2000–2001. This year SHOT received reports of 91 patients with a requirement to receive irradiated blood in accordance with BCSH guidelines 20 who received non-irradiated components in error. Of these, 69 were attributed to clinical errors and 22 to laboratory errors: fortunately none developed TA-GvHD. In the last 7 years a total of 596 such cases have been reported, none of whom developed TA-GvHD. 128 17. Transfusion-Associated Graft-versus-Host Disease (TA-GvHD)
■■ The requirement to irradiate blood components remains essential for patients at risk. Approximately 300,000 irradiated components were issued from UK blood services in 2008–2009. By far the majority of patients at risk of TA-GvHD receive irradiated components as indicated. Irradiation is a proven, effective intervention to prevent this catastrophic complication. The absence of new cases, given the numbers involved, is a testament to its successful prevention: it would be imprudent to interpret it as a sign there is no longer a risk of TA-GvHD. RECOMMENDATIONS Recommendations from this report There are no new recommendations from this report. Recommendations still active from previous years Year first made Recommendation Target Progress 2007 The importance of irradiation, and the rationale behind it, should be focused on during teaching of junior haematology and oncology doctors. This education is part of the curriculum for Specialist Trainees, but foundation year doctors in these specialities may remain ignorant despite being frequently called upon to order components. Hospital Trusts, Medical Schools, NBTC, Royal Colleges, Specialty Training Committees, GMC, PMETB 2007 Systems should be put in place for pharmacy to inform the hospital transfusion laboratory of prescriptions for purine analogues. Such systems work well in some Trusts and best practice can be shared. Hospital Trusts, Hospital Liaison networks, BBT network, SHOT Transfusion Practitioner network 2006 Awareness of groups at risk of this condition and knowledge of the risk factors, symptoms and signs must be maintained by all involved in the transfusion process. Hospital Trusts, Medical Schools, NBTC, Royal Colleges, Specialty Training Committees, GMC, BCSH 2003 Gamma or X-ray irradiation to 25 Gy of blood components for those at risk of GvHD remains essential. BCSH Blood Transfusion Task Force Guidelines, 1996, define groups requiring this prophylaxis. Hospital Trusts, Medical Schools, NBTC, Royal Colleges, Specialty Training Committees, GMC, BCSH An update of the BCSH guidelines is still in progress. A more recent table of indications can be found in the Transfusion Handbook, 4 th edition. 2003 Good communication is required in all cases but particularly when patient care is shared between different hospitals. Hospitals must have clear protocols to ensure accurate information relating to this risk is communicated in a timely manner. Utilisation of a patient card and leaflet are recommended: an example is the BCSH/NBS leaflet available from NBS Hospital Liaison or via the NBS hospitals website. Hospital Trusts, Hospital Liaison networks, BBT network, SHOT Transfusion Practitioner network 17. Transfusion-Associated Graft-versus-Host Disease (TA-GvHD) 129
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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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Case 10 Over-transfusion following
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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 and 128: exchange in patients with TTP. 43 I
Page 129 and 130: 15. Transfusion-Associated Dyspnoea
Page 131: 16. Post-Transfusion Purpura (PTP)
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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