SHOT Annual Report 2009 - Serious Hazards of Transfusion

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Since 1997, the UK blood services have introduced a number of precautionary measures: ■■ ■■ ■■ ■■ ■■ leucodepletion of all blood components (1999) use of methylene-blue virally inactivated FFP (MB-FFP) obtained outside the UK for children under 16 years old (2002) importation of plasma for fractionation (1998) imported solvent detergent (SD) treated FFP for adult patients with thrombotic thrombocytopenic purpura (TTP) (2006) 39 exclusion of donors who have received a blood transfusion in the UK since 1980 (2004). Table 45 Number of confirmed TTI incidents, infected recipients and outcomes (death, major morbidity, minor morbidity) in the UK between October 1996 and December 2009 (Scotland included from October 1998) NB No screening in place for the following TTIs at the time of transfusion: HAV, HEV, HTLV, vCJD/prion Infection Number of Incidents Number of Infected Recipients Death due to, or contributed to, by TTI Major morbidity Minor morbidity Bacteria 40 43 11 28 4 HAV 3 3 0 2 1 HBV 10 11 0 11 0 HCV 2 2 0 2 0 HEV 1 1 0 0 1 HIV 2 4 0 4 0 HTLV-I 2 2 0 2 0 Malaria 2 2 1 1 0 Prion 1 1 0 1 0 vCJD 3 3 3 0 0 Total 66 72 15 51 6 COMMENTARY Currently the greatest risk of transfusion-transmitted infection is associated with bacterial contamination, although there is likely to be under-reporting of both viral and bacterial incidents. A BCSH guideline on the management of acute transfusion reactions is currently in preparation, and a revised protocol is being devised by NHSBT. One of the confirmed bacterial incidents in 2009 was revealed only upon retrospective investigation after an expired unit of platelets was found to have a low pH and abnormal colouration, when the fate of associated components was investigated. This case demonstrates that acute transfusion reactions can be difficult to recognise, particularly when patients have other underlying symptoms and/or are taking antibiotics, which may mask their symptoms. This case was also the first known report of transfusion-transmitted Streptococcus pneumoniae infection in the UK. If bacterial contamination is suspected, staff should report the incident to the blood services as soon as possible, in order to facilitate the return of implicated packs and the recall of any associated units. A BCSH guideline on the management of acute transfusion reactions is currently in preparation, and a revised protocol is being devised by NHSBT. Attention should be paid to the sampling and storage of implicated units or their residues to avoid environmental contamination of the pack. Guidance for English hospitals can be found at: http://www.blood.co.uk/hospitals/library/request_forms/aer/. For other services please contact the local blood supply centre. 134 18. Transfusion-Transmitted Infection (TTI)
The most likely source of the organism in the Pseudomonas koreensis case was thought to have been environmental contamination within a cold storage room or issues area. While the MHRA’s ‘Orange Guide’ includes recommendations on standards of environmental cleanliness for ‘clean’ rooms (where sterile conditions are maintained), 28 there are no guidelines covering acceptable levels of cleanliness within cold storage areas. Nonetheless, cleaning protocols for such areas should be reviewed regularly and compliance with these should be audited. Strategies to reduce the bacterial contamination of blood components should be under continual review. At a meeting in July 2009, the Advisory Committee on the Safety of Blood, Tissues and Organs (SaBTO) did not recommend the adoption of pathogen inactivation (PI) of platelets at present, until further data on the cost benefit and safety of this method become available. Most of the UK blood services already screen platelet donations for bacterial contamination and this is planned for introduction in England in early 2011. It should be noted that the effectiveness of screening is influenced by the methodology used and data from a number of studies have shown that bacterial screening is unlikely to prevent all transmissions. 52 The UK Standing Advisory Committee on Transfusion Transmitted Infection (SACTTI) have tasked a subgroup to recommend how bacterial screening should be performed. The current estimated risks of transmission of HBV, HCV, HIV and HTLV via blood transfusion are low (1.09 per million donations for HBV, 0.01 per million for HCV, 0.19 for HIV and 0.04 for HTLV-1). 53 Learning point Clinicians investigating suspected viral TTIs should explore all possible risk exposures (e.g. surgery, or discuss with the patient any sexual risks, injecting drug use, occupational exposure) in parallel with the blood service investigations, as highlighted by the undetermined HIV investigation this year. RECOMMENDATIONS ■■ Staff should maintain a high index of suspicion for bacterial causes when managing acute transfusion reactions. Symptoms may appear to be related to the patient’s underlying condition, and temperature rises may be small or absent altogether. Action: Hospital Transfusion Teams ■■ Processing and issues teams at the UK blood services and hospital transfusion teams should be vigilant to any abnormalities or clumps present in packs prior to transfusion, as highlighted by the Near Miss case in 2009. Action: Hospital Transfusion Teams, UK blood services ■■ Cleaning protocols for cold rooms and processing and storage areas should be reviewed regularly. Compliance with these should be audited. Action: Hospital Transfusion Teams, UK blood services ■■ Clinicians investigating suspected viral TTIs should explore all possible risk exposures in parallel with the blood service investigations, in order to determine the patient’s most likely source of infection. Action: Clinicians, UK blood services 18. Transfusion-Transmitted Infection (TTI) 135
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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
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Excessive time to complete administ
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etween removing the component from
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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 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: Viral and parasitic TTIs Since 1996
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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