SHOT Annual Report 2009 - Serious Hazards of Transfusion

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ICS incidents n = 6 ■ ■ ■■ ■■ Operator errors Heparinised saline used in wrong bag, 1 case Machine errors Faulty optic – red cells spilled into waste bag, 2 cases Clinical adverse events Hypotension, 3 cases Case 1 Hypotension Patient had massive transfusion due to acute haemorrhage for placenta accreta. Allogeneic (donor) blood and intraoperative salvaged blood were transfused. Cell salvaged blood was administered and 5–10 minutes after this, the patient developed hypotension, with BP dropping from 88/25 to 61/28. The transfusion was stopped and BP returned to 90/30. Transfusion restarted and BP dropped to 66/34, with complete resolution when transfusion was again stopped. The patient had been given 3500 mL crystalloid and 4 units of allogeneic blood. Patient also had 2 or 3 episodes of hypotension prior to this event due to hypovolaemia. This year there were 5 cases of adverse reactions reported to postoperative, unwashed autologous transfusion. Previous reports to SHOT on this type of event have been sporadic but with the advent of the online reporting system it is envisaged that these reports may be a feature of future reports. In 2009 there were 3 reports of hypotension related to the reinfusion of cell salvaged blood. While an attempt has been made to analyse the clinical scenarios of each report the common factors, certainly in 2 cases, appear to be: ■■ ■■ Use of ACD as an anticoagulant Use of a leucodepletion filter (LDF) during the reinfusion of autologous washed red cells. There are a number of other clinical issues: ■■ ■■ ■■ ■■ Use of bedside LDF, which is known to cause hypotension when used with allogeneic blood as previously recognised. 54 These patients may be hypovolaemic and therefore more susceptible to the effect of reinfused vasoactive cytokines. All patients experienced transient but clinically significant hypotension, a blood pressure drop of 20% or more from the starting value, corrected by the cessation of infusion and/or vasopressors. No long term sequelae of this hypotension were noted. These phenomena will require further in-depth analysis to fully understand the consequences of such incidents. At this stage it is important to recognise this as a possible adverse event and treat by discontinuation of the infusion of salvaged red cells and with appropriate vasopressors. 138 19. Autologous Transfusion
RECOMMENDATIONS There are no new recommendations for this year. Recommendations still relevant from last year Year first made Recommendation Target Progress 2008 All cell salvage operators must undertake initial and regular update training and be assessed as competent. There should be documented evidence of competence in the form of a training record. Competency-assessment workbooks are available for both ICS and PCS at www.transfusionguidelines.org.uk Cell salvage leads /HTT Online survey currently being undertaken by the UK Cell Salvage Action Group, asking about training and competency. Education workbook produced and available on the website. 2008 All ICS and PCS related adverse events should be reported to SHOT. Cell salvage leads /HTT There is a specially designed section of the new web-based SHOT reporting system to facilitate this. 2008 Monitoring of patients is as important for the reinfusion of red cells collected by ICS or PCS as it is for allogeneic red cells. Cell salvage leads /HTT 2008 Cell salvage machines are classified as Medical Devices, so all adverse events attributable to machine errors and failures should be reported to the MHRA as well as SHOT. Cell salvage leads /HTT 19. Autologous Transfusion 139
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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
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Omission or late administration of
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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 and 138: Viral and parasitic TTIs Since 1996
Page 139 and 140: The most likely source of the organ
Page 141: 19. Autologous Transfusion Definiti
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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