SHOT Annual Report 2009 - Serious Hazards of Transfusion

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adverse outcome. In that report, a unit of blood was prescribed rather than the exact volume. The following 2 cases involve clinically significant over-transfusion. Case 4 A request was made for 110 mL of blood as a top-up transfusion for a 12-month-old child with endocarditis being ventilated and on inotropes on paediatric intensive care. One adult unit of blood (230 mL) was issued, and the nursing staff transfused the entire unit. The post-transfusion Hb was 19 g/dL and the patient required venesection. Case 5 A prescription was made for 140 mL of red cells for a 6-month-old infant on intensive care following surgery for congenital heart disease. The nurse asked the doctor if she should give 1 unit, and he agreed. The unit issued was an adult bag with 257 mL. The entire unit was transfused but there was no adverse outcome other than excessive flushing. One neonate had a delayed transfusion due to communication failures, misunderstandings and portering delays (see I&U chapter, page 66). In the final paediatric-related report there was confusion between the results for twin neonates. One had a low platelet count but platelets were requested and transfused to the other twin. There were 5 reports where age of the recipient was not a major factor in accounting for the problem. In 3 of these the patients were transfused platelets based on an initial platelet count that was subsequently highlighted as erroneous due to platelet clumping. One patient with lethargy and pallor was transfused on the basis of a low Hb of 7.8 g/dL later discovered to be from the week before. The Hb from the day of transfusion was 11 g/dL. Transfusion reactions n = 42 Acute transfusion reaction n = 37 In 2008 there was a striking increase in the number of paediatric ATRs reported, particularly from platelets (18 reported). This year, there were a similar number of reactions to platelets (14/37; 38%), but the majority of cases were in red cells with an increase in reports to 19/37 (51%). There were only a few ATR reports after FFP transfusion (3/37; 8%). These proportions are similar to the paediatric summary data 1996–2005. 55 Only 5/37 (14%) paediatric ATR reports were in infants < 1 yr old, including 2 in the neonatal group of which 1 was an anaphylactic reaction to platelets. A high proportion of reports in the ≥ 1 yr age group are of ATR, accounting for 32/76 (42%) total reports for this group, similar to 2008. Paediatric reports constitute 7% of all red cell ATR, but 16% of platelet ATR. The types of reactions reported are in broadly similar proportions to adults (see Figure 24), and there were more paediatric febrile reactions to red cells reported this year than in 2008. Allergic reactions mostly constituted rashes, frequently treated with antihistamines. One paediatric ATR report involved 3 paedipaks from the same donor being given to 3 different children and in each case there was an allergic reaction with rashes (see ATR chapter, page 88 for description). Paedipaks are usually employed for multiple transfusions to the same neonate in order to reduce donor exposure. This report does highlight that on occasion there can be disadvantages to having multiple donations from the same donor. 144 20. Paediatric Cases
Table 47 Types of reactions for each component comparing paediatric with adult reports Reaction Red cells Total platelets FFP Multiple components Total Adults < 18 yrs Adults < 18 yrs Adults < 18 yrs Adults < 18 yrs Adults < 18 yrs Febrile 158 9 16 4 4 1 1 0 179 14 Allergic 43 5 34 8 22 0 2 0 101 13 Mixed febrile and allergic 14 2 6 0 4 2 0 0 24 4 Anaphylaxis 4 1 10 2 10 0 2 1 26 4 Hypotensive 5 0 1 0 0 0 0 0 6 0 Unclassified 21 2 5 0 1 0 0 0 27 2 Total 245 19 72 14 41 3 5 1 363 37 Figure 24 Type of acute transfusion reactions – comparison between adult and paediatric reports 100 90 27 6 26 2 0 4 Key Unclassified 80 24 4 Hypotensive 70 Anaphylaxis Percentage of reports 60 50 40 101 13 Mixed febrile and allergic Allergic Febrile 30 179 20 14 10 0 Adults Children Haemolytic transfusion reaction n = 2 Both paediatric HTR reports were in patients with sickle cell disease, aged 4 and 7 years. One developed probably mild haemolysis post transfusion with JK b positive units and was found to have developed an anti-JK b . The second had had anti-M and anti-S detected at another hospital and was subsequently transfused with an S-positive unit (see HTR chapter, page 98, for further details). 20. Paediatric Cases 145
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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
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RECOMMENDATIONS New recommendations
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Case 1 Possible fatal reaction A ma
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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 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: incident group O D negative units w
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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