SHOT Annual Report 2009 - Serious Hazards of Transfusion

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11. Acute Transfusion Reactions (ATR) Definition Acute transfusion reactions are defined in this report as those occurring at any time up to 24 hours following a transfusion of blood or components excluding cases of acute reactions due to incorrect component being transfused, haemolytic reactions, transfusion-related acute lung injury (TRALI), TACO, or those due to bacterial contamination of the component. DATA SUMMARY Total number of cases 400 Implicated components Mortality/morbidity Red cells 264 Deaths due to transfusion 0 FFP (including 1 MB and 2 SD) 44 Deaths in which reaction was implicated 1 Platelets (57 apheresis, including 3 HLA matched components, 23 pooled, 7 unknown type, including 1 platelet component in PAS) 86 Deaths in which reaction was not implicated 1 Gender Age Multiple components transfused Emergency vs. routine and core hours vs. out of core hours 6 Major morbidity 27 Where transfusion took place Male Female Unknown 184 215 1 18 years+ 16 years+ to 18 years 1 year+ to 16 years 28 days+ to 1 year Birth to 28 days Total 363 4 28 3 2 400 Emergency Routine Not known In core hours Out of core hours Not known/applicable A & E Theatre ITU/HDU/Recovery Wards Community Other Not known 2 In total 440 questionnaires were received; 28 were withdrawn, 6 were transferred to the autologous chapter, 10 to the TACO chapter, and 2 to the TAD chapter. A further 6 cases were transferred in from other sections: 1 each from HSE, TRALI and TTI, and 3 from HTR. A total of 400 cases have been reviewed for this chapter. There were 193 febrile and 114 allergic reactions, and 30 whose features were indicative of anaphylaxis. There were also 28 reactions with mixed febrile and allergic features, 6 hypotensive reactions, and 29 which could not be classified further. Mortality In 1 case, the patient’s symptoms may have been attributable to a transfusion reaction and the possibility that the reaction could have contributed to the patient’s death could not be completely excluded. 88 11. Acute Transfusion Reactions (ATR)
Case 1 Possible fatal reaction A male patient with alcoholic liver disease was transfused with standard FFP. He became dyspnoeic and died during transfusion of the second unit. NHSBT was contacted and associated units from the donation were withdrawn. TRALI was ruled out as both plasma donors were male. Microbiological tests of the unit were negative. IgA investigations of the recipient were requested but not performed. The postmortem investigation demonstrated pneumonia and cirrhosis. It is not possible to state whether the dyspnoea was caused by a transfusion reaction of some type, and, if so, whether this contributed to the patient’s death, as case notes are no longer accessible. Figure 11 ATR cases 1996–2009 450 400 400 350 300 300 Number of reports 250 200 150 114 100 85 68 50 24 24 34 33 31 48 39 34 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 Classification of non-fatal acute transfusion reactions The classification of acute transfusion reactions can be difficult, as reactions are frequently seen in patients with intercurrent illness who may have other causes for their symptoms. Classification does not necessarily have any bearing on the management of the acute reaction or of future transfusions. Major morbidity Applying the SHOT criterion of ‘Life-threatening acute reaction requiring immediate medical intervention’, there were 27 cases of major morbidity from ATR where the immediate symptoms or signs were sufficiently severe for a delay in treatment to be life-threatening, even though recovery was usually rapid. There were 17 anaphylactic reactions, 1 of which complicated a severe postpartum haemorrhage and resulted in the patient temporarily requiring intubation (Case 3, below), and 5 of which led to the crash team being called; in all these cases the patient recovered without cardio-respiratory support. There were 7 severe febrile reactions: the case below; 2 patients described as having reversible shut-down of their peripheral circulation; and 4 patients requiring acute management of hypotension (2 with adrenaline and 2 with volume replacement). Life-threatening reactions were also experienced by 2 patients with severe mixed febrile and allergic reactions, and 1 with a severe allergic reaction. One patient suffered a severe febrile reaction to a red cell transfusion and experienced worsening of pre-existing renal failure (Case 2, below). 11. Acute Transfusion Reactions (ATR) 89
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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
Page 41 and 42: Table 15 Number of staff involved i
Page 43 and 44: All of the errors in this group wer
Page 45 and 46: Trust and sometimes in separate Tru
Page 47 and 48: IBCT events originating in the hosp
Page 49 and 50: multiple group O components; 1 grou
Page 51 and 52: Learning points ■■ ■■ Where
Page 53 and 54: Three interpretation errors occurre
Page 55 and 56: IT must be used to its full potenti
Page 57 and 58: Case 8 When the laboratory knows of
Page 59 and 60: ■■ All staff must take full pro
Page 61 and 62: 7.1 Errors Relating to IT Systems (
Page 63 and 64: to laboratory B. The clinical reque
Page 65 and 66: Improving Laboratory Standards (bas
Page 67 and 68: 7.2 Right Blood Right Patient (RBRP
Page 69 and 70: COMMENTARY Each year SHOT emphasise
Page 71 and 72: Core hours vs. out of hours and Whe
Page 73 and 74: Broad breakdown of where primary er
Page 75 and 76: Case 6 Dilute (possible drip arm) s
Page 77 and 78: Case 10 Over-transfusion following
Page 79 and 80: 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: RECOMMENDATIONS New recommendations
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 and 142: 19. Autologous Transfusion Definiti
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RECOMMENDATIONS There are no new re
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Introduction and overall trends In
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incident group O D negative units w
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Table 47 Types of reactions for eac
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always require notification by clin
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21. Near Miss Reporting Definition
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29 UK Resuscitation Council Emergen
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24. Acknowledgements The Steering G
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SHOT Annual Report 2009 - Serious Hazards of Transfusion

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