SHOT Annual Report 2009 - Serious Hazards of Transfusion

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Timing of reaction after start of implicated unit Where recorded, and excluding 34 cases in which the reaction was reported after the transfusion was completed, the median time of onset of symptoms was 45 minutes. The time of onset differs for different types of reactions as seen in Table 35. It is worth noting that, for all types of reactions except anaphylaxis, which tends to have a more rapid onset, the mean time of onset is greater than 15 minutes, at which time observations are usually first recorded. 19 This emphasises the need for close observation of patients throughout the duration of the transfusion. Table 35 Median time of onset of reaction by reaction type Type of reaction Number of cases where time given Median time of onset, mins (range) Febrile 177 60 (1–540) Allergic 107 40 (1–420) Anaphylactic 28 15 (1–110) Mixed febrile and allergic 25 35 (1–195) Hypotensive 6 20 (15–60) Unclassifiable 23 60 (5–660) Total 366 45 (1–660) Learning point ■■ Acute transfusion reactions can occur at any time during the transfusion. Patients require careful observation throughout the transfusion process. Reactions by component type The incidence of febrile and allergic/anaphylactic type reactions by component is summarised in Table 36 below. The data in Figure 12 (also below) suggest that febrile reactions are less common with plasma than with red cell or platelet transfusions; allergic or anaphylactic reactions are much more frequent with plasma-rich components, especially platelets. Table 36 Incidence of reactions by component type Component Febrile reactions, incidence per 100,000 units Allergic or anaphylactic reactions, incidence per 100,000 units Red cells 7.6 2.4 Platelets 7.5 20.3 Plasma 1.6 10.4 92 11. Acute Transfusion Reactions (ATR)
Figure 12 Reaction by component type (excluding 6 reactions which could not be attributed to a particular component) Key 100 23 21 5 7 1 6 Unclassified Mixed/Hypotensive 80 5 48 12 10 Anaphylactic Allergic Percentage of reactions 60 40 167 42 22 Febrile Each star represents a case of: Platelets in suspension medium HLA matched platelets Solvent Detergent plasma 20 Methylene Blue plasma 20 5 0 Red cells Platelets Plasma Component type Management of transfusion reactions Stopping or slowing the transfusion Drug treatment of transfusion reactions was covered in the 2008 SHOT Annual Report (page 96). Analysis of 2009 data shows no change in pattern. A breakdown of management of the transfusion (where information was available) is indicated in the table below. Table 37 Management of the transfusion during ATRs Action Number of reports Continue 6 Stop transfusion 264 Stop temporarily (not known if restarted) 21 Transfuse more slowly 7 Transfusion slowed, then stopped 3 Already completed 64 No information 35 Total 400 11. Acute Transfusion Reactions (ATR) 93
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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
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 and 92: RECOMMENDATIONS New recommendations
Page 93 and 94: Case 1 Possible fatal reaction A ma
Page 95: adequate resources both for monitor
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
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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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