4. Blood transfusion error Flashcards
What steps should be taken to minimise the risk of
administering incorrect blood products to a patient?
The Blood Transfusion Task Force has
issued guidelines on the process of
red cell transfusion.
A summary of these recommendations is as follows:
Once the decision to transfuse has been made, the following procedures should be followed to minimise the incorrect administration of red cells to the
patient:
1
> All staff involved in blood transfusions
must have undergone mandatory
training in blood transfusion safety.
2
> Decisions concerning the need
to transfuse the patient should be
documented in the medical notes.
3
> Identity of the patient must be confirmed (four standard identifiers required:
first name, surname, date of birth and hospital/NHS number).
4
> Samples must not be accepted by the laboratory without the correct four standard identifiers.
5 > Blood compatibility label must be checked to ensure that the blood is correct for the patient.
6
> Expiry date should be checked.
7
> Bag should be inspected to ensure
integrity of the plastic casing.
8
> Removed patient identification bands
must be replaced or reattached.
9
> Blood left out of a blood fridge for
longer than 30 minutes should be
transfused within 4 hours or discarded.
10 > Details of the unit of blood transfused should be recorded on the anaesthetic chart or in the contemporaneous clinical notes.
11
> Tear-off sticky labels may facilitate
this data recording.
12
> Volume of blood transfused should
be recorded once administered.
13
> 100% traceability of all allogeneic
blood transfused is a legal requirement
following the European Blood Directive.
14
> Good communication between the
medical staff and the laboratory is essential.
UK System - not important
Failure to adhere to the above recommendations increases the chances of a transfusion error occurring.
Blood transfusion errors are also evaluated
by the Serious Hazards Of Transfusion (SHOT).
Mortality from blood transfusion is low, but there is avoidable major
morbidity.
In 2007 there were 12 severe
(anaphylactic) cases of ABOincompatible
red cell transfusion,
9 arising from clinical error and
3 from laboratory error.
SABRE (Serious Adverse Blood Reaction and Events) is an online system submission of notification and subsequent confirmation of
blood-related adverse events and reactions.
What is an acute haemolytic transfusion reaction?
If blood is mistakenly administered
to the wrong patient,
the chances of ABO incompatibility are
approximately one in three.
The reaction is usually most severe if
Group A cells are transfused to a Group O patient.
Incompatible transfused cells react
with the patient’s own
anti-A or anti-B antibodies or other alloantibodies
(e.g. Kell/Duffy) to red cell antigens.
This reaction can lead to activation
of complement and
cause disseminated intravascular coagulation (DIC).
Infusion of ABO incompatible blood still almost always arises from errors in labelling the sample tube or the cross-match request form or from inadequate checks when blood is administered.
What are the symptoms and signs of a haemolytic transfusion reaction?
In a conscious patient even
a few millilitres of
ABO-incompatible blood may cause symptoms
(agitation, pain at infusion site, flushing, abdominal, flank or substernal pain and breathlessness)
within 1–2 minutes.
Signs may include pyrexia, hypotension, bleeding, haemoglobinaemia and haemoglobinuria.
In an unconscious or anaesthetised patient hypotension and uncontrollable bleeding secondary to DIC may be the only signs of an incompatible transfusion.
How would you manage an acute haemolytic transfusion reaction?
ABO incompatibility/acute haemolytic
transfusion reaction is a medical
emergency that requires
prompt recognition and management.
If an acute haemolytic transfusion
reaction is suspected,
the transfusion must be stopped
and urgent steps be taken
to confirm or exclude this possibility.
The differential diagnosis must include infusion of bacterially contaminated blood.
State that this is an anaesthetic emergency and that you would call for senior anaesthetic assistance.
1
> Adopt an ABC approach.
2
> Stop the blood transfusion and administer colloid.
3 > Support respiration and circulation as necessary with supplemental oxygen, bronchodilators, volume resuscitation and consider adrenaline, vasopressors and chlorpheniramine.
4
> Check that the compatibility label
of the blood unit corresponds with the
patient’s ID bands, blood forms and case-notes.
5 > If a mistake is discovered, inform blood bank urgently since the unit of blood intended for your patient could be given out to transfuse another patient.
6
> Inform the consultant haematologist.
7 > If clinical evidence of DIC develops, transfuse platelets, fresh frozen plasma and cryoprecipitate guided by clinical state and coagulation study results.
8
> If the patient requires red cell transfusion,
repeat cross-match.
9
> If bacterial contamination is suspected,
administer broad-spectrum IV antibiotics.
10 Take 35 mL blood for: • Haematology – 5 mL EDTA tube – FBC, platelet count, direct antiglobulin test (DAT ) and plasma haemoglobin
• 5 mL in a dry tube for repeat cross-matching
• 10 mL in a citrated tube –
for coagulation screen (PT, APTT, fibrinogen)
• Clinical chemistry – 5 mL for urea and electrolytes
11
> Take blood cultures.
12
> Return blood packs and
giving set to blood bank for bacteriology.
13
> Urine dip – haemoglobinuria.
14
> ABG – metabolic acidosis and hyperkalaemia.
15
> Monitor ECG –
for changes suggestive of hyperkalaemia (from
haemolysis).
16
> Maintain urine output to minimise
risk of acute kidney injury.
17
> Liaise with critical care, if indicated.
18
> Complete hospital critical incident reporting forms.
19
> Report incident to SABRE.
Can haemolytic reactions occur due to red cell antibodies other than ABO?
Haemolytic reactions can be caused
by other red cell antibodies in the
recipient’s blood,
including anti Rh D, Rh E, Rh C and K (Kell).
Reactions due to anti D are
rare since patients generally
receive Rh D–compatible red cells.
Reactions due to these antibodies
are usually less severe than those
caused by ABO incompatibility since
they do not activate complement.
Destruction of transfused red cells
occurs mainly in the liver and spleen.
The patient may experience
fever, nausea and shivering.
However, the Kidd and Duffy antigens
do activate complement and can
cause severe intravascular haemolysis leading to cardiac and renal failure.
Kidd antibodies are often difficult to find in
pre-transfusion samples.
A falling haemoglobin or a rise in haemoglobin
that is less than expected
after transfusion together
with a rise in bilirubin and a positive direct
antiglobulin test indicates that red cells are being destroyed.
