Factors contributing to transfusion-related adverse events

Certain circumstances increase the likelihood of an adverse event occurring during the transfusion process, and these include:

Patients who have previously been transfused, multiparous women and patients receiving emergency uncross-matched transfusion are at increased risk of immediate and delayed haemolytic transfusion reactions.

Febrile, allergic and anaphylactic reactions occur more commonly in multiparous women and in patients with IgA deficiency and anti-IgA antibodies.

Febrile reactions occur more commonly in multitransfused patients.

Transfusion-associated graft-versus-host disease (TAGVHD) occurs more frequently in certain immunocompromised patient groups.

Volume overload is a particular risk in the very young, the elderly and in patients with cardiovascular disease.

Platelet and granulocyte transfusions are associated with the highest rates of febrile non-haemolytic transfusion reactions.(1)

The incidence of such reactions can be modified by changes to the blood component in the way it is processed and by leucodepletion.

All red cell and platelet components produced by the blood service are leucodepleted.

Platelets, which require storage at 20–24 ºC, are associated with higher rates of bacterial contamination than red cells, which are routinely refrigerated.

All platelets are subject to routine bacterial culture and screening, which allows detection of a bacterial contaminated product.

Transfusion of fresh frozen plasma is associated with a higher risk of allergic reactions. Some reactions are mild, but severe life-threatening reactions such as anaphylaxis and Transfusion-related acute lung injury (TRALI) may occur.

All blood components are administered through specifically designed intravenous giving sets, which incorporate a 170–200 micron filter to remove debris and clots that may have accumulated during storage.

All equipment must be specifically designed, and assessed as safe for blood administration.

All equipment must be used in accordance with the manufacturer’s operational procedures, including regular maintenance and calibration.

Some examples of potential adverse effects due to inappropriate equipment include:

  • Heat damage to red cells due to an un-calibrated or poorly maintained blood warmer (ie, red cells should not be taken above

40 ºC)(2)

  • Mechanical damage to red cells through use of an inappropriate infusion pump

No medication or solutions should be added to or infused through the same tubing with blood or components except 0.9% Sodium Chloride, Injection (BP).

ABO-compatible plasma or 4% Albumin or other suitable plasma expanders may be used with approval of the patient’s physician.

Crystalloid and colloid solutions containing calcium (eg, Haemaccel) must never be added to or administered through the same intravenous line as blood or component collected in an anticoagulant containing citrate because they interfere with the anticoagulant effect, resulting in clotting.

Clear written procedures and adequate staff training are essential for all aspects of the clinical transfusion process—from initial collection of samples for pretransfusion testing through to final documentation of the transfusion process and outcome.

There are numerous opportunities for error during this process if procedures are not strictly followed. Recent reports (2005) from the UK indicate that nearly 60% of adverse events associated with transfusion are a result of 'wrong blood to wrong patient'.(3)

The majority of these errors are the result of failure to follow procedures, or inadequate or unclear procedures.

 
References
  1. Therapeutic Goods Act, 1989.
  2. Roback JD (ed). AABB Technical Manual 17th edition. AABB Press, Bethesda, 2011.
  3. Serious Hazards of Transfusion [on www.shotuk.org]