Haemovigilance in a general university hospital: need for a more comprehensive classification and a codification of transfusion-related events

Review of haemovigilance at the Rabat Regional Blood Transfusion Centre in Morocco (2017-2021)

Introduction

blood transfusion remains an essential therapeutic intervention, but the occurrence of transfusion reactions makes its administration even more complex. Vigilant reporting of such reactions by recipients of blood products is essential for effective haemovigilance. This study aimed to determine the frequency and nature of transfusion reactions.

Methods

conducted over five years (2017-2021) at the Haemovigilance Department of the Rabat Regional Blood Transfusion Centre, this retrospective study exploited incident forms notified by health establishments and data from the regional blood transfusion centre's computer system.

Results

from 1 January 2017 and 31 December 2021, the Rabat Regional Blood Transfusion Centre distributed 435,651 labile blood products to various healthcare establishments, which reported 191 transfusion reactions involving 191 patients. The median age of the patients was 44.3 years, with an overall cumulative incidence of transfusion reactions of 0.44 per 1000 labile blood products delivered. The predominant reactions were non-haemolytic febrile and allergic reactions, accounting for 41.36% and 35.60% respectively. Grade 1 reactions accounted for 87% of all reactions recorded. During the study period, three deaths were recorded, with ABO incompatibility and transfusion-related acute lung injury (TRALI) accounting for two and one case respectively. Transfusion reactions involving erythrocyte components were significantly more frequent than those involving platelet and plasma components.

Conclusion

this study revealed a relatively low incidence of transfusion reactions (0.44%), dominated by non-haemolytic febrile and allergic reactions. Several levels of failure were identified, in particular under-reporting of reactions and inadequate training in transfusion practices and haemovigilance, as well as the need for an effective electronic transfusion reaction reporting system to facilitate reporting and identification of underlying problems and risk factors to improve the quality of transfusion care provided to patients.

The incidence of transfusion-related acute lung injury using active surveillance: A systematic review and meta-analysis

BACKGROUND

Transfusion-related acute lung injury (TRALI) is a leading cause of transfusion-related mortality. A concern with passive surveillance to detect transfusion reactions is underreporting. Our aim was to obtain evidence-based estimates of TRALI incidence using meta-analysis of active surveillance studies and to compare these estimates with passive surveillance.

STUDY DESIGN AND METHODS

We performed a systematic review and meta-analysis of studies reporting TRALI rates. A search of Medline and Embase by a research librarian identified studies published between January 1, 1991 and January 20, 2023. Prospective and retrospective observational studies reporting TRALI by blood component (red blood cells [RBCs], platelets, or plasma) were identified and all inpatient and outpatient settings were eligible. Adult and pediatric, as well as general and specific clinical populations, were included. Platelets and plasma must have used at least one modern TRALI donor risk mitigation strategy. A random effects model estimated TRALI incidence by blood component for active and passive surveillance studies and heterogeneity was examined using meta-regression.

RESULTS

Eighty studies were included with approximately 176-million blood components transfused. RBCs had the highest number of studies (n = 66) included, followed by platelets (n = 35) and plasma (n = 34). Pooled TRALI estimates for active surveillance studies were 0.17/10,000 (95% confidence intervals [CI]: 0.03-0.43; I2  = 79%) for RBCs, 0.31/10,000 (95% CI: 0.22-0.42; I2  = <1%) for platelets, and 3.19/10,000 (95% CI: 0.09-10.66; I2  = 86%) for plasma. Studies using passive surveillance ranged from 0.02 to 0.10/10,000 among the various blood components.

DISCUSSION

In summary, these estimates may improve a quantitative understanding of TRALI risk, which is important for clinical decision-making weighing the risks and benefits of transfusion.

A Retrospective Analysis of Transfusion Reactions at a Tertiary Care Center: An Institutional Hemovigilance Study

BACKGROUND

The goal of our study was to determine the frequency and type of transfusion reactions (TRs) as well as other hemovigilance activities reported at a tertiary care hospital in Turkey over a period of 3 years.

METHOD

In this retrospective study, the notification sheets of TRs reported to the institution's local hemovigilance system between December 2017 and December 2020 were analyzed.

RESULTS

A total of 89,187 units of blood components were administered to patients during this period. A total of 197 TRs were reported to the hemovigilance system. The overall frequency of TRs was 0.22%. The most common TRs were allergic reactions (49.2%) and febrile nonhemolytic transfusion reactions (37.6%), respectively. Most of the adverse events were reported by clinical nurses.

CONCLUSION

Our study showed that the frequency of TRs was low, and most were manageable reactions. We found that reporting of all TRs and continuous nursing education can help to strengthen the hemovigilance system. [J Contin Educ Nurs. 2021;52(12):581-588.].

Transfusion reactions: A retrospective analysis of the Iranian national haemovigilance system (INHS) data

BACKGROUND

The use of blood and blood components is an essential and effective treatment for many patients, but the transmission of infectious agents via transfusion and the occurrence of non-infectious transfusion reactions (TRs) are unavoidable. The objective of our study was to determine the frequency and type of transfusion-related reactions reported in Iran between 2014 and 2018.

METHODS

This retrospective study was carried out in the Iranian blood transfusion organization (IBTO) during a period of five years (2014-2018). All TRs reported to the Iranian national haemovigilance system (INHS) were analyzed using SPSS software.

RESULTS

A total of 20,062 TRs were reported to the INHS from 2014 to 2018. The overall frequency of TRs was 0.14 %. The most common TRs were allergic (42.51 %) and febrile non-hemolytic reactions (37.17 %), respectively. The frequency of TRs to red blood cell (RBC) components was significantly higher than those to the components of platelet (PLT) and plasma (P < 0.05).

CONCLUSIONS

In the present study, the frequency of TRs was relatively low (0.14 %) and the majority of them were allergic and febrile non-hemolytic reactions. The recording and reporting of all occurred TRs, the implementation of INHS in all hospitals and the continuity of specific educational courses to physicians, nurses and blood banking staff, as well as the use of an online reporting system will help to improve the haemovigilance in Iran.

Hemovigilance: the experience of transfusion reaction reporting in a Teaching Hospital

OBJECTIVE

To describe the occurrence of immediate transfusion reactions received by the Risk Management Department of Hospital São Paulo.

METHOD

Cross-sectional and retrospective study which analyzed the notification sheets of transfusion reactions that occurred between May 2002 and December 2016 and were included in the Hemovigilance National System.

RESULTS

One thousand five hundred and forty-eight transfusion reaction notification sheets were analyzed, all of which concerned immediate reactions associated with packed red blood cells (72.5%). The most frequently reported reaction was febrile non-hemolytic transfusion reaction, and among severe and moderate cases, allergic reaction was the most common. The most frequently reported signs and symptoms were hyperthermia, sudoresis, chills, and skin lesions. No differences were observed regarding gender and age, and 90.7% of reactions occurred in patients with Rh+ factor.

CONCLUSION

This study allowed for a better assessment and understanding of transfusion reactions, which will help to improve the quality of blood circulation and provide greater safety of patients undergoing transfusion therapy.

Determination of health workers' level of knowledge about blood transfusion

OBJECTIVE:

This study was conducted to determine the knowledge level of healthcare workers about blood transfusion.

METHODS:

The study was conducted between October 1, 2015 and November 2, 2015 with 100 healthcare personnel working in a training and research hospital. A survey consisting of 19 questions based on the literature was prepared and administered. In addition to descriptive statistical methods (frequency), Fisher’s exact chi-square test and Yates’ correction for continuity were used to compare qualitative data. Significance was assessed at p<0.05.

RESULTS:

Of the total, 52% of the participants were ≤29 years of age and 94% were women. In all, 71% were nurses and 42% had been working at the hospital for 2 to 5 years. Seventy-nine percent indicated that they had been trained in blood and blood product transfusion, 86% stated that transfusions were performed to replace deficient blood volume, and 95% responded that blood was to be requested by a physician, and 97% indicated that informed consent of the patient should be obtained for a blood transfusion. In all, 78% of respondents identified crossmatching as the final check for ABO compatibility. With respect to blood unit quality, 90% of the respondents stated that they would return blood if the label could not be read and 98% would reject the product if the integrity of the blood bag was compromised or of the blood had a cloudy or foamy appearance. In the event of a patient experiencing fever and shock, 96% of the survey participants indicated that they would consider that it could be a reaction to a blood transfusion. The need to confirm the patient’s identity and the type of blood products was corroborated by 91%, and 85% agreed that no other medication should be added to the blood to be transfused. Furthermore, 88% of the study participants approved of continuous training regarding the transfusion of blood and blood products.

CONCLUSION:

According to the results of this research, while the knowledge of the healthcare professionals surveyed was adequate, standardization was lacking. In this respect, it may be advisable to conduct further studies on blood transfusion practices, and to provide additional in-service training to ensure patient safety and avoid medical errors.

Unacknowledged adverse transfusion reactions: Are they a mine to dig?

OBJECTIVES

Haemovigilance has long tried to characterize and understand transfusion reactions in order to prevent them. Unacknowledged ones are now a minority but they question us. Are they the result of incomplete clinical setting and/or insufficient medical reasoning, or can they contain real new entities we have not yet understood?

MATERIAL AND METHODS

Ten volunteer experts reviewed 30 recent unacknowledged cases. Their diagnostic propositions were compared with data issued from a five-year repository we have analysed in terms of statistical links between clinical signs and diagnoses.

RESULTS

Experts' opinions are only quite unanimous in 60% of the cases, and the proposed diagnosis remains unacknowledged in 53%. Repository comparison shows that signs like pain or digestive symptoms are far more frequent in unknown reactions. However, it is more the absence of some other signs which drives to that conclusion, in a default diagnosis mechanism.

CONCLUSION

Errors in transfusion reactions medical analysis are rare. Unacknowledged cases are more often linked to poor or unspecific clinical setting. But a particular attention must be paid with infrequent diagnoses which are far less characterised, like metabolic complications. Pain high occurrence in unknown cases also commands us to go further in the characterisation of acute pain transfusion reaction diagnosis, which is suggested by some authors.

Repeated exposure rather than the total volume of transfused components may influence the incidence of allergic transfusion reactions

BACKGROUND

The plasma fraction of blood components has an essential role in the etiology of allergic transfusion reactions (ATRs). The difference of incidences of ATRs between fresh-frozen plasma (FFP) and platelet concentrates (PCs), in which plasma is the main component, is not clearly understood. This study compares the frequency of ATRs to FFP versus PCs on both first and subsequent (nonfirst) transfusions and considers the factors influencing the risk of ATRs.

STUDY DESIGN AND METHODS

Five hospitals agreed to systematically collect and share 2 years of data (January 2010 through December 2011). This was a retrospective observational analysis of data including the number of transfusion episodes and ATRs for FFP and PCs on first-transfusion patients (without transfusion history) and previously transfused patients.

RESULTS

The incidence of ATRs to PCs (2.51%) was significantly higher than to FFP (1.68%) on subsequent transfusions (p < 0.001). On the other hand, there were no significant differences in the incidences of ATRs to FFP (2.67%) and PCs (2.82%) on first transfusions. This discrepancy was most pronounced among males: FFP versus PCs on first transfusions, 2.02% versus 2.60% (p = 0.30); and on subsequent transfusions, 1.58% versus 2.46% (p = 0.0007). Among females, FFP versus PCs on first transfusions was 3.59% versus 3.13% (p = 0.61) and on subsequent transfusions was 1.87% versus 2.61% (p = 0.029).

CONCLUSION

Repeated exposure rather than the total volume of transfused components may influence the incidence of ATRs.

The Incidence Rate of Acute Transfusion Reactions in Thalassemia Patients Referred to the Shiraz Thalassemia Centre, Shiraz, Iran, Before and After the Establishment of the Hemovigilance System

This study aimed to investigate the incidence rate of acute transfusion reactions in thalassemia patients before and after the establishment of the hemovigilance system. This prospective descriptive study was conducted at the Dastgheyb Hospital, Shiraz, Iran, from 2009 to 2012. The incidence rate, type, imputability and severity of acute transfusion reactions were compared in thalassemia patients before and after the establishment of the hemovigilance system. A total of 741 thalassemia patients were referred to the Dastgheyb Hospital for transfusions during the study period. The incidence rates of acute transfusion reactions were reported as 0.06% (11 out of 16,214), 0.11% (23 out of 19,660), 0.10% (28 out of 26,129) and 0.2% (50 out of 24,121), respectively, from 2009 to 2012. The most frequent were major allergic reactions and febrile non hemolytic transfusion reactions (FNHTR). The transfusion reactions were increasingly reported after the establishment of the hemovigilance system in 2011 (p < 0.05). The establishment of the hemovigilance system can improve reporting of transfusion reactions. Moreover, evaluation of the incidence rate of transfusion reactions is necessary to design preventive measures to reduce transfusion risks.

Incidence of transfusion-related adverse reactions per patient reflects the potential risk of transfusion therapy in Japan

OBJECTIVES

To describe the frequency of adverse reactions (ARs) after transfusion on both per transfused patient and per transfused unit bases.

METHODS

We performed a retrospective analysis of data available from records of 6 hospitals on the total number of transfusions and documented ARs between January 2008 and December 2009 for RBCs, fresh-frozen plasma (FFP), and platelet concentrates (PCs).

RESULTS

The incidence of ARs to RBCs, FFP, and PCs per transfused unit was 0.6%, 1.3%, and 3.8%, respectively. The incidence of ARs to RBCs, FFP, and PCs per patient was 2.6%, 4.3%, and 13.2%, respectively-almost 3-fold higher. Most RBC-ARs were febrile nonhemolytic transfusion reactions and allergic reactions, whereas most FFP-ARs and PC-ARs were allergic reactions.

CONCLUSIONS

The incidence of ARs per transfused patient may reflect better the potential risk of transfusion with blood components, taking into account the characteristics of the transfused patient.

Transfusion reactions: a comparative observational study of blood components produced before and after implementation of semiautomated production from whole blood

BACKGROUND

A semiautomated method of component production from whole blood was implemented at Canadian Blood Services. To assess safety of the new components, the frequency of adverse transfusion events (ATEs) to platelet components (PCs) and red blood cell (RBCs) produced before and after implementation of the new method was surveyed and compared.

STUDY DESIGN AND METHODS

This retrospective, observational, noninferiority study was conducted in 12 sentinel hospitals across Canada. The control group received RBCs in additive solution-3 (AS-3) and platelet-rich plasma (PRP)-produced platelets (PLTs) for 3 to 11 months before implementation of semiautomated production, and the study group received RBCs in saline-adenine-glucose-mannitol (SAGM) and buffy coat (BC)-produced PLTs for 3 to 11 months after implementation. ATE definitions at each hospital and standard practice for reporting did not change between control and study periods. Data for analysis were obtained from databases and original report forms.

RESULTS

The pooled risk ratio of a reaction to SAGM versus AS-3 RBCs was 0.77 (95% confidence interval [CI], 0.66-0.90), suggesting that SAGM products had significantly lower reaction rates than AS-3 products (p < 0.01). Reported allergic reactions to RBCs decreased from 0.07% (AS-3) to 0.04% (SAGM). For PLTs, the difference in reaction rates between BC and PRP was not significant (p = 0.37), and the pooled risk ratio of BC versus PRP was 1.14 (95% CI, 0.86-1.50).

CONCLUSION

The change in manufacturing method was associated with lower reaction rates to SAGM RBCs than to AS-3 RBCs. Pooled BC PLTs were noninferior to random-donor PRP PLTs with respect to ATEs.

Analysis of immediate transfusion incidents reported in a regional blood bank

BACKGROUND

Blood transfusion is imperative when treating certain patients; however, it is not risk free. In addition to the possible transmission of contagious infectious diseases, incidents can occur immediately after transfusion and at a later time.

AIMS

This study aimed to examine the immediate transfusion incidents reported in a regional blood bank in the state of Minas Gerais between December 2006 and December 2009. A retrospective quantitative epidemiological study was conducted. Data were obtained from 202 transfusion incident reports of 42 health institutions served by the blood bank. Data processing and analysis were carried out using the Statistical Package for the Social Sciences (SPSS) software.

RESULTS

The rate of immediate transfusion incidents reported in the period was 0.24%; febrile non-hemolytic reactions were the most common type of incident (56.4%). The most frequent clinical manifestations listed in transfusion incident reports were chills (26.9%) and fever (21.6%). There was a statistically significant association (p-value < 0.05) between the infusion of platelet concentrates and febrile non-hemolytic reactions and between fresh frozen plasma and febrile non-hemolytic reaction. The majority (73.3%) of transfused patients who suffered immediate transfusion incidents had already been transfused and 36.5% of the cases had previous transfusion incident reports.

CONCLUSIONS

Data from the present study corroborate the implementation of new professional training programs aimed at blood transfusion surveillance. These measures should emphasize prevention, identification and reporting of immediate transfusion incidents aiming to increase blood transfusion quality and safety.

Cost of allogeneic blood transfusion

Blood is a scarce and costly resource to society. Therefore, it is important to understand the costs associated with blood, blood components, and blood transfusions. Previous studies have attempted to account for the cost of blood but, because of different objectives, perspectives, and methodologies, they may have underestimated the true (direct and indirect) costs associated with transfusions. Recognizing these limitations, a panel of experts in blood banking and transfusion medicine gathered at the Cost of Blood Consensus Conference to identify a set of key elements associated with whole blood collection, transfusion processes, follow-up, and to establish a standard methodology in estimating costs. Activity-based costing (ABC), the proposed all-inclusive reference methodology, is expected to produce standard and generalizable estimates of the cost of blood transfusion, and it should prove useful to payers, buyers, and society (all of whom bear the cost of blood). In this article, we argue that the ABC approach should be adopted in future cost-of-transfusion studies. In particular, we address the supply and demand dilemma associated with blood and blood components; evaluate the economic impact of transfusion-related adverse outcomes on overall blood utilization; discuss hemovigilance as it contributes not to the expense, but also the safety of transfusion; review previous cost-of-transfusion studies; and summarize the ABC approach and its utility as a methodology for estimating transfusion costs.

Incidentes transfusionais imediatos: revisão integrativa da literatura

Este estudo de revisão integrativa da literatura teve como objetivo analisar as pesquisas que abordam a ocorrência de incidentes transfusionais imediatos e ações de hemovigilância implantadas. Os dados foram obtidos por meio de busca nas bases de dados - LILACS, MEDLINE e PUBMED - abrangendo o período de 1980 a 2009, nos idiomas português, inglês e espanhol. Foram identificados 1.382 artigos, dos quais 29 atenderam aos critérios de inclusão estabelecidos. Destes artigos, 20 (69,0%) eram estudos retrospectivos transversais, 8 (27,5%) prospectivos e um (3,5%) caso-controle. Em relação à abordagem, os estudos foram classificados em dois focos temáticos: tipos de incidentes transfusionais imediatos e ações de hemovigilância implantadas associadas aos tipos de incidentes transfusionais imediatos. A análise dos trabalhos destacou a maior ocorrência de reação febril não hemolítica e alérgica, avanço em ações de hemovigilância e maior preocupação com a qualidade da assistência hemoterápica.

Transfusion reaction reporting in the era of hemovigilance: where form meets function

BACKGROUND

Transfusion services rely on transfusion reaction reporting to provide patient care and protect the blood supply. By voluntary participation in the Hemovigilance Module of the Biovigilance Component of the National Healthcare Safety Network, health care facilities have an opportunity to share institutional transfusion reaction data nationally. An optimally designed reporting form is a critical part of reaction reporting.

STUDY DESIGN AND METHODS

All reports of transfusion reactions from 2006 to 2009 were analyzed to evaluate the frequency of reported signs and symptoms and the ability of our reporting form to capture this information. A total of 400 reactions with 879 reported signs and symptoms were reviewed. We then redesigned our reporting form to facilitate participation in hemovigilance reporting and capture with the check-box option at least 90% of historically reported signs and symptoms and all those reported in at least 2% of reactions.

RESULTS

Our original reporting form failed to capture 10 of 32 (31%) signs and symptoms present on the hemovigilance reporting tool. Although our original reporting form contained 27 check-box options, these captured only 657 (74.8%) of reported signs and symptoms. Our redesigned form captures all hemovigilance signs and symptoms. Based on our retrospective review, the new form would also capture up to 95% of previously reported signs and symptoms using the check-box option.

CONCLUSION

We believe that this study presents an evidence-based approach to the improvement of the transfusion reaction reporting form, which may be attractive for hospitals considering participation in the hemovigilance program.

[Pathogen reduction of blood components: from financial issues to possible long-term consequences]

Pathogen inactivation of blood products represents a global and major paradigm shift in transfusion medicine. In the next near future, it is likely that most blood products will be inactivated by various physicochemical approaches. The concept of blood safety will be challenged as well as transfusion medicine practice, notably for donor selection or biological qualification. In this context, it seems mandatory to develop analytical economic approaches by assessing costs-benefits ratio of blood transfusion as well as to set up cohorts of patients based on hemovigilance networks allowing rigorous scientific analysis of the benefits and the risks of blood transfusion at short- and long-term.

Clinical review: Prothrombin complex concentrates--evaluation of safety and thrombogenicity

Prothrombin complex concentrates (PCCs) are used mainly for emergency reversal of vitamin K antagonist therapy. Historically, the major drawback with PCCs has been the risk of thrombotic complications. The aims of the present review are to examine thrombotic complications reported with PCCs, and to compare the safety of PCCs with human fresh frozen plasma. The risk of thrombotic complications may be increased by underlying disease, high or frequent PCC dosing, and poorly balanced PCC constituents. The causes of PCC thrombogenicity remain uncertain but accumulating evidence indicates the importance of factor II (prothrombin). With the inclusion of coagulation inhibitors and other manufacturing improvements, today's PCCs may be considered safer than earlier products. PCCs may be considered preferable to fresh frozen plasma for emergency anticoagulant reversal, and this is reflected in the latest British and American guidelines. Care should be taken to avoid excessive substitution with prothrombin, however, and accurate monitoring of patients' coagulation status may allow thrombotic risk to be reduced. The risk of a thrombotic complication due to treatment with PCCs should be weighed against the need for rapid and effective correction of coagulopathy.