Adverse outcomes of blood transfusion in children: analysis of UK reports to the serious hazards of transfusion scheme 1996-2005

Between 1996 and 2005 the Serious Hazards of Transfusion (SHOT) scheme analysed 3239 reports of adverse reactions and events associated with transfusion of labile blood components in the UK. 321 reports (10%) related to transfusion of children under 18 years and 147/3239 (4.5%) to infants less than 12 months of age. There were 264 cases in children of 'incorrect blood component transfused', resulting from errors at all stages in the transfusion chain; 26/264 suffered actual or potential morbidity. Thirty acute transfusion reactions, three delayed transfusion reactions, 20 cases (three fatal) of transfusion-related acute lung injury, two cases (both fatal) of transfusion-associated graft-versus-host disease and two transfusion transmitted infections were reported. A population-based epidemiological study of transfused patients in 2004 showed that 4.2% of red cells are transfused to patients less than 18 years and 1.7% to infants less than 12 months. Interpretation of SHOT data against this context enabled the estimation of the incidence of an adverse outcome to be 18:100,000 red cells issued for children less than 18 years and 37:100,000 for infants less than 12 months, compared to 13:100,000 for adults. Adherence to relevant guidelines, knowledge of specialist transfusion needs of children and good communication are essential if this risk is to be reduced.

Changing indications for red cell transfusion from 2000 to 2004 in the North of England

Falling donor numbers and the threat of transfusion-transmitted variant Creutzfeldt-Jakob disease may lead to shortages in the national blood supply. Knowledge of current patterns of transfusion and trends in usage will help predict future change in blood use. Our previous survey identified medical indications as the major reason for transfusion, but detailed information within this category was limited. We performed prospective surveys of indications for red cell transfusion for two 14-day periods in 2004 in the North of England, concentrating on medical reasons for transfusion. Data were obtained for transfusion indications of 9003 units, which accounted for over 99% of red cell issues from the regional blood centre during the study. In 2004, medical patients received 62% (5558 units) of all transfused units, surgical patients 33% (3001 units) and Obstetric & Gynaecology patients 5% (444 units). These figures compare with 52, 41 and 6% for Medicine, Surgery, and Obstetrics & Gynaecology in 1999/2000. The three largest uses of blood within the medical category were for patients with primary haematological disorders (18.2% of all transfused blood), for management of gastrointestinal haemorrhage (13.8%) and for patients with nonhaematological malignancies (8.8%). There has been a significant reduction in use of blood for surgical indications over the last 5 years, but an absolute increase in use of blood for medical indications. Lower transfusion triggers, education, use of cell salvage, the increasing price of a unit of red cells and changing population demographics may all have contributed to the reduction in surgical blood use. Promotion of good transfusion practice and alternatives to allogeneic transfusion should now focus on medical and surgical use of blood transfusion.

Recovery from post-operative anaemia

Acceptance of lower transfusion thresholds and shorter post-operative stays results in patients leaving hospital after surgery with lower haemoglobin (Hb) than previously. We undertook a prospective observational study to assess the haematological response to post-operative anaemia and to determine the utility of quality of life (QoL) measures in assessing the impact of anaemia on such patients. Thirty patients undergoing unilateral hip arthroplasty had blood samples taken and QoL questionnaires administered pre-operatively and at 7, 28 and 56 days post-operatively. Increased erythropoiesis was evident at day 7 post-operatively. Approximately two-thirds of the post-operative Hb deficit was corrected by day 28. There was evidence of functional iron deficiency in more than one-quarter of patients at day 56. QoL scores used did not show any relationship with Hb in the post-operative period. Red cell 2,3-diphosphoglycerate (2,3DPG) levels increased in proportion to the degree of post-operative anaemia. We concluded that substantial recovery of Hb occurs between day 7 and day 28 post-operatively. Complete recovery of Hb may be delayed beyond day 56 due to development of iron deficiency. Patients are at significant risk of developing post-operative iron deficiency depending on operative blood loss and pre-operative iron stores. Increased red cell 2,3DPG may offset the effect of anaemia on oxygen delivery. We found no evidence that anaemia produces a measurable effect on chosen QoL scores in the post-operative period.

The incidence of red cell alloantibodies underlying panreactive warm autoantibodies

A recognized hazard of administering blood transfusions to patients with panreactive warm autoantibodies is that alloantibodies may be masked. Studies have shown the incidence of underlying alloantibodies to be 30 to 40 percent. Adsorption procedures can be used to remove autoantibodies and allow detection and identification of underlying alloantibodies. This study contains data from 126 patients referred to the Red Cell Immunohaematology laboratory at the National Blood Service, Newcastle upon Tyne, United Kingdom. These patients were from the northeast of England, a population for which data have not previously been reported. Samples identified as containing panreactive warm autoantibodies were subjected to adsorption procedures (95 by alloadsorption and 31 by autoadsorption). Absorbed sera were then tested to identify underlying alloantibodies. Of 126 samples, 39 (31%) contained a total of 61 RBC alloantibodies; 15 (12%) contained 2 or more antibody specificities; and 14 (11%) contained alloantibodies not found within the Rh or Kell blood group systems. Antibodies identified included the following specificities: E (19), D (9), c (7), C (6), S (5), Fy(a) (3), Jk(a) (2), Jkb (2), K (2),Kp(a) (2), Fy(b),C(w),N, and f (ce). This study reinforces the value of adsorption studies, whether using autologous or allogeneic RBCs, when panreactive warm autoantibodies are present. In addition, this study confirms that it is not appropriate in these cases simply to issue blood which is "least incompatible" or Rh phenotype- and K antigen-matched.

Where does blood go? Prospective observational study of red cell transfusion in north England

OBJECTIVE

To collect population based information on transfusion of red blood cells.

DESIGN

Prospective observational study over 28 days.

SETTING

Hospital blood banks in the north of England (population 2.9 million).

MAIN OUTCOME MEASURES

Indications for transfusion, number of units given, and the age and sex of transfusion recipients.

PARTICIPANTS

All patients who received a red cell transfusion during the study period. Data completed by hospital blood bank staff.

RESULTS

The destination of 9848 units was recorded (97% of expected blood use). In total 9774 units were transfused: 5047 (51.6%) units were given to medical patients, 3982 (40.7%) to surgical patients, and 612 (6.3%) to obstetric and gynaecology patients. Nearly half (49.3%) of all blood is given to female recipients, and the mean age of recipients of individual units was 62.7 years. The most common surgical indications for transfusion were total hip replacement (4.6% of all blood transfused) and coronary artery bypass grafting (4.1%). Haematological disorders accounted for 15.5% of use. Overall use was 4274 units per 100 000 population per year.

CONCLUSION

In the north east of England more than half of red cell units are transfused for medical indications. Demand for red cell transfusion increases with age. With anticipated changes in the age structure of the population the demand for blood will increase by 4.9% by 2008.

Erythroleukaemia in the north of England: a population based study

AIMS

To evaluate the incidence and outcome of acute myeloid leukaemia (AML), FAB M6 (erythroleukaemia).

METHODS

A demographic study in the Northern Health Region of England between 1983 and 1999.

RESULTS

Thirty three cases were diagnosed and registered prospectively. The overall incidence was 0.077 cases/100,000/year. There was a pronounced rise in incidence in patients aged 56 years or more: 6.6 times higher than that in younger patients. Overall survival was poor; median survival was 11 months for those aged less than 56 years, and three months for patients aged 56 years and above (p = 0.045). Acquired karyotypic abnormalities were found in 17 of 27 patients where analysis was attempted. When classified according to the criteria of the Medical Research Council AML trials, karyotype predicted survival, with a median overall survival of 14 months for those with "standard risk" cytogenetic results and two months for "poor risk" results (p = 0.005).

CONCLUSION

This study demonstrates a worse survival for patients with erythroleukaemia than that reported in some published trials of selected patients.

Improved Cleanup Method for Determination of Biphenyl in Citrus Fruits and in Biphenyl-impregnated Kraft Papers by Thin Layer Chromatography

A simple, rapid, and efficient method has been developed for determining biphenyl in citrus fruit and in biphenyl-impregnated kraft papers. Biphenyl is separated from citrus tissue by steam distillation and from biphenyl-impregnated papers by solution in iso-octane. Plastic sheets coated with silica gel, to which a polyvinyl alcohol binder and a fluorescent indicator have been added, are used for cleanup by thin layer chromatography (TLC). The TLC spots are extracted and measured spectrophotometrically at 248 m/µ. Recoveries of added biphenyl ranged from 92 to 98%. The new method is simple and brief; it is more accurate than cleanup by oxidative degradation since the variable background is practically eliminated. The new method is easier and faster than the silicic acid chromatostrip technique, and is just as accurate.