ABO incompatible red cell transfusions: incidence, consequences, management, and prevention

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ABO incompatible red cell transfusions
incidence, consequences, management, and
prevention

• Charles Eby, M.D.

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gunshot wound to pelvis

• Massive transfusion protocol activated
• First box 10 u O red cells
• Correctly labeled tube for TS received in BB
• Forward typing B (pts red cells agglutinate
  with anti-B)
• Reverse typing matched (pts serum agglutinates A
  red cells and not B cells)
• Rh
• Subsequent resuscitation over 72 hours
• 14U B red cells, 20 B FFP

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Clinical course

• Lacerated iliac artery and vein repaired
• Post-op hypotensive, pressor support, intubated,
  
• acute renal failure BUN/Cr 77/6.5
• hepatic failure AST 19720 (11-47 IU/L)
• ALT 9265 (7-53 IU/L)
• T Bili 22.9 (0.3-1.1 mg/dl)
• WBC/Hg/Hct/Plt 15.4/7.3/21.3/59

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Repeat TS required every 72 hours

• Forward typing agglutination reactions
• Anti-A 2, anti-B 3 type AB
• Reverse typing agglutination reactions
• A cells 1, B cells 1 type O
• Discrepant results somethings definitely wrong
• Indirect Coombs- (screening cells type
  O)-negative
• Direct Coombs- positive
• Eluate anti-A and anti-B specificity

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Actions

• Examine original tube, repeat TS B
• Obtain new sample, repeat TS AB
• Original tube mislabeled, patient is A
• Change future transfusion support to
• Washed O red cells, AB FFP and platelets
• Inform ICU team of acute hemolytic tax event
• Investigate source of error

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Root cause analysis

• How was tube for TS collected and labeled in ER?
• Could an unlabeled tube collected from a
  different patient been labeled incorrectly?
• Eventually, the blood type of the prior patient
  in the trauma room was obtained B
• Blood collection policy in the ER reviewed,
  improved compliance through education

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Its happened before

• 2002
• CT-ICU,unstable CABG pt on Hemosol study,verbal
  order for 2U rbcs
• Runner took transfusion authorization form to BB
  stamped with wrong patients name
• Two MDs performed bedside confirmation of blood
  and patient identity and hung blood
• Patient rapidly deteriorated and died lt 48hr
• Audit by research study coordinator
• Patient was O, units were A
• Investigations by FDA, Joint commission, CAP
• Malpractice suit settled
• Actions policies reviewed, education
• Technology for barcode swiping of pt ID and blood
  bag before infusion anticipated to be installed
  in 4-5 years

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Fatal ABO incompatible transfusion reactions are
rare
Linden JV et al Transfusion 2000401207
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Linden JV et al Transfusion 2000401207
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Center for Biologics Evaluation and Research 2008
FDA annual report
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ABO mismatched Tx estimates

• All cases
• NY state 1990-1999 1/38,000
• Fatal cases
• NY state 1990-1999 0.5/ x106 rbc tx
• National/FDA 0.3-1.0/1 x106 rbc tx
• BJH 2002-2009 3.6/1 x 106 rbc tx

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Sources of ABO Transfusion errors
Linden JV et al Transfusion 2000401207
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perspective

• Estimates of risk of viral transmission from
  blood products
• Hepatitis B 1 in 0.2/million
  (anti HBsAg)
• Hepatitis C 1 in 1.5-2/million (NAT)
• HIV 1 in 2/million (NAT)

• BJH medication-related fatalities
• 2004-3
• 2005-0
• 2006-0
• 2007-1
• 2008-1
• Denominator millions
• BJH pharmacy dept

Alter HJ, Klein HG. Blood 20081122617
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Signs/symptoms of acute hemolytic transfusion
reaction

• Symptoms
• Fever
• Back pain
• Signs
• Tachycardia preceding Hypotension-shock
• Hemoglobinuria/hemoglobinemia
• Acute renal failure

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mechanisms

• IgM-Complement mediated intravascular hemolysis
• Human data
• No systematic investigations
• Few opportunistic observations
• Extrapolate from SIRS literature
• cytokine storm TNF, IL-6,
• Tissue factor expression/ thrombomodulin
• Nitric oxide binding to free hemoglobin

Capon SM. Transfusion 199535513
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Mouse model of IgG and IgM mediated hemolysis
Schrimer et al. Blood20071093099
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More incompatible red cells, greater risk of
morbidity and mortality
Janatpour et al Am J Clin Path 2008129276
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management

• Pre-emptive stop transfusion immediately
• Aggressive red cell exchange, eculizumab?
• Supportive

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Prevention
Dzik et al Br J Haem 2006136181
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WBIT 94 of 411,705 TS (2.3/10,000)
Figueroa et al Am J Clin Path 2006126422
Est. at BJH 12 WBIT/yr, 80,000 TS performed
1.5/10,000
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Prevention of WBIT

• Follow procedures
• Compare blood type in tube to historical type
• Available 62 of time at UCLA
• If no previous TS, send a check tube from BB
• Only for non-type O, non-emergent
• Requires 2nd phlebotomy
• Delays TAT for cross-matched blood
• Increased TS volume 15 at UCLA (2000-2003)
• Increased WBIT detection by 12
• Bar code technology

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Prevention of transfusion of wrong unit

• Follow policies and procedures
• failure rate 25 in observation of 4000
  transfusions
• Bar code confirmation of pt/ blood product/order
• Radiofrequency identification (passive)
• Mechanical barrier Bloodloc system

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Follow up of case

• BJH transfusion subcommittee recommendations
  delivered 4/23/07
• Educate, change culture, hold staff accountable
  for mislabeled/WBIT specimens delivered to all
  laboratories
• Request bar code system for TS tube labeling and
  blood transfusion rough estimate 2 million
• Monitor mislabeled tube rates after first
  intervention. If no improvement consider check
  tubes for first TS

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Capon SM. Transfusion 351995513
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Capon SM. Transfusion 351995513
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