ABSTRACT
Blood transfusions are an essential part of supportive care for certain patient cohorts, particularly those on palliative care. Most transfusions occur in the hospital setting, including community hospitals. Transfusion in the patient's home supports individualised care, reduces demand on acute services and inconvenience for patient travel to hospital. Decision to undertake home transfusions requires assessment of risks and benefits, with regular review. Risk of acute transfusion reaction in any setting is rare but can result in major morbidity or death. This review looks at adverse events and reactions reported to Serious Hazards of Transfusion (SHOT), the UK haemovigilance scheme, where the transfusion was performed in the patient's home. SHOT cases submitted 2010-2020 were identified using the terms 'home', 'home transfusion' and 'patient's home'. Data were manipulated in MS Excel identifying reactions (febrile, allergic and hypotensive [FAHR], transfusion-associated circulatory overload [TACO]) and events (right blood right patient (RBRP), avoidable, delayed and over/under-transfusion [ADU], incorrect blood component transfused-specific requirements not met [IBCT-SRNM]). 20 cases of home transfusion were identified. FAHR accounted for 10/20 cases, IBCT-SRNM (3/20), HSE (3/20), RBRP (2/20), TACO (1/20) and ADU (1/20). Where patient sex was recorded, 12/19 were male. Age range 3-90 years (median 66, SD 24.9). Red cell components were implicated in 12/20 cases, platelet concentrates in 7/20 cases and one fresh frozen plasma. Patient underlying condition was haematological in 12/20 cases, others included pancytopaenia, angiodysplasia, metastatic cancer and anaemia. Chronic anaemia was the indication in 8/12 red cell transfusion cases and prophylaxis for 4/7 of platelet transfusions. Reactions ( n -11) were febrile (5/11), allergic reactions (3/11), TACO (1/11), 1 anaphylaxis and 1 unclassified. 7/11 patients (6 FAHR and 1 TACO) required hospital admission as a result of the reaction. Four patients were identified as not suitable for home transfusion after the event, SHOT expert review noted one patient should have been ineligible in the first place due to risk of TACO. Adverse events ( n = 9) included cold chain failures (2/9), one failure to inform the laboratory of home transfusion, failure to provide irradiated red cells (2/9), errors in labelling (2/9), incorrect administration rate, failure to provide antigen-negative blood and delay due to an incorrect Hb result. There are no data regarding the number of home transfusions in the UK, therefore it remains unclear whether reactions and errors are over-represented in these cases. Careful consideration should be given to the eligibility of patients to receive home transfusion, particularly the risk of TACO and previous transfusion reactions, before this regime is implemented. No data were available regarding staff performing the transfusions, nurses administering home transfusions must be transfusion trained and competent in identification and management of reactions. There must be robust processes for urgent transfer to hospital. There are no national guidelines for safe practice for home transfusions, including informed consent. Home transfusion is an increasingly important component of patient care, particularly during the COVID-19 pandemic to minimise risk for vulnerable patients, the infrastructure supporting this must have patient safety at its core.
ABSTRACT
Introduction: The COVID-19 pandemic put a huge pressure on all aspects of healthcare. Staff shortages were widely reported in the media;however, there were additional difficulties on staff including worries about putting their own health and that of their families at risk by continuing to support patient care. An additional challenge in provision of safe blood transfusions early in the pandemic was the lack of and published data regarding whether the virus could be transmitted via blood of infected patients. This introduced uncertainty around the safety of performing manual serological tests, commonly employed and recommended by the British Society for Haematology (Milkins et al, 2012), in antibody identification and investigation of haemolytic transfusion reactions (HTR). Method: HTR reports submitted to SHOT in 2020 were compared to those reported in the preceding two years to identify whether the pandemic had affected the incidence and the profile of serological investigations performed (e.g. direct antiglobulin test (DAT)). Results: The total number of HTR reported to SHOT in 2020 is comparable to the number reported in preceding two years, with 35, 49 and 46 reactions reported in 2018, 2019 and 2020 respectively. However, in 2020, a DAT was only reported in 27/46 (58.7%) of cases. This is a significant reduction when compared to 40/49 (81.6%) in 2019 and 34/35 (97.1%) in 2018. Discussion: Although there has been no significant increase in the incidence of HTR reported in 2020, the investigation of HTR has been affected, which may be a result of the additional challenges laboratories faced while managing the COVID-19 pandemic, and the effect of decreased testing may be observed in future years. As the DAT is a relatively simple test that can be performed by almost all transfusion laboratories in the UK, this may be indicative of a wider problem. Clear, timely guidance should be released by national bodies such as the BSH or National Blood Transfusion Committee in times of uncertainly, to enable transfusion laboratories to confidently provide the best standard of care to patients, whilst protecting the safety of staff.
ABSTRACT
Convalescent plasma, donated by persons who have recently recovered from COVID-19, is the acellular component of blood that contains antibodies, including those that specifically recognise SARSCoV-2 virus. Safety and efficacy of COVID-19 Convalescent Plasma (CCP) was tested as part of two large randomised controlled trials (RCT) in UK (REMAP-CAP and RECOVERY). Serious Adverse Reactions (SAR) data relating to use of CCP reported to SHOT between April 2020 and Feb 2021 (inclusive) were reviewed. A total of 13 407 units of CCP were transfused under the two trials in the UK, with 11 477 (86%) of these given under RECOVERY. There were 14 confirmed SAR (one from REMAP-CAP and 13 relating to RECOVERY) equating to a risk of SAR of 1 in 958 units of CCP. The most common reactions seen in CCP recipients were pulmonary reactions (9/14, 64.3%). Transfusion-associated circulatory overload (TACO) was confirmed in 4 cases and transfusion associated dyspnoea (TAD) in the other 5. Moderate to severe febrile, allergic, hypotensive reactions were reported in 5 patients, all of whom recovered fully. Four patients with pulmonary reactions (3 with TACO and one with TAD) died with death possibly related to the transfusion complication. All reactions were reported in adult patients, with the average age being 65.6 years. TACO checklist was used in only 4/9 (44.4%) pulmonary reactions. One case of TAD was possibly preventable, all other cases were not. Significant co-morbidities were present in 9/14 (64.8%) cases, including COPD and cardiac disease (among many others). Imputablity assessment was challenging given the multisystem nature of severe COVID-19 illness-no reactions reported to SHOT have been noted by experts to be definitely related to CCP. The two large RCT from UK have helped establish the evidence that CCP does not improve survival or other clinical outcomes in patients hospitalised with COVID-19. A systematic review and meta-analysis published in February 2021 confirmed that treatment with CCP compared with placebo or standard of care was not significantly associated with a decrease in all-cause mortality or with any benefit for other clinical outcomes. Data from SHOT shows that the febrile, allergic hypotensive reactions and pulmonary complications were the most commonly reported reactions. Conclusion: The HFs day-to-day observation checklist was considered a useful tool for identifying behaviours that could lead to errors, waste in the system, staff injuries and lost time. The next step is to use the findings for change that will improve the process and lead to a better level of BMS engagement.