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ORIGINAL CONTRIBUTION
Year : 2000  |  Volume : 54  |  Issue : 8  |  Page : 330-334
 

Blood transfusion associated fatalities


Department of Pathology, B.J. Medical College, Pune 411 001, India

Correspondence Address:
M V Jadhav
8, Mulay Classic, Near M.S.E.B. Colony, Bhosalenagar, Pune-411007
India
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PMID: 11143746

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How to cite this article:
Jadhav M V, Kurade N, Sahasrabudhe N, Bapat V M. Blood transfusion associated fatalities. Indian J Med Sci 2000;54:330-4

How to cite this URL:
Jadhav M V, Kurade N, Sahasrabudhe N, Bapat V M. Blood transfusion associated fatalities. Indian J Med Sci [serial online] 2000 [cited 2014 Jul 26];54:330-4. Available from: http://www.indianjmedsci.org/text.asp?2000/54/8/330/12174


Apprehension to the blood trans­fusion reaction particularly when it is fatal still remains in the minds of medical world though 60 years have passed since the set up of first blood bank in Barcelona in 1936. [1] While clinical staff is over enthusiastic iu blaming the death on blood transfusion even when it is unrelated, blood bank staff is busy denying it even in genuine reaction. A casual glance at histo­rical aspects of Transfusion Medi­cine will emphasise the fact that this attitude has influenced the transfusion practice unfavourably. On the other hand, the long his­tory of unsuccessful transfusions due to severe reaction like hemoly­sis and death led to tremendous growth in the amount of knowledge about the human blood groups and made blood transfusion practi­cable. [2] This has prompted us to share our experience with others.


 ¤ Materials and Methods Top


15 blood transfusion associated fatalities occurring in Sassoon General Hospitals Pune over a period of 6 years and 1 month from January 1995 were studied. 13 of these cases had received blood transfusion from regional blood bank of present institute. 2 additio­nal cases were transfused outside the hospitals and were admitted to present institute for management of reaction. Records of one more fatal transfusion reaction occurring in the same period in another blood bank were also reviewed on their kind permission. The study was conducted by reviewing the clini­cal and blood bank records, by performing clinical autopsies in 10 cases and medicolegal autopsies in 2 cases and by carrying out per­tinent laboraory investigations on samples collected at post mortem. The data was analysed to find out the role of transfusion in cause of death.


 ¤ Observation Top


It can be seen from [Table 1] that post transfusion endotoxaemia was the most frequent mode of death and occurred in 7 cases. The clini­cal presentation of these cases was in the form of disseminated intra­vascular coagulation (DIC) in 2 cases and shock with autonomic disturbances in rest of the cases. The bacterial culture was not done in 2 cases, showed. Citrobacter, Klebsiella and E coli in 3 cases and no growth in 2 cases. Post trans­fusion septicaemia cost the life of 3 patients who presented with feb­rile reactions, one such reaction was hemolytic in nature, another was associated with gangrene of transfused arm and the remaining case had septicaemic shock. The organisms encountered in respon­sible blood units were Aeromonas in 2 cases and Citrobacter in 1 case. Post transfusion cardiac over­load was responsible for death in 5 cases, all of which were severely anaemic and in failure. One in addi­tion had primary pulmonary hyper­tension and the other had calcific aortic stenosis. Boh these condi­tions were diagnosed at post-mor­tem. The amount of blood trans­fused ranged from 30 ml to 120 ml and the rate of transfusion exceed­ed the prescribed rate in 2 cases (case no. 10, 11). In 2 cases co­existence of post transfusion car­diac overload and endotoxaemia was thought of.

In 3 cases the death was not related to transfusion (case no. 5, 12, 15). 6 patients were clinically stable before transfusion while rest were morbidly ill. 3 patients were transfused intraoperatively and were mildly anaemic. Rest of the patients were transfused in the wards, 2 for acute blood loss, 2 for carcinoma of esophagus, 4 for mo­derate degree of anaemia and 5 for severe anaemia.


 ¤ Discussion Top


Every registered post-transfusion death may not be necessarily trans­fusion associated fatality. The prac­tice of attributing death to transfusion even when it is not related to it can be dated back to 17th cen­tury. [2] In present study it has occur­red in 3 instances. One such case died of hemorrhagic shock follow­ing multiple injuries. In one case, patient developed post transfusion urticaria, which was cleared quite well before death. The patient died of hypovolemic shock due to loose motions with which he was suffer­ing even before a transfusion. In one case death was due to adverse reaction to halothane (anaesthetic drug). This patient developed re­peated cardiac arrests and succumbed to it. The only known cause of transfusion associated car­diac arrest is citrate toxicity which occurs after massive transfusion, and present patient had received only few millilitres of blood. The present study emphasizes the im­portance of critical evaluation of pre transfusion clinical status and clinical diagnosis in investigating a post transfusion fatality. Equally important is the consideration of post transfusion course of the pa­tient and information regarding the technique of transfusion. The need to review original clinical condition and its diagnosis in investigating a post transfusion fatality has been stressed by Myhrt. [3] The diagnosis of septicaemia was based on clini­cal and autopsy findings in 2 cases and on clinical grounds in 1 case. The cases were labelled as endo­toxaemia mainly on clinical grounds and on failure to find out evidence of septicaemia at autopsy. It could not be always substantiated with bacterial culture.

The pre transfusion compromis­ed clinical status of the patient had an important bearing on post trans­fusion clinical course. The patient with compromised cardio-respira­tory status due to severe anaemia in failure along with primary pulmo­nary hypertension and calcific aortic stenosis readily developed post transfusion cardiac over load which was intractable and fatal. Severe and symptomatic anaemia is considered a fairly valid indication of transfusion. At the same time such patients are prone to fatal post transfusion cardiac over­load. [4] One is faced with the dilem­ma as there is no other option but to transfuse the patient with blood to alleviate the symptoms. This increases the haemoglobin by merely 1 gm%, per unit of blood but may put the life of a patient at stake. Use of packed red cells would not have changed the destiny of 5 patients with fatal post transfusion cardiac overload in present study as none was transfused with more than 120 cc of blood. Here comes the role of meticulous dissection technique during surgi­cal procedures which definitely re­duce the blood loss and , transfusion requirements. Khurana et al [5] have stressed the need to improve the medical education in proper management of blood transfusion in clinical practice and strategies to avoid the need for blood trans­fusion. It was a relief to note that none of the fatalities in present study were attributable to clerical or technical error on part of blood bank or hospital staff.

Myhre [3] and Honig and Bove [6] in 1980 studied Food and Drug Ad­ministration records of 1975 to 1979 to find out the details of blood bank associated fatalities. There were 113 such fatalities in 37 million transfusions with the incidence of 0.00023%. 33 of such fatalities were due to hepatitis which is a late transfusion reaction and 3 cases were donor associated. 73 fatalities were the recipient associated im­mediate post transfusion fatalities, 47 of which were due to clerical error and 8 were due to laboratory errors. One case was contributed by wrong technique (over warming of blood). All these can be consi­dered as preventable. The unpre­ventable and unpredictable fatalities consisted of anaphylaxis (4 cases), multiple antibodies (5 cases), delayed reactions (3 cases), respiratory distress (4 cases), DIC (2 cases), Graft verses host reaction (1 case) and Gram negative endotoxaemia (2 cases). Honig and Bove [6] have referred io aetiology of these fatalities. Anti­body mediated hemolysis was the most frequent cause. Thermal hemolysis was observed once. Mehta et al' have reported 2 fata­lities amongst 94 transfusion reac­tions and 32126 transfusions with the incidence of 0.006 amongst total transfusions and 2.14 amongst total reactions. Incidence of fatal transfusion reactions was high in pre­sent institute when compared with other institutes and in literature. However it should be viewed in the light of socio-economic status of the patients that we are catering for. Most of these patients were morbidly ill and had compromised clinical status when they were ad­mitted, thus leaving us with very few treatment options. Nonethe­less part of the high incidence still can be attributed to overuse of transfusion services and prompt re­cording which is possible due to location of blood bank within the hospital. Some of the cases were included form autopsy records though they were not registered in blood bank.

In conclusion, one can expect safe and fruitful transfusion only when administered to a properly selected patient and for absolutely indicated clinical condition.


 ¤ Summary Top


16 post transfusion deaths were studied by reviewing clinical and blood bank records and by post­mortem examination whenever pos­sible. 13 of these cases belonged to regional blood bank, 2 were transfused in other hospitals and referred for management of trans­fusion reactions and one case belonged to other blood bank in the city. 3 deaths could not be attributed to transfusion reaction. Post transfusion endo­toxaemia (7 cases) was the most frequent mode of transfusion asso­ciated fatality followed by cardiac overload (5 cases) and septicaemia (3 cases). In two cases endoto­xaemia coexisted with cardiac overload. The pretransfusion com­promised clinical course unfavour­ably thereby contributing signifi­cantly in death. The 3 clinically stable patients succumbed to post-­transfusion endotoxaemia. The incidence of transfusion associated fatality in the present institute was 0.028% amongst total transfusions.[7]

 
 ¤ References Top

1.Obeman H. The history of blood transfusion in clinical practice of blood transfusion pp 9-20, Lawrence D., Petz and Scott N. Swisher. New York Edinburgh London and Mel­bourne. 1981.  Back to cited text no. 1    
2.Mollison PL. Engelfriet CP, Contreras M. Red cell incompati­bility in vivo. In Blood transfusion in clinical medicine, pp 515-586, 8th Edn. Oxford London. Edin­burg, Boston, Paloalto, Melbourne, 1987.  Back to cited text no. 2    
3.Myhre B.A. Fatalities from blood transfusion. JAMA, 1980, 244, 1333­-1335.  Back to cited text no. 3    
4.de Gruchy : Blood groups; Blood transfusion: Acquired Immune Defi­ciency Syndrome. In de Gruchy's clinical haematology in medical practice pp 475-496, 5th Edn. Black­well Science Cambridge, special reprint for India by Thomson Press. 1996.  Back to cited text no. 4    
5.Khurana SK, Thergaonkar A, Dhupia JS, Verma SK, Talib VH. Rationale and strategy for utiliza­tion of available blood in transfu­sion practice. An overview. Indian J Pathol Microbiol, 1996;39:343-354.  Back to cited text no. 5    
6.Honig C. and Bove J. Transfusion associated fatalities - Review of Bureau of Biologic Reports. 1976 - 1978, Transfusion, 1980:20:653-661.  Back to cited text no. 6    
7.Mehta A, Lahiri A, Kumar S, Rao M. Immediate transfusion reaction: A retrospective. Indian J Haematol Blood Trans, 1993, 11 Suppl. 1.  Back to cited text no. 7    



 
 
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