The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [289]
The SHOT report 2008 emphasizes that, on occasion, transfusion reactions can occur many hours and sometimes days after the transfusion is completed. Therefore, for patients receiving a transfusion as a day case, it is important to ensure that they are counselled on the possibility of later adverse reactions and that they have access to clinical advice at all times. The BCSH recommends that day-case and short-stay patients are issued with a contact card facilitating 24-hour access to appropriate clinical advice, similar to the scheme used for patients receiving chemotherapy treatments on an outpatient basis (BCSH 2009).
Complications
Transfusion-associated graft-versus-host disease (TA-GVHD)
Although rare, TA-GVHD is a serious complication for recipients and is often fatal. TA-GVHD is usually caused by an IBCT incident where non-irradiated blood components containing immunocompetent T lymphocytes are given to severely immunocompromised recipients. The donor T lymphocytes engraft and multiply, reacting against the recipient’s ‘foreign’ tissue, causing a graft-versus-host reaction (Davies and Williamson 1998). It is not commonly associated with fresh frozen plasma (FFP) or cryoprecipitate. Onset occurs 1–2 weeks after transfusion and the condition is predominantly fatal (McClelland 2007). Irradiation (25 gray) of blood and blood products, to inactivate T lymphocytes (McClelland 2007), is essential in the prevention of TA-GVHD and is especially important in the following recipients:
foetuses receiving intrauterine transfusions
patients undergoing or who have undergone blood or bone marrow progenitor cell transplantation
immunocompromised recipients.
Bacterial infections
Contamination of blood and blood products can occur during donation, collection, processing, storage and administration. Despite strict guidelines and procedures, the risk of contamination remains. Most common contaminating organisms are skin contaminants such as staphylococci, diphtheroids and micrococci, which enter the blood at the time of venesection (Barbara and Contreras 2009, Provan et al. 2009). Bacterial contamination can lead to severe septic reaction.
Viral infections
Viruses transmissible via blood transfusions can be either plasma borne or cell associated (Barbara and Contreras 2009, Williamson et al. 1999). Plasma-borne viruses include hepatitis B, hepatitis C, hepatitis A (rarely), serum parvovirus B19, and human immunodeficiency viruses (HIV-1 and HIV-2). Cell-associated viruses include cytomegalovirus (CMV), Epstein–Barr virus, human T cell leukaemia/lymphoma viruses (HTLV-1/HTLV-2) and HIV-1/HIV-2.
Human T cell leukaemia/lymphoma virus type 1 (HTLV-1)
Human T cell leukaemia/lymphoma virus type 1 is an oncogenic retrovirus, associated with the white cells that cause adult T cell leukaemia, and is connected with several degenerative neuromuscular syndromes. The enzyme-linked immunosorbent assay (ELISA) has been recommended because of concerns relating to the transmission of the virus via blood transfusion, and the associated long incubation period of adult T cell leukaemia. In the UK all blood is tested for HTLV (JPAC 2005).
Cytomegalovirus (CMV)
Cytomegalovirus is classified as part of the herpes family and hence has the ability to establish latent infection with reactivation during periods of immunosuppression (Barbara and Contreras 2009, Louis and Heslop 2009). Approximately 50% of the population in the UK has antibodies to CMV. Therefore it is recognized that the virus may be transmitted by transfusion. Although it poses little threat to immunologically competent recipients, CMV infection in vulnerable patient groups can cause significant morbidity and mortality. For example, CMV pneumonitis carries an 85% mortality rate in blood and bone marrow transplant recipients (Mollison et al. 1997). Screening of donors and