Casesfromthe2010Report-final-ShoT.ppt

Failure to monitor the transfusion requirements during a GI haemorrhage An elderly patient was admitted to the MAU with a haematemesis and an initial Hb of 10.6 g/dL. No details are provided of her observations or the findings on endoscopy but she had further episodes of vomiting blood. Five units of red cells were transfused before a repeat Hb was performed, which was 20.4 g/dL. The patient was recognised to have circulatory overload and died shortly thereafter. Over-transfusion requiring venesection An elderly patient with a severe GI bleed had repeat Hbs of 6.1 and 6.4 g/dL. Six units of red cells were transfused prior to rechecking the Hb, which was 17.1 g/dL. The patient developed circulatory overload and required venesecting 2 units. Over-transfusion leading to polycythaemia and a cerebral infarct An elderly female patient of low body weight (29 kg) was admitted with an initial Hb of 7 g/dL. Three units of red cells were prescribed and the post-transfusion Hb was 17 g/dL, confirmed with a repeat sample the following day. She sustained a cerebral infarct 48 hours following the transfusion, which resulted in long-term morbidity. The reporters were apparently very confident of the initial Hb and felt that an inappropriate volume had been prescribed. Patient given a transfusion despite responding to oral iron Following iron deficiency during pregnancy, a female delivered with a Hb of 7.8 g/dL. A decision was taken in conjunction with the patient not to transfuse her, but to discharge her on oral iron. Nine days later, her Hb was checked by the midwife and found to have risen to 8.9 g/dL. Two weeks later, without a further check on her Hb, she was admitted to the community hospital for a blood transfusion at the GP’s request. Lack of communication between shifts A patient with known hereditary spherocytosis was admitted with an Hb of 7.2 g/dL. The consultant haematologist decided in consultation with the patient that a transfusion was not necessary. Howe