Jonathan Hughes1, Janet McNaughton1, Jennifer Andrews1, Tracy George2, Cassandra Bergero3, Kimberly Pyke-Grimm3, Susan A Galel1, Christopher Gonzalez1, Lawrence Tim Goodnough4, Magali J Fontaine5. 1. Department of Pathology, Stanford University, Stanford, CA. 2. Department of Pathology, University of New Mexico, Albuquerque, NM. 3. Center for Nursing Excellence, Center for Quality and Clinical Effectiveness, Lucile Packard Children's Hospital (LPCH), Palo Alto, CA. 4. Department of Pathology, Stanford University, Stanford, CA Medicine, Stanford University, Stanford, CA. 5. Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA magalifontaine7@gmail.com.
Abstract
CONTEXT: Hemoglobinuria was observed after packed red blood cell transfusion in a series of patients at our pediatric treatment center. Laboratory testing was suggestive of intravascular hemolysis with no support for an immunohematologic process. OBJECTIVE: We investigated these adverse events to define a quality improvement plan and to prevent future hemolytic adverse events. Multiple factors were investigated, and the only change identified was the implementation of a new infusion pump (Pump A) that replaced a previous model (Pump B). DESIGN: In vitro pump analyses, a retrospective review of urinalyses, and prospective urinalysis and nursing surveillances were also performed. RESULTS: In in vitro analysis of the pumps, irradiated units with higher hematocrit at a low flow rate through Pump A had a greater than thirty-fold increase in free hemoglobin from baseline compared to minimal free hemoglobin changes seen with Pump B. Irradiated units with a lower hematocrit had a minimal change in free hemoglobin from baseline with both Pumps A and B at either low or high flow rate. Subsequently, only units with lower hematocrits were issued for transfusion of pediatric patients, and Pump A was replaced by Pump B in the outpatient unit. Retrospective and prospective surveillances found no additional unexplained cases of gross hemoglobinuria associated with transfusion. CONCLUSION: The investigation determined that infusion of higher hematocrit units using a specific commercial pump was associated with mechanical hemolysis. The change to units with lower hematocrit through an alternative pump has been an effective corrective action to date.
CONTEXT: Hemoglobinuria was observed after packed red blood cell transfusion in a series of patients at our pediatric treatment center. Laboratory testing was suggestive of intravascular hemolysis with no support for an immunohematologic process. OBJECTIVE: We investigated these adverse events to define a quality improvement plan and to prevent future hemolytic adverse events. Multiple factors were investigated, and the only change identified was the implementation of a new infusion pump (Pump A) that replaced a previous model (Pump B). DESIGN: In vitro pump analyses, a retrospective review of urinalyses, and prospective urinalysis and nursing surveillances were also performed. RESULTS: In in vitro analysis of the pumps, irradiated units with higher hematocrit at a low flow rate through Pump A had a greater than thirty-fold increase in free hemoglobin from baseline compared to minimal free hemoglobin changes seen with Pump B. Irradiated units with a lower hematocrit had a minimal change in free hemoglobin from baseline with both Pumps A and B at either low or high flow rate. Subsequently, only units with lower hematocrits were issued for transfusion of pediatric patients, and Pump A was replaced by Pump B in the outpatient unit. Retrospective and prospective surveillances found no additional unexplained cases of gross hemoglobinuria associated with transfusion. CONCLUSION: The investigation determined that infusion of higher hematocrit units using a specific commercial pump was associated with mechanical hemolysis. The change to units with lower hematocrit through an alternative pump has been an effective corrective action to date.
Authors: Ana Maria Miranda Martins Wilson; Maria Angélica Sorgini Peterlini; Mavilde da Luz Gonçalves Pedreira Journal: Rev Lat Am Enfermagem Date: 2018-10-11