A Clinical Experience upon Acute Renal Failure due to Mismatched Blood Transfusion

Kim, Yong Lack; Kim, Dong Kwon; Kim, Haeng Shick

doi:10.4097/kjae.1978.11.1.49

Korean J Anesthesiol

1978

DOI: 10.4097/kjae.1978.11.1.49

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A Clinical Experience upon Acute Renal Failure due to Mismatched Blood Transfusion

Yong Lack Kim

Dong Kwon Kim

Haeng Shick Kim

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“…We found 32 ABOi transfusion cases in total-nine in the written judgments (cases 1-9), 16 in the KOHEVIS reports (cases 9-24), and nine in literature published in Korea (cases 9 and 25-32) [7][8][9][10][11][12]. Data of the ABOi transfusion cases reported in Korea are presented in Table 1.…”

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ABO-Incompatible Transfusion Events Reported in Written Judgments and in the Korean Hemovigilance System

Choi

Hyun

et al. 2021

Ann Lab Med

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Fatal ABO-incompatible (ABOi) transfusion is one of the most common causes of transfusion-related death, but its reporting has been limited in Korea. We comprehensively reviewed ABOi transfusion events in Korea by analyzing cases reported in literature, Korean hemovigilance system (KOHEVIS) annual reports, and written judgments. Written judgments were assessed using a written judgment management system or a comprehensive legal information system. We found nine cases of ABOi transfusion events in written judgments (from 1953 to 2019), 16 in the KOHEVIS (from 2008 to 2018), and nine in published reports (from 1978 to 2019). One case was found in all three sources. Overall, we found 32 cases of ABOi transfusion events. Four cases died and 23 survived, while the outcomes for five were unavailable. ABOi transfusion errors occurred at the administration (50%, 16/32), sample (13%, 4/32), and testing (9%, 3/32) stages. The causes of errors were unavailable for nine cases (28%, 9/32). We report the status of ABOi transfusions in Korea and expect our results to contribute to the prevention of adverse reactions due to ABOi transfusion.

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confidence: 99%

ABO-Incompatible Transfusion Events Reported in Written Judgments and in the Korean Hemovigilance System

Choi

Hyun

et al. 2021

Ann Lab Med

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Acute Hemolytic Transfusion Reaction due to ABO-Incompatible Blood Transfusion: A Fatal Case Report and Review of the Literature

Lim

Kim

et al. 2018

KJBT

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A 77-year-old female patient who was suspected to have had an acute hemolytic transfusion reaction was admitted to the emergency room. She received one unit of type A red blood cells in a type B patient during a total knee arthroplasty operation at another medical institution. ABO-incompatible transfusion was carried out due to an identification error between the patient and blood product. At the time of admission, acute hemolytic reaction, lactic acidosis, and disseminated intravascular coagulation were observed. She was admitted to the intensive care unit and received continuous renal replacement therapy. She maintained renal function and was moved to the general ward on the 7th day. Complications such as pulmonary edema, gastrointestinal bleeding, and ischemic colitis persisted, and the patient died on the 111th after admission. This case is the first report of death due to an ABO-incompatible transfusion in Korea. Efforts to establish a safe transfusion environment are necessary not only at individual medical institutions but also at the national level.

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A Clinical Experience upon Acute Renal Failure due to Mismatched Blood Transfusion

Cited by 2 publications

References 0 publications

ABO-Incompatible Transfusion Events Reported in Written Judgments and in the Korean Hemovigilance System

ABO-Incompatible Transfusion Events Reported in Written Judgments and in the Korean Hemovigilance System

Acute Hemolytic Transfusion Reaction due to ABO-Incompatible Blood Transfusion: A Fatal Case Report and Review of the Literature

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