Hospital Harm: Infusion, Transfusion and Injection Complications

Overview and Implications

Healthcare Excellence Canada has developed this Hospital Harm Improvement Resource – a compilation of resources to support patient safety and improvement efforts.

Air embolism following infusion, transfusion and therapeutic injection

An air embolism is a bubble that becomes trapped in a blood vessel and blocks the vessel. It is a rare but potentially fatal event. The seriousness of the blockage depends on which part of the body the affected blood vessel supplies blood to, and the size of the air bubble. For example, an air embolism in the arteries leading to the brain may cause a decreased level of consciousness, dizziness, slurred speech, seizures, and/or a stroke. An air embolism that travels to the coronary arteries may cause a myocardial infarction or an arrhythmia. An air embolism that travels to the lungs may cause a pulmonary embolism (Gordy & Rowell 2013; National Health Service 2015).

Vascular complications following infusion, transfusion and therapeutic injection

Phlebitis refers to inflammation of the vein and it may be a complication of peripheral cannulation. Phlebitis may be painful, and it compromises future venous access. Other symptoms include warmth, tenderness, erythema or palpable venous cord. If it is bacterial and untreated, it may lead to a bloodstream infection. Phlebitis may be localized to the insertion site or travel along the vein. It may occur during catheterization or up to 48 hours after cannula removal (Ray-Burruel et al. 2014).

ABO incompatibility reaction

Acute hemolytic transfusion reaction is a possible complication of a blood transfusion. It may be associated with ABO-incompatibility, other blood group incompatibilities (there are 29 blood group systems, in addition to ABO, that may cause incompatibility), and with rare cases when group O platelets with high titers of anti-A and/or anti-B are transfused to a non-group O recipient (Callum et al. 2016; Fung et al. 2007).

ABO-incompatibility is the most common cause of morbidity from RBC transfusion. The reaction is often due to a clerical error, or an error in patient identification. Half of all errors are due to administering properly labelled blood to the wrong patient, while other errors are the result of improper labelling of samples or testing errors. One in 38,000 red cell transfusions are ABO-incompatible due to transfusing the wrong blood to a patient, and less than 10 per cent of ABO-incompatible transfusions result in a fatal outcome. The risk of death correlates with the amount of incompatible blood transfused (Callum et al. 2016).

Symptoms of hemolytic reaction include back pain, bloody urine, chills, fainting or dizziness, fever, flank pain and flushing of the skin (National Heart Lung and Blood Institute 2011; Transfusion reaction 2016).

Rh incompatibility reaction

Rh is known as the D antigen. Less than 15 per cent of the population do not have this antigen expressed on their red blood cells and are typed as D negative, more commonly known as Rh negative. If an Rh negative person is exposed to Rh positive blood, either by a blood transfusion or their fetus during pregnancy, a small percentage will form an antibody to the D antigen (Anti-D). If the patient does develop anti-D, subsequent exposures to Rh positive blood products can produce a hemolytic reaction (Ontario Regional Blood Coordinating Network 2016).

In the case of pregnancy, if an Rh negative mother develops Anti-D during her first pregnancy with an Rh positive baby, her second or subsequent babies could suffer devastating effects as the anti-D in her plasma may attack the D-antigen on the surface of the baby's red cells causing hemolysis. This is a known cause of hemolytic disease of the fetus and newborn (HDFN). An infant with HDFN may show signs of anemia, jaundice, hypotonia, lethargy, or in some cases, brain damage or even death can occur. The administration of Rh Immune globulin (Rhogam) during prenatal care can reduce the likelihood of developing Anti-D, which would affect future pregnancies (Ontario Regional Blood Coordinating Network 2016).

Anaphylaxis to serum

Anaphylactic shock can result from a blood transfusion. It is the most severe form of allergic reaction and accounts for approximately three per cent of transfusion associated fatalities (Food and Drug Administration, 2009). The occurrence rate for anaphylaxis is rare at one in 40,000. The vast majority of anaphylactic reactions are unexplained (Callum et al. 2016).

Anaphylactic/anaphylactoid reactions usually begins within one to 45 minutes of the start of the infusion and are associated with cutaneous reactions (urticaria), hypotension, hypoxia, hoarseness, stridor, wheezing, chest pain, dyspnea, anxiety, feelings of impending doom, gastrointestinal symptoms (nausea, vomiting) and rarely death (Callum et al. 2016).

Other serum reactions

Urticaria may present as one lesion or be widespread lesions. Urticaria may be associated with pruritus, erythema, flushing or mild upper respiratory symptoms (cough, wheezing), nausea, vomiting, abdominal cramps or diarrhea (Callum et al., 2016). Minor allergic reactions affecting the skin with occurrence of hives, rash, and urticaria are far more common occurring at a rate of one in 100 blood products transfused (Callum et al., 2016).

Importance to Patients and Families

Air embolism is an uncommon, but potentially catastrophic, event that occurs as a consequence of the entry of air into the vasculature (O'Dowd & Kelley 2019)

Patients experiencing acute hemolytic transfusion reactions most often present with fever, chills and hemoglobinuria. Less common symptoms are pain, hypotension, nausea/vomiting, dyspnea, renal failure and disseminated intravascular coagulation (Callum et al. 2016).

Patient Story

Blood on their hands: man dies after transfusion mix-up at Coney Island Hospital

"There's bad blood at Coney Island Hospital — and it's deadly. A 40-year-old male patient died at the city-run hospital last week after receiving the wrong type blood during a transfusion, The Post has learned. Transfusions that don't match a patient's blood type — giving Type-A to a person who is Type-B, for example — causes the body to attack the new red blood cells, a violent and painful reaction that can lead to shock and a fatal kidney shutdown. "The blood was mislabeled in the lab. It wasn't a nursing issue," said one hospital professional who spoke yesterday on condition of anonymity. "It shouldn't have happened; it's just carelessness. It's a huge problem," he added. A source said the fatal error occurred in the hospital's sixth-floor lab, where blood drawn from patients is screened and 'typed'. A technician labeled the patient's blood as the wrong type, and the patient was given the wrong blood during a transfusion."

(Italiano 2013)