Man dies after receiving contaminated blood

PUBLISHED : Tuesday, 08 January, 2008, 12:00am
UPDATED : Tuesday, 08 January, 2008, 12:00am

Experts recommend measures to cut transfusion risk

A 52-year-old man died yesterday, three days after receiving bacteria-contaminated blood in a transfusion, as an expert team recommended a string of interim measures to prevent a recurrence.

Wong Yun-cheun, who had anaemia and chronic liver problems, was admitted to Tuen Mun Hospital on Thursday for a red blood-cell transfusion but suffered shock and low blood pressure within two hours of the procedure. It was found his blood and the blood he had been given contained the common bacterium Pseudomonas fluorescens.

The head of the team investigating the incident, Yuen Kwok-yung, said after visits to the Red Cross Blood Transfusion Service and the hospital's blood bank that he could not find a cause for the contamination. 'At the same time, we are identifying some steps which are highly critical - some steps that might lead to blood contamination,' said Professor Yuen, chair professor of microbiology at the University of Hong Kong.

Records between October 9 and Thursday were checked to see if any machine or refrigerator in which blood was stored had been faulty.

Samples were also taken from blood bags and refrigerators for tests to see if they carried the bacteria.

Initial recommendations include standardising the time for disinfecting the skin of patients by using stop clocks, avoiding condensation in containers when blood bags are being transported, increasing disinfection of blood containers and refrigerators, and checking discarded blood to see if it contains bacteria.

Professor Yuen also suggested patients with adverse reactions to a blood transfusion be given an injection of antibiotics to increase their survival chances. 'If doctors and nurses cannot find a reason why a patient has fever or shock after having a blood transfusion, an injection of antibiotic should be given. If tests show the blood is clean, then doctors can stop using antibiotics,' he said.

But in most cases, bacterial infection had nothing to do with patients developing fever after a transfusion.

'If a doctor doesn't give antibiotics to a patient, he is not wrong,' he said. 'He is right more than 99.9 per cent for not giving antibiotics. But there are some weird cases like this - a blood bag is contaminated with bacteria. The patient's survival chances will be lower if no antibiotic is given. But I think this is not the doctor's fault.'

A younger brother of the dead man, who left a wife and child, said he hoped the four-member expert team would find the truth. 'We will wait for the report to decide if we will seek compensation but first we have to see if the report identifies whether anyone has made any mistake in the incident,' the brother, who gave his name only as Mr Wong, said.

Margaret Ip Bik-yiu, professor of microbiology at Chinese University, said P. fluorescens was 'a well-known cause for contamination in blood transfusions'. While such infections were rare, any bacterial illness from a blood transfusion or intravenous fluids was likely to be caused by this organism.

'It is impossible to completely eradicate it because there is always a risk,' she said. 'My advice is blood transfusion should not be given unnecessarily but the risk has to be told to the patient.'

Lee Cheuk-kwong, senior medical officer at the blood transfusion centre, said the female donor of the blood in question had been informed and was 'perfectly all right'.