Transfusion-associated Circulatory Overload Cases Research Articles

The impact of revised definitions for transfusion-associated circulatory overload and transfusion-related acute lung injury on haemovigilance reporting.

Transfusion-associated circulatory overload (TACO) and transfusion-related acute lung injury (TRALI) are serious adverse transfusion reactions. Standardized surveillance definitions are important to ensure consistent reporting of cases. Recently, revised definitions have been developed for TACO and TRALI, the latter of which has not yet been widely implemented. This study aimed to assess the impact of the new TACO and TRALI definitions on haemovigilance reporting. The Australian Red Cross Lifeblood Adverse Transfusion Reaction database was accessed to identify all cases of suspected or confirmed TACO and TRALI referred from 1 July 2015 to 30 June 2019. Cases were assessed against both the former and new definitions and the results were compared. A total of 73 cases were assessed. There were 48 TACO cases identified. Only 26 of 48 cases strictly met the former 2011 International Society of Blood Transfusion (ISBT) definition of TACO; 6 cases did not meet the definition and 16 cases lacked sufficient clinical details. In comparison, 46 cases met the revised 2018 ISBT definition, with only 2 cases having insufficient details. There were 24 cases of TRALI according to the existing 2004 Canadian Consensus Conference (CCC) definition compared with 25 cases according to the proposed 2019 revised definition. The revised TACO definition captured more cases than the former definition. No significant differences were observed in the number of TRALI cases under the proposed new definition. This is the first study to provide validation data for the revised TRALI definition.

Development of the Chinese Haemovigilance Network and reporting of adverse transfusion reactions from 2018 to 2020.

To advance blood transfusion safety, the Chinese Haemovigilance Network (CHN) was put into operation in 2018. This report describes the development of the CHN and evaluates its role by analysing reported adverse transfusion reactions (ATRs) from 2018 to 2020. All data in this study were obtained from the CHN online reporting platform. A timeline of CHN development is presented, and the activities of CHN-enrolled facilities are analysed by year. The reported ATRs were analysed in detail for ATR types, blood components involved and adherence to case definition, severity and imputability criteria. Incidence rates were calculated and compared with international examples. During 2018-2020, a total of 3061 ATRs were reported through the CHN online reporting system. The rate of reported ATRs in all facilities and the 10 highest reporting facilities was 0.7‰ and 1.8‰, respectively. When analysed by year, the incidence rate showed an increasing trend from 2018 to 2020. Allergic (68.2%) and febrile non-haemolytic transfusion reaction (27.1%) were the most common. The vast majority of ATRs (92.0%) were not serious, but serious cases of transfusion-associated circulatory overload, transfusion-associated dyspnoea and hypotensive reaction were common. Most (86.0%) of reported cases were definitely or probably associated with transfusion. Under-reporting of ATRs occurs in many Chinese hospitals, but the establishment of CHN has increased ATR recognition and management. More effort will be needed in the future to detect transfusion problems and improve transfusion practice in China.

Transfusion-Associated Circulatory Overload (Taco) Presentations In Pediatric Patients

Abstract Introduction/Objective Limited literature exists regarding Transfusion Associated Circulatory Overload(TACO) in children. Its clinical expressions compared to those in adults remains to be fully explored. We report two TACO cases in children <18 months of age describing their clinical presentations compared to those in older patients. Methods/Case Report Case series Results (if a Case Study enter NA) Case 1: 1.13 kg 18 day old male neonate (27 weeks premature) with anemia requiring hemotherapy(HT). He received 35 ml aliquot of Red Blood Cells(RBCs) which he tolerated well on postoperative day(POD) 1 after bowel surgery. On POD 2, he was transfused RBCs(18 mls). Within 15 minutes of HT initiation, marked elevations in blood pressure(BP) were noted. Workup for a suspected transfusion reaction(STR) was initiated. Blood Bank studies revealed vital sign value(VSV) changes similarly seen in adults with TACO(Transfusion: 52; 2311, 2012). NT-proBNP levels post HT were markedly elevated (8,000 and 64,000 pg/ml).Case 2: 17 month old(11 kg) female with a three weeks prior history of COVID-19 admitted with fever/dehydration and subsequently diagnosed with multisystem inflammatory syndrome in children (MIS-C). Intravenous immunoglobulin(IVIG) infusion ordered and within 20 minutes of starting IVIG, she developed grunting. STR workup showed post HT BP/temperature elevations/chest X-ray with increased interstitial markings. Of note she had also received 1070 ml of intravenous fluids within 48 hours prior to HT. Elevated NT-proBNP levels pre/post HT were measured(17,121 pg/ml and 19, 824 pg/ml respectively). Symptoms improved with diuretics. Conclusion Children experiencing TACO can clinically manifest similarly as in adults with respect to BP elevations and pulmonary changes. Grunting may be an underappreciated manifestation of TACO in pts < 18 months of age. IVIG infusions used in the treatment of patients with MIS-C may present problematic fluid challenges. Recognition of and mitigation strategies for TACO risk factors in such patients may enhance HT safety in this vulnerable patient population.

TACO‐BEL‐3: a feasibility study and a retrospective audit of diuretics for patients receiving blood transfusion at ten hospitals

Transfusion-associated circulatory overload (TACO) is the leading cause of transfusion-related morbidity and mortality. A recently completed pilot trial randomized patients to pre-transfusion furosemide versus placebo but had a slower than expected enrollment rate. We sought to determine whether the lack of recruitment was due to a paucity of eligible patients or excessively restrictive eligibility criteria. At 10 sites, eligible patients were retrospectively identified by first screening blood bank databases over one month for all transfusion episodes meeting trial inclusion criteria, defined as non-surgical patients receiving single RBC unit transfusions. The age threshold was decreased from 65 to 50years. The first 10 patients meeting inclusion criteria then underwent detailed chart review for the exclusion criteria. The incidence of TACO and furosemide use was also recorded. At the 10 sites, 11969 red cell units were transfused over 1month and 1356 met the inclusion criteria. Of the 100 charts reviewed, 60 (60%) had no exclusion criteria. Active bleeding was the most common reason for ineligibility. There were 813 eligible transfusion episodes. Of the eligible patients, 17 (28·3%) had evidence of congestive heart failure, and furosemide was prescribed in 24 (40%). Despite the use of a lower age threshold, three cases of TACO were detected with an incidence of 3%. A large number of transfusion episodes met eligibility criteria. With a 3% incidence of TACO, 50% decrease through the use pre-transfusion furosemide and a target consent rate of 30%, a definitive trial of approximately 3000 patients could be completed within 1year.

Revised international surveillance case definition of transfusion-associated circulatory overload: a classification agreement validation study

Transfusion-associated circulatory overload (TACO) is a major cause of transfusion-related morbidity and mortality in countries with well developed transfusion services. The International Society of Blood Transfusion, the International Haemovigilance Network, and AABB (formerly American Association of Blood Banks), have developed and validated a revised definition of TACO. International Haemovigilance Network-member haemovigilance systems (Australia, Austria, Denmark, Finland, Greece, India, Ireland, Italy, Japan, Malta, Netherlands, New Zealand, Norway, Slovenia, United Kingdom and United States) provided cases of respiratory complications categorised by their systems, including clinical parameters listed in the 2017 draft definition (part 1). Individual transfusion professionals were then invited to assess 24 case descriptions according to the draft definition (part 2). Positive and negative agreement and inter-rater agreement (κ) were calculated. Based on validation results, cases were reanalysed and slight adjustments made to yield the final 2018 TACO definition. In part 1, 16 (44%) of 36 haemovigilance systems provided 178 cases, including 126 TACO cases. By use of the 2018 definition, 96 (76%) of 126 cases of TACO were in positive agreement. 19 (37%) of 52 cases were recognised as non-TACO respiratory complications. In part 2 (47 experts from 20 countries), moderate all-case agreement (κ=0·43) and TACO-specific agreement (κ=0·54) were observed. Excluding cases missing some clinical information (eg, N terminal pro-brain natriuretic peptide, distinctive chest x-ray findings, and relationship with existing respiratory co-morbidities like pneumonia and chronic obstructive pulmonary disease) improved all-case agreement to κ=0·50 (moderate) and κ=0·65 (good) for TACO cases. The two-part validation exercise showed that the revised 2018 TACO surveillance case definition captures 76% of cases endorsed as TACO by participating haemovigilance systems. This definition can become the basis for internationally consistent surveillance reporting and contribute towards increased awareness and mitigation of TACO. Further research will require reporting more complete clinical information to haemovigilance systems and should focus on improved distinction between TACO and other transfusion respiratory complications. International Society of Blood Transfusion, International Haemovigilance Network, and AABB.

Outcomes and risk factors of transfusion-associated circulatory overload: a case control study.

Transfusion-associated circulatory overload (TACO) is a growing concern in clinical practice. A case control study was performed at the Nîmes University Hospital, France. TACO cases occurring after RBC transfusion reported from January 1, 2014, to May 31, 2017, were included as cases. Four controls by case were randomly selected among the other RBC recipients on the same day. During the study period, 60 TACO diagnoses were reported for 37,029 transfused RBCs to a total of 8787 patients; 240 controls were included. The average rate of TACO was one case every 616 RBCs transfused. One in 146 transfused patients experienced TACO. TACO was associated with a higher 28-day mortality (22% vs. 11%; p = 0.003), and a longer hospital stay compared with controls (23.5 ± 19.6 days vs. 15.9 ± 20.1 days; p < 0.001). Four risk factors were independently associated with TACO in multivariable analysis: chronic use of loop diuretics (odds ratio [OR], 6.5, 95% confidence interval [CI], 3.3-12.9), hemorrhagic shock (OR, 12; 95% CI, 2.9-50), body weight <46 kg (OR, 7.9; 95% CI, 2.3-26.8) and chronic hypertension (OR, 4.1; 95% CI, 2-8.5). TACO was frequent and associated with poor outcome. Four independent risk factors were identified: hemorrhagic shock, low body weight, chronic use of diuretics, and chronic hypertension.

Contemporary Risk Factors and Outcomes of Transfusion-Associated Circulatory Overload.

Transfusion-associated circulatory overload is characterized by hydrostatic pulmonary edema following blood transfusion. Restrictive transfusion practice may affect the occurrence and severity of transfusion-associated circulatory overload in critically ill patients. We sought to examine contemporary risk factors and outcomes for transfusion-associated circulatory overload. Case-control study. Four tertiary care hospitals. We prospectively enrolled 200 patients with transfusion-associated circulatory overload identified by active surveillance and 405 controls matched by transfusion intensity. None. Among 20,845 transfused patients who received 128,263 blood components from May 2015 until July 2016, transfusion-associated circulatory overload incidence was one case per 100 transfused patients. In addition to cardiovascular comorbidities, multivariable analysis identified the following independent predictors of transfusion-associated circulatory overload: acute kidney injury, emergency surgery, pretransfusion diuretic use, and plasma transfusion-the latter especially in females. Compared with matched controls, transfusion-associated circulatory overload cases were more likely to require mechanical ventilation (71% vs 49%; p < 0.001), experienced longer intensive care and hospital lengths of stay following transfusion, and had higher mortality (21% vs 11%; p = 0.02) even after adjustment for other potentially confounding variables. Despite restrictive transfusion practice, transfusion-associated circulatory overload remains a frequent complication of transfusion and is an independent risk factor for in-hospital morbidity and mortality. In addition to cardiovascular and renal risk factors, plasma transfusion was associated with transfusion-associated circulatory overload after controlling for other covariates. Additional research is needed to examine the benefit of reduced erythrocyte or plasma exposure in patients at high risk for transfusion-associated circulatory overload.

Transfusion-associated circulatory overload in a pediatric intensive care unit: different incidences with different diagnostic criteria.

The incidence of transfusion-associated circulatory overload (TACO) is not well known in children, especially in pediatric intensive care unit (PICU) patients. All consecutive patients admitted over 1 year to the PICU of CHU Sainte-Justine were included after they received their first red blood cell transfusion. TACO was diagnosed using the criteria of the International Society of Blood Transfusion, with two different ways of defining abnormal values: 1) using normal pediatric values published in the Nelson Textbook of Pediatrics and 2) by using the patient as its own control and comparing pre- and posttransfusion values with either 10 or 20% difference threshold. We monitored for TACO up to 24 hours posttransfusion. A total of 136 patients were included. Using the "normal pediatric values" definition, we diagnosed 63, 88, and 104 patients with TACO at 6, 12, and 24 hours posttransfusion, respectively. Using the "10% threshold" definition we detected 4, 15, and 27 TACO cases in the same periods, respectively; using the "20% threshold" definition, the number of TACO cases was 2, 6, and 17, respectively. Chest radiograph was the most frequent missing item, especially at 6 and 12 hours posttransfusion. Overall, the incidence of TACO varied from 1.5% to 76% depending on the definition. A more operational definition of TACO is needed in PICU patients. Using a threshold could be more optimal but more studies are needed to confirm the best threshold.

Differentiating pulmonary transfusion reactions using recipient and transfusion factors.

It is increasingly recognized that recipient risk factors play a prominent role in possible transfusion-related acute lung injury (pTRALI) and transfusion-associated circulatory overload (TACO). We hypothesized that both transfusion and recipient factors including natriuretic peptides could be used to distinguish TRALI from TACO and pTRALI. We performed a post hoc analysis of a case-control study of pulmonary transfusion reactions conducted at the University of California at San Francisco and Mayo Clinic, Rochester. We evaluated clinical data and brain natriuretic peptides (BNP) levels drawn after transfusion in patients with TRALI (n = 21), pTRALI (n = 26), TACO (n = 22), and controls (n = 24). Logistic regression and receiver operating characteristics curve analyses were used to determine the accuracy of clinical and biomarker predictors in differentiating TRALI from TACO and pTRALI. We found that pTRALI and TACO were associated with older age, higher fluid balance, and elevated BNP levels relative to those of controls and TRALI. The following variables were useful in distinguishing cases of pTRALI and TACO from TRALI: age more than 70 years, BNP levels more than 1000 pg/mL, 24-hour fluid balance of more than 3 L, and a lower number of transfused blood components. Using the above variables, our logistic model had a 91% negative predictive value in the differential diagnosis of TRALI. Models incorporating readily available clinical and biomarker data can be used to differentiate transfusion-related respiratory complications. Additional studies examining recipient risk factors and the likelihood of TRALI may be useful in decision making regarding donor white blood cell antibody testing.

The association of fever with transfusion-associated circulatory overload.

Fever is described in transfusion-associated circulatory overload (TACO), reflecting either comprehensive haemovigilance or an inflammatory pathobiology (such as congestion-associated atheroma disruptions). Hospital haemovigilance data (1/1/2010-31/12/2012) were reviewed for TACO cases (frequency and mode of referral). TACO with or without fever (TACO+F/-F) was examined for its association with patient age (as a surrogate for atheroma burden) and product age (as a surrogate for storage-related pyrogens). Fever in allergic transfusion reactions was also compared. Of 972 reactions, 107 suspected cases of TACO (11%) were seen. TACO+F vs. TACO-F occurred in 42·1 vs. 57·9%, respectively. TACO+F cases were discovered in referrals to investigate either a fever (in 47·1%) or dyspnoea (in 52·9%). Among TACO+F cases, 24·4% had already been febrile, whereas 75·6% exhibited a new reaction-associated fever. After excluding preexisting fevers, TACO+F occurred in 31·8% of TACO, compared with 8·2% of allergic reactions with fever, for an odds ratio of 5·2 (2·9-9·4 [95% CI]), P < 0·001. TACO+F/TACO-F showed no difference in median host age (69 vs. 64 years, P = 0·3), RBC age (22 days +F/-F, P = 0·9) or severity. Transfusion-associated circulatory overload disproportionately exhibits fever compared with allergic reactions. However, TACO+F did not associate with patient or product age, nor reflect severity. To better understand TACO+F, the fever-congestion sequence merits attention. Further study is needed to see whether TACO+F occurs as reproducibly elsewhere, and in association with atherosclerosis in a better characterized cohort.

Incidence and clinical characteristics of transfusion-associated circulatory overload using an active surveillance algorithm.

The concordance of haemovigilance criteria developed for surveillance of transfusion-associated circulatory overload (TACO) with its clinical diagnosis has not been assessed. In a pilot study to evaluate an electronic screening algorithm, we sought to examine TACO incidence and application of haemovigilance criteria in patients with post-transfusion pulmonary oedema. From June to September 2014, all transfused adult inpatients at four academic hospitals were screened with an algorithm identifying chest radiographs ordered within 12 h of blood component release. Patients with post-transfusion pulmonary oedema underwent case adjudication by an expert panel. TACO incidence was calculated, and clinical characteristics were compared with other causes of post-transfusion pulmonary oedema. Among 4932 transfused patients, there were 3412 algorithm alerts, 50 cases of TACO and 47 other causes of pulmonary oedema. TACO incidence was 1 case per 100 patients transfused. TACO classification based on two sets of haemovigilance criteria (National Healthcare Safety Network and proposed revised International Society for Blood Transfusion) was concordant with expert panel diagnosis in 57% and 54% of reviewed cases, respectively. Although the majority of clinical parameters did not differentiate expert panel adjudicated TACO from other cases, improved oxygenation within 24 h of transfusion did (P = 0·01). The incidence of TACO was similar to that observed in prior studies utilizing active surveillance. Case classification by haemovigilance criteria was frequently discordant with clinical diagnoses of TACO in patients with post-transfusion pulmonary oedema. Improvements in oxygenation within 24 h of transfusion merit further evaluation in the diagnosis of TACO.

The usefulness of a classification and regression tree algorithm for detecting perioperative transfusion-related pulmonary complications.

Transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO) are leading causes of transfusion-related mortality. An electronic medical record-based screening classification and regression tree (CART) algorithm was previously developed for predicting transfusion-related pulmonary complications. In the Republic of Korea, TRALI is not sufficiently recognized and an accurate TRALI incidence has not been reported. Therefore, we carried out this study to assess the incidence of TRALI and to determine whether the CART algorithm can be applied to our hospital data. A retrospective analysis of all patients who received any type of transfusion during anesthesia was performed. After the patients were diagnosed by the relevant diagnostic criteria, they were reclassified by the CART algorithm. The validity of the algorithm was evaluated with sensitivity, specificity, likelihood ratios, and misclassification rate. Among 1948 patients who had received 11,269 units of transfusion, 26 TRALI and 20 TACO cases were identified. The incidence of TRALI among the transfused patients was 1.33% and per unit of transfused blood product was 0.23%. The sensitivity and specificity of the TRALI algorithm were estimated to be 73.1% (95% confidence interval [CI], 53.9%-86.3%) and 57.0% (95% CI, 52.5%-61.4%). For TACO, the sensitivity and specificity were 90.0% (95% CI, 69.9%-97.2%) and 56.0% (95% CI, 51.6%-60.4%), respectively. Low specificity of the CART algorithm adopted previously indicated its limited diagnostic value in the Republic of Korea. A new algorithm is needed to facilitate the detection of transfusion-related complications.

A Retrospective Review of Patient Factors, Transfusion Practices, and Outcomes in Patients With Transfusion-Associated Circulatory Overload

Transfusion-associated circulatory overload (TACO) is a common yet underrecognized and underreported complication of transfusion associated with significant morbidity and mortality. The objective of this study was to examine patient and transfusion characteristics in a cohort of TACO cases. A retrospective medical record review of 100 consecutive TACO episodes reported at 2 academic centers was performed. Information related to demographics, medical history, radiologic and echocardiographic investigations, infusion practices, reaction features, management, and outcome were collected. Ninety-eight cases were accessible for review. A history of congestive heart failure (41%), renal dysfunction (44%), and age more than 70 years (56%) were common in TACO patients. Suboptimal fluid status management and inappropriate infusion practices were often seen (eg, verbal orders, double red cell transfusions, rapid infusion rates, lack or improper timing of preemptive diuretics). The median volume of blood ordered was 500 mL, and the median volume of crystalloid or colloid (preceding 24 hours) was 2200 mL. A physician order specifying the infusion rate was documented in 50% of transfusion orders. Preemptive diuretics were ordered in only 29% of cases, most commonly introduced midway or after the transfusion at a dose of furosemide 20 mg intravenously. After TACO, 18% of patients required transfer to the intensive care unit, 8% suffered a major complication, and 2% died. Suboptimal ordering and infusion practices may be contributing to the high incidence and severity of TACO. Research in TACO prevention strategies, such as slow rates of infusion and preemptive diuretics, is warranted.

Transfusion‐associated circulatory overload (TACO) and potential risk factors among the inpatient US elderly as recorded in Medicare administrative databases during 2011

Transfusion-associated circulatory overload (TACO) is a serious transfusion complication resulting in respiratory distress. The study's objective was to assess TACO occurrence and potential risk factors among elderly Medicare beneficiaries (ages 65 and older) in the inpatient setting during 2011. This retrospective claims-based study utilized Medicare administrative databases in coordination with Centers for Medicare & Medicaid Services. Transfusions were identified by recorded procedure and revenue centre codes, while TACO was ascertained via ICD-9-CM diagnosis code. We evaluated TACO diagnosis code rates overall and by age, gender, race, number of units and blood components transfused. Multivariate logistic regression analyses were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). Among 2,147,038 inpatient transfusion stays for elderly in 2011, 1340 had TACO diagnosis code, overall rate of 62·4 per 100,000 stays. TACO rates increased significantly with age and units transfused (P < 0·0001). After adjustment for confounding, significantly higher odds of TACO were found for women vs. men (OR = 1·40, 95% CI 1·26-1·60), White people vs. non-White people (OR = 1·38, 95% CI 1·20-1·62) and persons with congestive heart failure (OR = 1·61, 95% CI 1·44-1·88), chronic pulmonary disease (OR = 1·19, 95% CI 1·08-1·32) and different anaemias. Our study identified largest number of potential TACO cases to date and showed a substantial increase in TACO occurrence with age and number of units transfused. The study suggested increased TACO risk in elderly with congestive heart failure, chronic pulmonary disease and anaemias. Overall, study shows importance of large administrative databases as an additional epidemiological tool.

Guidelines on the management of anaemia and red cell transfusion in adult critically ill patients.

Forward This document aims to summarize the current literature guiding the use of red cell transfusion in critically ill patients and provides recommendations to support clinicians in their day-to-day practice. Critically ill patients differ in their age, diagnosis, co-morbidities, and severity of illness. These factors influence their tolerance of anaemia and alter the risk to benefit ratio of transfusion. The optimal management for an individual may not fall clearly within our recommendations and each decision requires a synthesis of the available evidence and the clinical judgment of the treating physician. This guideline relates to the use of red cells to manage anaemia during critical illness when major haemorrhage is not present. A previous British Committee for Standards in Haematology (BCSH) guideline has been published on massive haemorrhage (Stainsby et al, 2006), but this is a rapidly changing field. We recommend readers consult recent guidelines specifically addressing the management of major haemorrhage for evidence-based guidance. A subsequent BCSH guideline will specifically cover the use of plasma components in critically ill patients.

Incidence and transfusion risk factors for transfusion‐associated circulatory overload among medical intensive care unit patients

Transfusion-associated circulatory overload (TACO) is a frequent complication of blood transfusion. Investigations identifying risk factors for TACO in critically ill patients are lacking. We performed a 2-year prospective cohort study of consecutive patients receiving blood product transfusion in the medical intensive care unit (ICU) of the tertiary care institution. Patients were followed for development of transfusion-related complications. TACO was defined as acute hydrostatic pulmonary edema occurring within 6 hours of transfusion. In a nested case-control design, transfusion characteristics were compared between cases (TACO) and controls after matching by age, sex, and ICU admission diagnostic category. In a secondary analysis, patient characteristics before transfusion were compared between cases (TACO) and randomly selected controls. Fifty-one of 901 (6%) transfused patients developed TACO. Compared with matched controls, TACO cases had a more positive fluid balance (1.4 L vs. 0.8 L, p = 0.003), larger amount of plasma transfused (0.4 L vs. 0.07 L, p = 0.007), and faster rate of blood component transfusion (225 mL/hr vs. 168 mL/hr, p = 0.031). In a secondary analysis comparing TACO cases and random controls, left ventricular dysfunction before transfusion (odds ratio [OR], 8.23; 95% confidence interval [CI], 3.36-21.97) and plasma ordered for the reversal of anticoagulant (OR, 4.31; 95% CI, 1.45-14.30) were significantly related to the development of TACO. Volume of transfused plasma and the rate of transfusion were identified as transfusion-specific risk factors for TACO. Left ventricular dysfunction and fresh-frozen plasma ordered for the reversal of anticoagulant were strong predictors of TACO before the onset of transfusion.

Long-Term Survival and Quality of Life After Transfusion-Associated Pulmonary Edema in Critically III Medical Patients

Transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO) commonly complicate transfusion in critically ill patients. Prior outcome studies of TACO and TRALI have focused on short-term morbidity and mortality, but the long-term survival and quality of life (QOL) of these patients remain unknown. In a nested case-control study, we compared survival and QOL between critically ill medical patients who developed pulmonary edema after transfusion (TRALI or TACO) and medical critically ill transfused controls, matched by age, gender, and admission diagnostic group. QOL in survivors was assessed with a 36-item short form health survey 1 year after initial hospitalization. Hospital, 1-year, and 2-year mortality among the 74 TRALI cases and 74 matched controls were 43.2% vs 24.3% (P = .020), 63.8% vs 46.4% (P = .037) and 74.3% vs 54.3% (P = .031), whereas among the 51 TACO cases and 51 matched controls these values were 7.8% vs 11.8% (P = .727), 38.0% vs 28.0% (P = .371), and 44.9% vs 38.8% (P = .512). When adjusted for age and baseline severity of illness in a Cox proportional hazard analysis, the development of TRALI remained associated with decreased survival (hazard ratio 1.86; 95% CI, 1.19-2.93; P = .006). Both TRALI (P = .006, P = .03) and TACO (P = .03, P = .049) were associated with prolonged ICU and hospital lengths of stay. In critically ill medical patients, development of TRALI, but not TACO, is independently associated with decreased long-term survival.

Transfusion Associated Circulatory Overload (TACO) Incidence and Risk Factors.

Abstract 3157Poster Board III-94 IntroductionTransfusion circulatory overload (TACO) is a complication of transfusion, often confused with transfusion acute lung injury (TRALI), and is probably under-reported. The pathophysiology is believed to be caused by increased hydrostatic blood pressure leading to fluid leakage in the alveolar space, emulating congestive cardiac failure. We report on a large cohort of TACO cases in Ireland. MethodsAll consecutive TACO cases reported to the National Haemovigilance Office of Ireland between 2000-2008 were retrospectively reviewed. The incidence of TACO was calculated on units issued from the Irish Blood Transfusion Service (IBTS). Comparative analysis of patient demographic and clinical data was made using Fisher's exact test. Results179 TACO cases were reviewed. 149 (83%) involved red cell concentrate (RCC), platelets (PLT) n=4 (2%); fresh frozen plasma (FFP) /solvent detergent plasma (SDP) n=16 (8%); multiple components n=10 (6%). During the study period, a total 1,614,973 blood components (RCC, FFP, SDP and PLT) were issued corresponding to a TACO incidence of 1/10.000 of all components issued. TACO incidence per RCC, platelets and plasma issued was 1/8000, 1/48000 and 1/15000 respectively, excluding the cases where multiple components were transfused. While the majority of patients developing TACO were elderly (> 70years)(n= 120, 67%), up to eight cases (4%) were reported in young patients (<30 years). There was no difference in gender. An underlying cardiovascular condition was reported in 73% (131) cases. Patient outcome was specified in 178 cases. One hundred and fifty three (85%) patients recovered post reaction. However, 15 (8%) patients experienced morbidity ranging from prolonged resolution of symptoms, to myocardial infarction (n=2), cancellation of surgery (n=1), and admission to intensive care (n=4). 25 (14%) deaths were reported, and TACO was identified as possible cause of death in n=5 (2%) cases. Four of these patients were male and one patient was female. A total of 158 (88%) patients received diuretics before (n=36), during (n=26) or post (n=124). Nineteen patients (11%) did not receive diuretics; four of these patients died, one of which was possibly attributed to transfusion. Information was unavailable in two cases. Patients treated with diuretics post transfusion were more likely to survive (80% vs. 40%); however statistical significance was not reached (p=0.07). The median transfused volume was 275 mls (range 80-9500 mls). There was no statistical significance between actual time of transfusion and time over which transfusion were prescribed. Approximately 10 % (18) cases involved large volume transfusion most likely in an emergency situation. While only three of these transfusion events met the clinical definition of a massive transfusion (150mls per minute), patients in this cohort received between 300 and 8200 mls per hour. The median volume transfused was 1500mls (range 1000mls – 9500mls). Eleven (61%) patients had underlying cardiovascular conditions. Seven patients were > 70 years, all of whom had underlying cardio–vascular conditions. Four (22%) patients died, one death which was possibly attributed to transfusion, and a further three patients (17%) required admission to intensive care. Four (22%) cases involved young female patients (age < 30 years) who had no underlying cardiovascular condition, but one patient had asthma. These patients were being treated for obstetric bleeding, and all recovered. ConclusionThis study reports a TACO incidence of 1 /10 000 units issued from the IBTS. Although this incidence is based on units issued rather than transfused, it probably reflects significant underreporting, and perhaps even under-recognition. This study identified TACO has significant impact on patient outcome with approximately 8% (15) of patients suffering significant morbidity and a further 2% (5) of patients dying following onset of TACO. Finally, patients receiving large volume transfusion in emergency situations even young patients are at risk of developing TACO. DisclosuresNo relevant conflicts of interest to declare.