Vox Sanguinis (2015) © 2015 International Society of Blood Transfusion DOI: 10.1111/vox.12234
ORIGINAL PAPER
Passive reporting greatly underestimates the rate of transfusion-associated circulatory overload after platelet transfusion J. S. Raval,1 M. A. Mazepa,1 S. L. Russell,2 C. C. Immel,2 H. C. Whinna1 & Y. A. Park1 1
Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA Transfusion Medicine Service, University of North Carolina Hospitals, Chapel Hill, NC, USA
2
Background Transfusion-associated circulatory overload (TACO) is the second leading cause of reported transfusion-related fatalities in the United States. While its occurrence has been previously investigated after red cell and plasma transfusion, no data are available regarding its association with platelet transfusion. Our goal was to determine the rate of platelet-associated TACO at our university medical centre. Study Design and Methods This study had retrospective and prospective analyses. The 13-year retrospective analysis served to determine the historical rate of platelet-associated TACO by passive reporting. The 30-day prospective analysis included active surveillance of all non-emergently issued and non-operative platelet recipients ≥16 years old with no transfusions in the previous 6 h determined by analysis of blood bank product issue records. Data collected included demographics, vital signs pre- and posttransfusion, fluid balances, supplemental oxygen use, reports of dyspnoea, and infusion rates. For the prospective analysis, all variables were collected within 24 h of transfusion from the medical record and, when necessary, interviews with care providers and/or patients. Results In the retrospective analysis, 366 reactions were reported, of which 6 (16%) were TACO. The historical rate of TACO was 1:5997 transfused platelet units. During the prospective analysis, 225 eligible patients received a total of 334 units of platelets. The average platelet transfusion volume was 261 – 26 ml, and the average infusion rate was 391 – 198 ml/h. Two unreported TACO reactions were discovered and characterized by new-onset hypertension, crackles on lung auscultation, dyspnoea, hypoxia and supplemental oxygen requirements which resolved completely with diuresis. The rate of TACO during this prospective analysis was 1:167 transfused platelet units.
Received: 19 September 2014, revised 14 November 2014, accepted 14 November 2014
Conclusion Platelet-associated TACO is greatly underestimated by passive reporting in the adult patient population. Key words: platelet, transfusion, transfusion-associated circulatory overload, volume overload.
Introduction Correspondence: Jay S. Raval, Department of Pathology and Laboratory Medicine, University of North Carolina, CB#7525, Brinkhous-Bullitt Building, Chapel Hill, NC 27599-7525, USA E-mail: [email protected]
Transfusion-associated circulatory overload (TACO) is an adverse event which results in hydrostatic pulmonary oedema due to overwhelming a transfused patient’s circulatory system [1, 2]. This can occur either as a function of the transfused volume or rate of transfusion and
1
2 J. S. Raval et al.
essentially is congestive heart failure. Patients at the greatest risk of developing TACO include those who are very young or old, have a preexisting positive fluid balance, have been transfused with either plasma for coagulopathy reversal or multiple blood components, and kidney or heart dysfunction [3–7]. Transfusion-associated circulatory overload has been defined by the International Society of Blood Transfusion (ISBT) by the criteria shown in Table 1 [8]. The clinical findings that classically characterize TACO include the acute onset of respiratory dysfunction, manifested by cough, dyspnoea, tachypnea, rales/rhonchi/wheezing on auscultation and desaturations requiring supplemental oxygen; hypertension; tachycardia; jugular venous distention; profuse diaphoresis; and response to diuretic therapy [1, 2]. Laboratory analysis of pre- and posttransfusion specimens may also demonstrate a significant increase in brain natriuretic peptide (BNP) or pro-BNP levels in patients with TACO [4, 9]. Radiographic analysis will often reveal bilateral alveolar infiltrates/interstitial pulmonary oedema, indistinct hila/pleural effusions and vascular redistribution/Kerley lines. While any one of these clinical findings in isolation may be found in other transfusion reactions associated with pulmonary involvement, such as transfusion-related acute lung injury (TRALI) and allergic reactions, the constellation of these clinical, laboratory and radiologic findings together can help make the diagnosis of TACO. According to the US Food and Drug Administration, TACO is currently the second leading cause of transfusion-associated mortality over the past 5 years [10]. The rates of TACO after transfusion with red cell or plasma components have been reported to be between 1% and 8% [3, 5, 11–13]. While there are numerous studies investigating the occurrence of this adverse event, little data are available regarding its association with platelets [2]. Given the notable increase in platelet transfusion in the United States [14], our goal was to determine the prevalence of platelet-associated TACO at our university medical centre.
Study design and methods University medical centre and blood bank Our university medical centre has 783 hospital beds. Every year the hospital discharges >40 000 inpatients, accommodates >850 000 clinic visits, delivers >4000 babies and performs >400 solid organ and bone marrow transplants. Approximately 24 000 red cell units, 6000 plasma units and 6000 platelet units are transfused annually. The blood bank exclusively provides leucoreduced apheresis platelets to all patients. According to apheresis platelet quality control data, the average unit of apheresis platelets has a volume of 266 – 18 ml. Platelets are routinely transfused for platelet counts
ORIGINAL PAPER
Passive reporting greatly underestimates the rate of transfusion-associated circulatory overload after platelet transfusion J. S. Raval,1 M. A. Mazepa,1 S. L. Russell,2 C. C. Immel,2 H. C. Whinna1 & Y. A. Park1 1
Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA Transfusion Medicine Service, University of North Carolina Hospitals, Chapel Hill, NC, USA
2
Background Transfusion-associated circulatory overload (TACO) is the second leading cause of reported transfusion-related fatalities in the United States. While its occurrence has been previously investigated after red cell and plasma transfusion, no data are available regarding its association with platelet transfusion. Our goal was to determine the rate of platelet-associated TACO at our university medical centre. Study Design and Methods This study had retrospective and prospective analyses. The 13-year retrospective analysis served to determine the historical rate of platelet-associated TACO by passive reporting. The 30-day prospective analysis included active surveillance of all non-emergently issued and non-operative platelet recipients ≥16 years old with no transfusions in the previous 6 h determined by analysis of blood bank product issue records. Data collected included demographics, vital signs pre- and posttransfusion, fluid balances, supplemental oxygen use, reports of dyspnoea, and infusion rates. For the prospective analysis, all variables were collected within 24 h of transfusion from the medical record and, when necessary, interviews with care providers and/or patients. Results In the retrospective analysis, 366 reactions were reported, of which 6 (16%) were TACO. The historical rate of TACO was 1:5997 transfused platelet units. During the prospective analysis, 225 eligible patients received a total of 334 units of platelets. The average platelet transfusion volume was 261 – 26 ml, and the average infusion rate was 391 – 198 ml/h. Two unreported TACO reactions were discovered and characterized by new-onset hypertension, crackles on lung auscultation, dyspnoea, hypoxia and supplemental oxygen requirements which resolved completely with diuresis. The rate of TACO during this prospective analysis was 1:167 transfused platelet units.
Received: 19 September 2014, revised 14 November 2014, accepted 14 November 2014
Conclusion Platelet-associated TACO is greatly underestimated by passive reporting in the adult patient population. Key words: platelet, transfusion, transfusion-associated circulatory overload, volume overload.
Introduction Correspondence: Jay S. Raval, Department of Pathology and Laboratory Medicine, University of North Carolina, CB#7525, Brinkhous-Bullitt Building, Chapel Hill, NC 27599-7525, USA E-mail: [email protected]
Transfusion-associated circulatory overload (TACO) is an adverse event which results in hydrostatic pulmonary oedema due to overwhelming a transfused patient’s circulatory system [1, 2]. This can occur either as a function of the transfused volume or rate of transfusion and
1
2 J. S. Raval et al.
essentially is congestive heart failure. Patients at the greatest risk of developing TACO include those who are very young or old, have a preexisting positive fluid balance, have been transfused with either plasma for coagulopathy reversal or multiple blood components, and kidney or heart dysfunction [3–7]. Transfusion-associated circulatory overload has been defined by the International Society of Blood Transfusion (ISBT) by the criteria shown in Table 1 [8]. The clinical findings that classically characterize TACO include the acute onset of respiratory dysfunction, manifested by cough, dyspnoea, tachypnea, rales/rhonchi/wheezing on auscultation and desaturations requiring supplemental oxygen; hypertension; tachycardia; jugular venous distention; profuse diaphoresis; and response to diuretic therapy [1, 2]. Laboratory analysis of pre- and posttransfusion specimens may also demonstrate a significant increase in brain natriuretic peptide (BNP) or pro-BNP levels in patients with TACO [4, 9]. Radiographic analysis will often reveal bilateral alveolar infiltrates/interstitial pulmonary oedema, indistinct hila/pleural effusions and vascular redistribution/Kerley lines. While any one of these clinical findings in isolation may be found in other transfusion reactions associated with pulmonary involvement, such as transfusion-related acute lung injury (TRALI) and allergic reactions, the constellation of these clinical, laboratory and radiologic findings together can help make the diagnosis of TACO. According to the US Food and Drug Administration, TACO is currently the second leading cause of transfusion-associated mortality over the past 5 years [10]. The rates of TACO after transfusion with red cell or plasma components have been reported to be between 1% and 8% [3, 5, 11–13]. While there are numerous studies investigating the occurrence of this adverse event, little data are available regarding its association with platelets [2]. Given the notable increase in platelet transfusion in the United States [14], our goal was to determine the prevalence of platelet-associated TACO at our university medical centre.
Study design and methods University medical centre and blood bank Our university medical centre has 783 hospital beds. Every year the hospital discharges >40 000 inpatients, accommodates >850 000 clinic visits, delivers >4000 babies and performs >400 solid organ and bone marrow transplants. Approximately 24 000 red cell units, 6000 plasma units and 6000 platelet units are transfused annually. The blood bank exclusively provides leucoreduced apheresis platelets to all patients. According to apheresis platelet quality control data, the average unit of apheresis platelets has a volume of 266 – 18 ml. Platelets are routinely transfused for platelet counts
