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Transfusion-associated circulatory overload

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Transfusion associated circulatory overload
Other namesTACO[1]
Peripheral edema in the lower extremity that can result from volume overload following large volume blood transfusions.
SpecialtyHematology
Symptomsdyspnea, orthopnea, peripheral edema, hypertension.
Usual onsetWithin 12 hours of transfusion

In transfusion medicine, transfusion associated circulatory overload (aka TACO) is a transfusion reaction (an adverse effect of blood transfusion) resulting in signs or symptoms of hypervolemia within 12 hours after transfusion.[2] It can occur due to a rapid transfusion of a large volume of blood but can also occur during a single red cell transfusion (about 15% of cases).[2] It is often confused with transfusion-related acute lung injury (TRALI), another transfusion reaction that results in respiratory distress without signs or symptoms of hypervolemia.

Symptoms and signs

The primary symptoms of TACO are signs of respiratory distress (dyspnea, orthopnea, hypoxemia) along with signs of hypervolemia (peripheral edema, hypertension, and tachycardia).[3]

On physical exam, patients may present with crackles on auscultation of the lungs, an S3 murmur upon auscultation of the heart, bilateral lower extremity peripheral edema, jugular venous distension, and a widened pulse pressure.[3]

Risk factors

Risk factors that can promote the development of TACO include conditions that predispose individuals to a positive fluid balance (liver failure causing hypoalbuminemia[4], heart failure[5][6], renal insufficiency[5][6], or nephrotic syndrome[6]), conditions that place increased stress on the respiratory system (lung disease[5]), and conditions necessitating large volume transfusions (severe anemia[5]). Age has also been found to be a risk factor where individuals less than 3 years old and over 60 years old are at increased risk.[4]

In addition, the risk of TACO increases as the number of units of blood products transfused increases.[7]

Diagnosis

The National Healthcare Safety Safety Network division of the Centers for Disease Control and Prevention (CDC) released an updated criteria table in 2021.[8]

Patients diagnosed with TACO should have at least 1 of the following characteristics within 12 hours after the transfusion was ended:

A chest x-ray showing pulmonary edema with bilateral pleural effusions.

Along with:

Classification

TACO can be categorized by severity[8]:

  • Non-severe - where no permanent damage would arise if treatment was not given. However, treatment is still needed.
  • Severe - where the patient either requires hospitalization as a result or, if already hospitalized, has an extended length of stay as a result. Treatment is needed to avoid permanent damage.
  • Life threatening - where intensive care such as vasopressor agents and mechanical ventilation is required in order to prevent death.
  • Death

Differential diagnosis

TACO and transfusion-related acute lung injury (TRALI) are both complications following a transfusion, and both can result in respiratory distress.[2] TACO and TRALI are often difficult to distinguish in the acute situation.

Assessing fluid status is key in differentiating between the two. In TACO, the patient will always have a positive fluid balance and will often present with hypertension, jugular venous distension, elevated BNP, peripheral edema, and will respond well to diuretics. In contrast , TRALI is not associated with fluid overload and the patient may have a positive, even, or net fluid balance. Patients with TRALI often present with hypotension, no signs of right-heart fluid overload, normal BNP, and lack of clinical improvement in response to diuretics.[9][10][5]

Other causes of edema that can promote a volume-overloaded state and predispose individuals to TACO include: heart failure, renal insufficiency, nephrotic syndrome, cirrhosis, and chronic venous insufficiency.[11]

An illustration of an individual receiving intravenous blood transfusion.

Pathogenesis

The pathogenesis of TACO is thought to be due to a 2-hit mechanism.[12] The first hit is the clinical state of the patient and the second hit is the blood transfusion itself. A patient may be receiving blood from any number of etiologies and, as a result, may have cardiac or renal dysfunction or may already be volume overloaded. Upon transfusion of the blood product, the patient's clinical state is unable to accommodate the excess fluid and they develop symptoms related to volume overload.

Prevention

Transfusion associated circulatory overload is prevented by avoiding unnecessary transfusions by following strict criteria necessitating blood transfusion, closely monitoring patients receiving transfusions, and transfusing smaller volumes of blood at a slower rate. Blood products are typically transfused at 2.0 to 2.5 ml/kg per hour but can be reduced to 1.0 ml/kg per hour for individuals at increased risk for TACO.[13] Patients susceptible to volume overload (eg, renal insufficiency or heart failure) may be pre-treated with a diuretic either during or immediately following transfusion to reduce the overall net fluid balance.[14]

A person receiving supplemental oxygen via nasal cannula.

Management

If TACO is suspected, the transfusion is stopped immediately and the patient is sat upright to prevent the fluid from backing up into the lungs. Treatment is two-fold: respiratory support and removal of excess fluid.[14] Patients with respiratory distress and/or hypoxemia are given supplemental oxygen or ventilatory support (through non-invasive or mechanical ventilation, if needed). To remove the excess fluid, patients are given diuretic therapy and their urine output is closely monitored to quantitate the amount removed.

Occurrence

It is difficult to determine the incidence of TACO, but its incidence is estimated at about one in every 100 transfusions using active surveillance,[15][16] and in one in every 10000 transfusions using passive surveillance.[15] TACO is the most commonly reported cause of transfusion-related death and major morbidity in the UK,[2] and second most common cause in the USA.[17]

The risk increases with patients over the age of 60, patients with cardiac or pulmonary failure, renal impairment, hypoalbuminemia or anemia. [3][2]

References

  1. ^ Agnihotri, Naveen; Agnihotri, Ajju (2014). "Transfusion associated circulatory overload". Indian Journal of Critical Care Medicine. 18 (6): 396–398. doi:10.4103/0972-5229.133938. PMC 4071685. PMID 24987240.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  2. ^ a b c d e Bolton-Maggs, Paula (Ed); Poles, D; et al, on behalf of the Serious Hazards of Transfusion (SHOT) Steering Group (2017). The 2016 Annual SHOT Report (2017) (PDF). Serious Hazards of Transfusion (SHOT). ISBN 978-0-9558648-9-6.
  3. ^ a b c Noninfectious Adverse Events of Transfusion - Transfusion Transmitted Injuries Section - Blood Safety Surveillance and Health Care Acquired Infections Division - Public Health... Archived 2008-06-20 at the Wayback Machine
  4. ^ a b Bolton-Maggs, PHB; Poles, D, eds. (2018). "The 2017 Annual SHOT Report (2018)" (PDF). {{cite journal}}: Cite journal requires |journal= (help)
  5. ^ a b c d e "Transfusion-associated circulatory overload (TACO)(2018)" (PDF). ISBT. Retrieved 24 June 2019.
  6. ^ a b c Clifford, Leanne; Jia, Qing; Subramanian, Arun; Yadav, Hemang; Schroeder, Darrell R.; Kor, Daryl J. (March 2017). "Risk Factors and Clinical Outcomes Associated with Perioperative Transfusion-associated Circulatory Overload". Anesthesiology. 126 (3): 409–418. doi:10.1097/ALN.0000000000001506. PMC 5309147. PMID 28072601.
  7. ^ Menis, M.; Anderson, S. A.; Forshee, R. A.; McKean, S.; Johnson, C.; Holness, L.; Warnock, R.; Gondalia, R.; Worrall, C. M.; Kelman, J. A.; Ball, R. (2014-02). "Transfusion-associated circulatory overload (TACO) and potential risk factors among the inpatient US elderly as recorded in Medicare administrative databases during 2011". Vox Sanguinis. 106 (2): 144–152. doi:10.1111/vox.12070. {{cite journal}}: Check date values in: |date= (help)
  8. ^ a b Centers for Disease Control and Prevention (March 2021). "National Healthcare Safety Network Biovigilance Component Hemovigilance Module Surveillance Protocol" (PDF). N/A. 2.6: 9.
  9. ^ Popovsky, M. A. (September 2006). "Transfusion-related acute lung injury and transfusion-associated circulatory overload". ISBT Science Series. 1 (1): 107–111. doi:10.1111/j.1751-2824.2006.00046.x.
  10. ^ Skeate, Robert C; Eastlund, Ted (November 2007). "Distinguishing between transfusion related acute lung injury and transfusion associated circulatory overload". Current Opinion in Hematology. 14 (6): 682–687. doi:10.1097/MOH.0b013e3282ef195a. PMID 17898575.
  11. ^ Goyal A, Cusick AS, Bansal P. Peripheral Edema. [Updated 2021 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554452/
  12. ^ Semple, John W.; Rebetz, Johan; Kapur, Rick (2019-04-25). "Transfusion-associated circulatory overload and transfusion-related acute lung injury". Blood. 133 (17): 1840–1853. doi:10.1182/blood-2018-10-860809. ISSN 0006-4971.
  13. ^ Maynard K. Administration of Blood Components. In: Technical Manual, 18th edition, Fung MK, Grossman BJ, Hillyer CD, et al (Eds), AABB, 2014.
  14. ^ a b Gauvin, France; Robitaille, Nancy (2020-02). "Diagnosis and management of transfusion‐associated circulatory overload in adults and children". ISBT Science Series. 15 (1): 23–30. doi:10.1111/voxs.12531. ISSN 1751-2816. {{cite journal}}: Check date values in: |date= (help)
  15. ^ a b Raval, J. S.; Mazepa, M. A.; Russell, S. L.; Immel, C. C.; Whinna, H. C.; Park, Y. A. (May 2015). "Passive reporting greatly underestimates the rate of transfusion-associated circulatory overload after platelet transfusion". Vox Sanguinis. 108 (4): 387–392. doi:10.1111/vox.12234. PMID 25753261.
  16. ^ Clifford, Leanne; Jia, Qing; Yadav, Hemang; Subramanian, Arun; Wilson, Gregory A.; Murphy, Sean P.; Pathak, Jyotishman; Schroeder, Darrell R.; Ereth, Mark H.; Kor, Daryl J. (January 2015). "Characterizing the Epidemiology of Perioperative Transfusion-associated Circulatory Overload". Anesthesiology. 122 (1): 21–28. doi:10.1097/ALN.0000000000000513. PMC 4857710. PMID 25611653.
  17. ^ "Fatalities Reported to FDA Following Blood Collection and Transfusion Annual Summary for Fiscal Year 2015". FDA. Retrieved July 17, 2017.
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