SHOT Annual Report 2009 - Serious Hazards of Transfusion

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14. Transfusion-Associated Circulatory Overload (TACO) Definition TACO includes any 4 of the following that occur within 6 hours of transfusion: ■■ ■■ ■■ ■■ ■■ Acute respiratory distress Tachycardia Increased blood pressure Acute or worsening pulmonary oedema Evidence of positive fluid balance. DATA SUMMARY Total number of cases 34 Implicated components Mortality/morbidity RBC only (OA, PR, WB) 22 Deaths due to transfusion 0 Platelets only 1 Deaths in which reaction was implicated FFP only (MB-FFP) 1 Major morbidity 9 RBC + platelets 5 RBC + FFP (untreated) 3 RBC + FFP + platelets 1 RBC + FFP + platelets + cryo 1 4 Gender Age Emergency vs. routine and core hours vs. out of core hours Where transfusion took place Male Female Unknown 11 23 0 18 years+ 16 years+ to 18 years 1 year+ to 16 years 28 days+ to 1 year Birth to 28 days Unknown Total 34 34 Emergency Routine Not known In core hours Out of core hours Not known/applicable 6 6 22 17 17 0 ED Theatre ITU/NNU/HDU/Recovery Wards Community Other* Not known 0 1 3 16 0 4 10 * Emergency Assessment Unit/Clinical Decision Unit Twenty questionnaires on TACO were received; 9 were transferred in from the ATR section and 5 from the TRALI section, resulting in a total of 34 cases which are reported in this chapter. Definition Cases were assessed by the reviewer for probability of a diagnosis of TACO based on the International Society of Blood Transfusion (ISBT) definition. 14 Five of 34 cases were assessed to be highly likely, 14 probable and 15 possible. Patients There were 11 men and 23 women. The median age was 72.5 (range 27 to 89) years, with 20 patients (58.8%) 70 years or over and 5 patients under 50 years. There were no patients under 18 years. 116 14. Transfusion-Associated Circulatory Overload (TACO)
Table 42 Cases classified according to diagnostic criteria, probability of TACO and imputability NS: not stated by reporter NR: not recorded in the clinical records Case no. Age Sex Acute respiratory distress Tachycardia Increased BP Acute or worsening pulmonary oedema Evidence of positive fluid balance Probability of TACO Imputability 1* F89+ Yes NS NS Yes NS Possible 1 2 F59 Yes Yes Yes Yes NR Highly likely 3 3 F75 Yes Yes Yes NS Yes Probable 2 4 F61 Yes Yes Yes NS NR Possible 1 5** F62++ Yes NS NS Yes Yes Probable 2 6* F84 Yes NS NS Yes NS Probable 2 7** F29 Yes NS NS Yes Yes Probable 1 8** F68 Yes Yes Yes NS No Possible 1 9 M67 Yes No No Yes NS Possible 1 10 M74 Yes Yes Yes NS NR Possible 1 11 F83 Yes NR NR NR Yes Possible^^^ 1 12* M86 Yes Yes Yes NS NS Possible 1 13 F86 Yes No Yes Yes NS Probable 2 14 F71+++ Yes Yes Yes Yes NR Possible^^ 1 15* M84 Yes NS NS NS NS Possible 1 16* F83 NS Yes NS NS NS Possible 1 17 M78 Yes Yes No Probably Yes Probable 2 18* M88 Yes NS No Yes NS Probable 2 19 F68 Yes Yes Yes No Yes Probable 2 20 M32 Yes Yes No No NR Possible 1 21 F30 Yes No No Yes Yes Probable 2 22 M64 Yes Yes Yes Yes Yes Highly likely 3 23 F85^ Yes NS Yes Probably NS Possible 1 24* M75 Yes Yes Yes Yes NS Highly likely 3 25 F65 Yes No Yes Probably Yes Probable^^^ 2 26 F27 Yes Yes Yes Yes NR Highly likely 3 27 F87 Yes NS No Yes NR Probable^^ 2 28 F69 Yes NS No Yes Yes Probable 2 29* M88 Yes Yes Yes Yes NS Probable 2 30 F40 Yes NR NR Yes Yes Probable 2 31 F84 Yes NS Yes Probably NR Possible 1 32* F76 Yes Yes Yes NS NS Possible 1 33** M61 Yes No No Yes Yes Possible^^ 1 34** F70 Yes Yes Yes Yes No Highly likely 3 + * Transferred from ATR section chest pain and raised troponin t ++ ** Transferred from TRALI section pneumocystis pneumonia on bronchoscopy ^ hypertensive on admission +++ new lateral wall changes on ECG, ST down, T down ^^ onset 6–12 hours after transfusion ^^^ onset 12–24 hours after transfusion 14. Transfusion-Associated Circulatory Overload (TACO) 117
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Annual Report 2009 Affiliated to th
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Requests for further information sh
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1. Foreword The Serious Hazards of
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2. SHOT - The UK Haemovigilance Sch
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3. Participation in Haemovigilance
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Figure 2 Number of reports sent per
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For the first time this year, SHOT
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4. SHOT 2009-2010 UK Transfusion La
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Update on 2008 recommendations Last
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Numbers of components issued In 200
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Table 10 Cumulative mortality/morbi
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Acute transfusion reaction (ATR) Th
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6. Key Messages and Main Recommenda
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Recommendation All pulmonary compli
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2005 Appropriate use of blood compo
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7. Incorrect Blood Component Transf
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Table 12 Summary of IBCT cases Type
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Major morbidity There were 2 cases
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Wrong blood components transfused t
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Learning points ■■ All componen
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Table 15 Number of staff involved i
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All of the errors in this group wer
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Trust and sometimes in separate Tru
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IBCT events originating in the hosp
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multiple group O components; 1 grou
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Learning points ■■ ■■ Where
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Three interpretation errors occurre
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IT must be used to its full potenti
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Case 8 When the laboratory knows of
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■■ All staff must take full pro
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7.1 Errors Relating to IT Systems (
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to laboratory B. The clinical reque
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Improving Laboratory Standards (bas
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7.2 Right Blood Right Patient (RBRP
Page 69 and 70: COMMENTARY Each year SHOT emphasise
Page 71 and 72: Core hours vs. out of hours and Whe
Page 73 and 74: Broad breakdown of where primary er
Page 75 and 76: Case 6 Dilute (possible drip arm) s
Page 77 and 78: Case 10 Over-transfusion following
Page 79 and 80: 9. Handling and Storage Errors (HSE
Page 81 and 82: Excessive time to complete administ
Page 83 and 84: etween removing the component from
Page 85 and 86: 10. Adverse Events Relating to Anti
Page 87 and 88: Omission or late administration of
Page 89 and 90: Anti-D Ig given to the wrong patien
Page 91 and 92: RECOMMENDATIONS New recommendations
Page 93 and 94: Case 1 Possible fatal reaction A ma
Page 95 and 96: adequate resources both for monitor
Page 97 and 98: Figure 12 Reaction by component typ
Page 99 and 100: Bacterial culture of patient and un
Page 101 and 102: Previous recommendations that are s
Page 103 and 104: Figure 13 Number of cases of HTR re
Page 105 and 106: Antibody only detectable in eluate
Page 107 and 108: Table 39 Serology, laboratory signs
Page 109 and 110: Table 40 DHTRs - New specificities
Page 111 and 112: 13. Transfusion-Related Acute Lung
Page 113 and 114: Classification of cases according t
Page 115 and 116: Comparative data on implicated comp
Page 117 and 118: Case Histories TRALI probable Case
Page 119: RECOMMENDATIONS New recommendations
Page 123 and 124: Clinical details and transfused flu
Page 125 and 126: Cases in which RBC transfusion was
Page 127 and 128: exchange in patients with TTP. 43 I
Page 129 and 130: 15. Transfusion-Associated Dyspnoea
Page 131 and 132: 16. Post-Transfusion Purpura (PTP)
Page 133 and 134: ■■ The requirement to irradiate
Page 135 and 136: Two incidents (both bacterial, desc
Page 137 and 138: Viral and parasitic TTIs Since 1996
Page 139 and 140: The most likely source of the organ
Page 141 and 142: 19. Autologous Transfusion Definiti
Page 143 and 144: RECOMMENDATIONS There are no new re
Page 145 and 146: Introduction and overall trends In
Page 147 and 148: incident group O D negative units w
Page 149 and 150: Table 47 Types of reactions for eac
Page 151 and 152: always require notification by clin
Page 153 and 154: 21. Near Miss Reporting Definition
Page 155 and 156: 29 UK Resuscitation Council Emergen
Page 157: 24. Acknowledgements The Steering G
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SHOT Annual Report 2009 - Serious Hazards of Transfusion

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