Transfusion-associatedcirculatoryoverload (TACO)

Draft revisedreporting criteria

International Society of Blood Transfusion

Working Party on Haemovigilance

in collaborationwith

The International Haemovigilance Network

These proposed surveillance reporting criteria represent a revision of thepreviousinternational TACO definitionpublishedbythe International Society for Blood Transfusion Haemovigilance working party and International Haemovigilance Network:

Rationale fortherevision

At the Amsterdam meeting of the ISBT haemovigilanceworking party (2013), a number of members requestedrevision of the TACO definition. Notably, strictapplication of thedefinition leads to non-acceptance of cases whichwouldbeaccepted as TACO bycliniciansandbysomehaemovigilance systems.

A draft revisedversion was circulated in December 2014 andtestedbycontributorsfromhaemovigilance systems in severalcountriesandcontinentsbyapplyingittotheirown cases. Thisdefinition was found tobe more inclusivethanthe 2011 version but limitedbytheweightplaced on enlargement of thecardiacsilhouetteandincrease of BNP – both are oftennotinvestigated or notrecorded in haemovigilancereports.

The revisiongrouprecognisesthatthe chief priority is toadopt standard reporting criteria whichwillenable professionals toraise awareness of TACO and lead toimprovedreporting, research andreduction of transfusioncomplications. The revisiongroupincludesrepresentativesfrom AABB, andthisopenspossibilitiesforharmonisation. In future, the criteria mayneedtobeadjusted in the light of accumulatingevidence.

The revisiongroup(listedalphabetically)

Chester Andrzejewski, Paula Bolton-Maggs, SharranGrey, Kevin Land, HarrietLucero, Mark Popovsky, Philippe Renaudier, Pierre Robillard, Matilde Santos, Martin Schipperus, Dafydd Thomas, BarbeeWhitaker, Johanna Wiersum-Osselton (convenor).

Proposedstandard reporting criteria (2017)

Transfusion-associatedcirculatoryoverload (TACO)

Context

  • The term transfusion-associatedcirculatoryoverload or TACO indicatesthatthere is atemporalassociationwithbloodtransfusion. The imputability, thecausalcontribution of thetransfusion, is assessedseparately.
  • Certainclinicalconditions, e.g. cardiovascular, renal, pulmonarydiseasesand severe anemia, are risk factors for TACO. These conditions do notpreclude a diagnosis of TACO.
  • Otherfluidsgivenbefore or aroundthe time of thetransfusioncontributetoandcanexacerbatethefluidchallengesposedbytransfusion.The volume of transfused products may constitute only a percentage of fluidsadministered overall.
  • Patientswith TACO cardinally manifest respiratory system-relatedsignsandsymptomssuch as tachypnea, dyspnea, anddecreasedoxygensaturations, typicallyoccurringduring or within 12 hours of transfusion.
  • Close monitoring of thepatientandthevitalsignsduringtransfusionare important; review of vitalsignvalues/net fluidbalanceforat least 24 hours prior tothetransfusion of the unit identifiedwiththereactionmaybe of value.
  • An increase of bloodpressureandtachycardiamaybewarningsigns; appropriateclinical management mayprevent development of TACO.
  • Radiographicchest imaging of adequate quality at the time of thereaction is an important means of gainingdiagnosticinformation andshouldbeconsidered. However, cases without chest imaging maybereported as TACO providingother features are present.
  • Patientswith TACO mayexperienceanincrease in body temperature. An increase of body temperatureshouldbeinvestigatedaccordingto protocol andclinicaljudgement. Increased body temperature does not exclude TACO if the reporting criteria are met.
  • Patientsreceivingventilatory support: In ICU patientswhomaybereceivingvaryingdegrees of PEEP (positive end expiratorypressure) ventilatory support, pulmonaryoedemamaybedifficultto diagnose at higher PEEP settingswith TACO becoming apparent onlyif PEEP settings are reduced or ventilation is discontinued.

TACO reporting criteria*

Patientsclassifiedwith a TACO (surveillance diagnosis)shouldhave acute or worseningrespiratorycompromiseduring or up to 12 hoursaftertransfusionandshouldexhibittwo or more of the criteria below:

  • Evidence of acute or worseningpulmonaryoedemabased on:
  • clinicalphysical examination (seeNote 1), and/or
  • radiographicchest imaging and/or othernon-invasive assessment of cardiacfunctione.g. echocardiogram (seeNote 2)
  • Evidenceforcardiovascular system changes notexplainedbythepatient’sunderlyingmedicalcondition, including development of tachycardia, hypertension, jugularvenousdistension, enlargedcardiacsilhouetteand/orperipheraloedema(seeNote 3)
  • Evidence of fluidoverloadincludingany of thefollowing: a positivefluidbalance; response todiuretictherapycombinedwithclinicalimprovement; andchange in thepatient’sweight in the peri-transfusionperiod (seeNote 4)
  • Elevation in B typenatriuretic peptide (NP) levels (e.g., BNP or NT-pro BNP) togreaterthan 1.5 timesthepretransfusionvalue.A normalpost-transfusionNP level is not consistent with a diagnosis of TACO; serialtesting of NP levels in the peri-transfusionperiodmaybehelpful in identifying TACO.

*These criteria establish a surveillance definition based on a complete description of an event, including information that becomes available well after onset. This is for reportingand tracking purposesandthe criteria do notconstituteclinical diagnosis forthepurpose of real-time clinicalinterventions.

Notes

  1. Clinicalfindingscouldincludecrackles on lungauscultation, orthopneaandcough,cyanosisanddecreasedoxygensaturationvalues in the absence of otherspecificcauses.
  1. Diagnosticradiographic imaging

Findings consistent withpulmonaryoedemafromcirculatoryoverloadcouldincludepresence of new or worseningpleuraleffusions, progressive lobar vessel enlargement, peribronchial cuffing, bilateral Kerley lines, alveolar oedema with nodular areas of increased opacity and/orcardiacsilhouetteenlargement.

  1. Blood pressure monitoring

Oftenthe arterial pressure is raised, oftenwithwidenedpulsepressure; howeverhypotensionmaybe a presenting feature, e.g. in patients in a state of acute cardiaccollapse.

Blood pressureshouldbemonitoredespeciallyifmulti-unittransfusions are given.

  1. Change in thepatient’sweight

Typicallythepatient’sweightwillincrease. Howevertheremaybe a decreasefollowingdiuretictherapy.

Imputability

The imputability, thecausalcontribution of thetransfusion, is assessedseparately.

TACO definitionrevisiongroup1April 2017

IHN/ISBT haemovigilanceworking party/AABB