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

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.

Post-operative Anemia After Major Surgery: a Brief Review

Purpose of Review Anemia is a very common complication in the post-operative period. Post-operative anemia is associated with poor outcomes including but not limited to infections, increased length of stay, circulatory overload, and mortality. The strategy of patient blood management focuses on three pillars that include the detection and treatment of pre-operative anemia; reduction of peri-operative blood loss; and harnessing and optimizing the patient-specific physiological reserve of anemia. Recent Findings Multiple studies in surgical patients have been conducted to study various methods of management of post-operative anemia. Recent advances in surgical techniques have also been studied to minimize blood loss. There is a widespread consensus on the use of intravenous iron in hospitalized post-operative patients after major surgery. Summary We discuss the most common causes of post-operative anemia and management focusing on measures to reduce blood loss and measures to increase red blood cell (RBC) mass. In this brief review, we present updates from the most relevant articles in the past 5 years and include updates from the 2018 international consensus statement on the management of post-operative anemia after major surgical procedures.

Transfusion associated circulatory overload (TACO): Significance of appropriate pre-transfusion risk assessment to prevent fatal health outcomes

Madam, Transfusion of blood products is a life rescuing medical intermediation; however, associated adverse transfusion reactions are major pitfalls. Transfusion-associated circulatory overload (TACO) is life-threatening pulmonary oedema that develops secondary to volume overload. Underlying precipitating factors include ages >60 years or <3 years, low body mass index (BMI), rapid transfusion rate and pre-existing volume overload conditions such as heart disease, renal failure, lung disease or low albumin levels. Sign and Symptoms include dyspnoea, tachypnoea, tachycardia, hypoxia, raised jugular venous pressure, broad pulse pressure and hypertension, that appears during or either six hours posttransfusion [1]. TACO should be discriminated from transfusion-related acute lung injury (TRALI) by high jugular venous pressure, pulmonary arterial pressure to >18mmHg, hypertension, brain natriuretic peptide levels (>1200pg/ml) and response to diuretics. Management of TACO includes immediate discontinuation of transfusion, diuretics, supplementary oxygen, and assisted ventilation if indicated [2]. Serious Hazards of Transfusion (SHOT) in 2018 reported TACO as the most typical reason for transfusion-related deaths. Over the period of 11 years (2007-2018), overall cases raised from six to one hundred and ten, including the increase in mortality from one to five and one significant morbidity from three to thirty-six cases [3]. Interestingly, timely and appropriate preventive actions can reduce this severe reaction to zero. A precise risk assessment before transfusion is recommended by SHOT for TACO elimination, especially if the patient has underlying risk factors. Preventive strategies in such predisposed patients include reviewing the need for transfusion, deferring the transfusion until issue can be resolved, transfuse according to body weight, measure fluid balance, consider prophylactic diuretic, slow transfusion rate and monitoring vital signs including oxygen saturation. Thus, TACO is a serious but avoidable transfusion reaction. Appropriate assessment prior to transfusion in every patient is important to ensure safe blood transfusion practice. Continuous...

Early Safety Indicators of COVID-19 Convalescent Plasma in 5,000 Patients

Background: Convalescent plasma is the only antibody based therapy currently available for COVID-19 patients. It has robust historical precedence and sound biological plausibility. Although promising, convalescent plasma has not yet been shown to be safe as a treatment for COVID-19. Methods: Thus, we analyzed key safety metrics after transfusion of ABO-compatible human COVID-19 convalescent plasma in 5,000 hospitalized adults with severe or life threatening COVID-19, with 66% in the intensive care unit, as part of the US FDA Expanded Access Program for COVID-19 convalescent plasma. Results: The incidence of all serious adverse events (SAEs) in the first four hours after transfusion was <1%, including mortality rate (0.3%). Of the 36 reported SAEs, there were 25 reported incidences of related SAEs, including mortality (n=4), transfusion-associated circulatory overload (TACO; n=7), transfusion-related acute lung injury (TRALI; n=11), and severe allergic transfusion reactions (n=3). However, only 2 (of 36) SAEs were judged as definitely related to the convalescent plasma transfusion by the treating physician. The seven-day mortality rate was 14.9%. Conclusion: Given the deadly nature of COVID-19 and the large population of critically-ill patients included in these analyses, the mortality rate does not appear excessive. These early indicators suggest that transfusion of convalescent plasma is safe in hospitalized patients with COVID-19.