TACO: a call to action

Transcription

1 TACO: a call to action Johanna (Jo) Wiersum-Osselton TRIP (Transfusion and Transplantation Reactions in Patients) Also: Sanquin donor physician No financial conflicts

2 Photo: University of Virginia website Is TACO a (transfusion) problem? Recognising TACO call for a better definition Preventing TACO

3 Reports to TRIP Transfusion-associated acute lung injury (TRALI) Transfusion-associated circulatory overload (TACO) Transfusion-associated dyspnea (TAD) NL approx 1/10000 Clifford et al, Anesthesiology 2015; 122:21-8 Retrospective electronic EPD screening (Adults, non-cardiac surgery) 2004: 5.2% TACO 2011: 3.0% TACO

4 Aantal meldingen Serious reactions Serious reactions (definite, probable or possible imputability) TACO TRALI 30 Allergic Hemolytic reaction Other reaction Bacterial Non-hemolytic reaction Viral or other infection PTP Reactions following errrors/incidents

5 Cardiogenic pulmonary edema: CT ratio > 50% Vascular pedicle width > 60mm VPW Naam persoon IHN-ISBT-AABB TACO meeting 14 Nov 2017, P. Van der Valk Slide 2 25/7/18

6 Brain-type Natriuretic peptide (BNP) AA) Triepels et al, Ned. Tijdschr. Klin. Chem Labgeneesk 2004, vol. 29, no. 1 Signalling peptide (26 AA) AA) Blood AA) AA) BNP Associated with ventricular wall stretching stimulates natriuresis, diuresis and vasodilatation T ½ 20 mins N-terminal pro-bnp inactive; T ½ 120 min, more stable (72h) in sample

7 BNP(2) Tobian et al, TRANSFUSION 2008;48: (n=40 patients total) Li et al, TRANSFUSION 2009;49: Normal BNP excludes congestive cardiac failure; rising BNP suggests TACO Patients who developed TACO often had high BNP before transfusion Poor discrimination between TACO and TRALI

8 TACO and fever TRIP /47 reports (30%) /38 reports (26%) Cause or consequence or coincidence? SHOT 38% (personal information P. Bolton-Maggs, 2017) Parmar et al, Vox Sanguinis 2016 (972 reactions): 31.8% of TACO cases show new rise in body temp

9 Work on international definition Former ISBT-IHN definition (2011): TACO is characterized by any 4 of the following: Acute respiratory distress Tachycardia Increased blood pressure Acute or worsening pulmonary edema on frontal chest radiograph Evidence of positive fluid balance occurring within 6 hours of completion of transfusion. Many cases did not meet the criteria ->revision launched in 2013

10 Work on international definition International Society for Blood Transfusion haemovigilance working party International Haemovigilance Network AABB Draft revised reporting criteria (2017) TRALI definition is also being reconsidered (different task force; in contact with the ISBT group)

11 Timeline for Revision and Updating of Transfusion-Associated Circulatory Overload (TACO) Case Surveillance Definition Surveillance definition for TACO (ISBT/IHN) st revised draft tested, not yet sufficiently inclusive April 2017 validation launched 2017 Manuscript in preparation ISBT HV Working Party launched revision Phase I HV systems tested using previously classified cases nd revised draft version proposed. Posted for public comment Phase II HV professionals assessed 24 example case reports. November 2017 Amsterdam TACO consensus planning meeting

12 Draft revised reporting criteria Validation version, April 2017 Patients classified with a TACO (surveillance diagnosis) should have acute or worsening respiratory compromise during or up to 12 hours after transfusion and should exhibit two or more of the criteria below: Evidence of acute or worsening pulmonary oedema based on: clinical physical examination (see Note 1), and/or radiographic chest imaging and/or other non-invasive assessment of cardiac function e.g. echocardiogram (see Note 2) Evidence for cardiovascular system changes not explained by the patient s underlying medical condition, including development of tachycardia, hypertension, jugular venous distension, enlarged cardiac silhouette and/or peripheral oedema (see Note 3) Evidence of fluid overload including any of the following: a positive fluid balance; response to diuretic therapy combined with clinical improvement; and change in the patient s weight in the peri-transfusion period (see Note 4) Elevation in B type natriuretic peptide (NP) levels (e.g., BNP or NT-pro BNP) to greater than 1.5 times the pretransfusion value. A normal post-transfusion NP level is not consistent with a diagnosis of TACO; serial testing of NP levels in the peritransfusion period may be helpful in identifying TACO.

13 Preventable? 26% of costs of serious reactions Preventability estimated at 64% (26 91%) 28% of potentially preventable costs Magee et al 2013: $14,062 increase in hospital costs 3227 per serious TACO fluid overload in patients who received FFP

14 TRIP TACO risk factor case review 61 reports (18 hospitals) in Counted as TACO risk factor TACO Cardiovascular (n=41) Suspicion of (impending) congestive heart failure (n=35) Previous history E.g.: Hypertension; coronary vascular disease; heart valve problems; congestive heart failure; cardiomyopathy (1 or more) Current preceding Tf Pos fluid balance, raised pro-bnp/troponin; CCF symptoms (1 or more) Renal (n=31) Chronic renal failure Acute renal failure Pulmonary (n=19) Age (n=54) Medication/intoxication (n=17) Anemia (n=25) Post-operative (n=10) Fluids (n=18) 1-8 risk factors per patient, average 4 COPD; pulmonary hypertension; post (partial) lobectomy Age >60 years; cardiotoxic drugs; chronic/deep anemia; weight <50 kg; (recent) pregnancy Pneumonie; chest trauma Surgery; starated cardiotoxic medication; IV fluids

15 No. of patients Units transfused in 24h before TACO onset 1 risk factor 2 risk factors 3 risk factors 4 risk factors 5 risk factors 6 risk factors 7 risk factors 8 risk factors

16 Diuretics as preventive measure? Sarai M et al, Cochrane review 2015 Population: adults and children who are recipients of any blood product transfusion Intervention: prophylactic administration of loop diuretics (furosemide, bumetanide, ethacrynic acid, or torsemide) Comparison placebo, no treatment, or general fluid restriction Outcome: therapeutic advantage (that is, a favourable risk benefit ratio) Primary outcome: TACO or TRALI Secondary: admission, death, intervention needed to prevent heart failure, heart failure, acute renal failure, ototoxicity or electrolyte disturbances associated with diuretics

17 Cochrane review 2015 CONCLUSIONS: 4 RCT or quasi-rct studies (all with furosemide), total of 100 patients 1 study: improvement in fraction of inspired oxygen (in favour of furosemide) 2 studies: improvement in pulmonary capillary wedge pressure (in favour of furosemide) No study investigated the predefined outcomes More work needed!

18 SHOT (UK) TACO checklist

19 National recommendations 2018 survey of IHN member systems: 16 countries response 3 have specific tool; others mentioned preventive recommendations in guidelines 10 november

20 And now to work! Acknowledgements: TRIP contacts in hospitals TRIP colleagues and advisory board International TACO task force Thank you for your attention!