Background/Case Studies: Transfusion-associated circulatory overload (TACO) is the leading cause of transfusion-related morbidity and mortality. Oncology patients are at a high risk of TACO, given the common side effects of chemotherapy on cardiac and renal function. Here we evaluated the incidence of TACO and its association with new fever at a comprehensive cancer center.
Study
Design/Methods: Retrospective review of our Hemovigilance database from July 2019 to October 2020 identified 100 possible-to-definite TACO cases following the CDC-NHSN guidelines, (IRB 2019-0453). TACO cases were classified as HOT-TACO (N=16) or regular TACO (N=84) based whether or not they had new onset of fever. New fever was considered when the fever developed during transfusion and/or within 6 hours post cessation of transfusion. TACO cases with reported fever 12 hours prior to transfusion or more than 6 hours after completion of transfusion were included in the regular TACO group. Both groups were assessed for the type and age of blood products involved, gender, race, reaction severity (non-severe vs severe), cancer diagnosis, and baseline WBC counts. Wilcoxon rank-sum tests and the Fisher’s exact tests were used to compare the groups as appropriate. All statistical analysis was performed using R version 3.6.1.
Results/Findings: Among 1,382 transfusion reactions during the study period, the incidence of TACO reaction was 7.2% (N=100); of these, 16% (N=16) were HOT-TACO cases. The median age of patients diagnosed with TACO was 63 (range 18-86) years. Patient demographics included 52% male, 48% female, 71% White, 11% African American, 6% Asian, 9% other, and 3% not reported. The blood components involved were pRBC 64%, FFP 5%, and platelets 31%. Hematologic malignancy was the cancer diagnosis found in 77.4% (N=65) of TACO cases and 62.5% (N=10) of HOT-TACO cases, while solid tumor was found in 37.5% (N=6) of HOT-TACO and in 22.6% (N=19) of TACO cases. There were no significant differences in pre or post event WBC counts, age of the products involved or reaction severity between groups (Table.1) Conclusions: The incidence of TACO was found to be 7.2% in our oncology population. Patients with hematologic malignancies are at a high risk for TACO likely associated with the frequency and volume transfused. We found an association of new fever with TACO in 16% of cases compared with a 32% reported in non-oncologic setting [1]. Findings are likely related with the inability to mount immune response present in cancer patients due to immunosuppression. Nevertheless, our findings support that fever should not be used to distinguish TRALI from TACO. Sample size and imputability criteria are limitations in the study. NHSN: National Healthcare Safety Network Transfusion -related acute lung injury (TRALI) 1-The association of fever with transfusion-associated circulatory overload. Vox Sang. 2017 Jan;112(1):70-78. PMID: 28001310
Importance of research: Awareness that TACO can be associated with fever specially in the setting of neutropenia is important during diagnostic evaluation. Our findings support that fever should not be used to distinguish TRALI from TACO in adverse events presenting with new onset or exacerbation of acute respiratory distress associated with transfusion.
