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Adverse Reactions to Transfusion:
TRALI and TACO
Objectives
Review the historical perspective and background of TRALI and
TACO including definition of both
Identify mechanisms of action, management, outcomes and
prevention of both TRALI and TACO
2015-APL-02503 1
Transfusion Related Fatalities by Complication, FY2009 through
FY2013
2015-APL-02503 2
Transfusion Related Acute Lung Injury
(TRALI)
2015-APL-02503 3
TRALI: Historical Perspective
1950’s Description Acute hypoxemia and noncardiogenic
pulmonary
edema
1950 and 1960 Literature Document transfusion associated
pulmonary
edema without evidence of volume overload
2015-APL-02503 4
TRALI: Historical Perspective
1980’s Marked the emergence of a basic understanding of
TRALI1992 1st fatality reported to CBER
2000 to 2015 2000 TRALI represented 13% of all transfusions #1
cause of transfusion related fatalities
2015-APL-02503 5
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TRALI: ReportsFatalities Majority of deaths associated with
FFP
Less frequent with RBCs, cryo, platelets and rare with IvIg
Investigation Donor antibody screens implicated multiparous
females
Non-Fatal Events Reports by licensed blood establishments are on
the
increase Because of misdiagnosis and/or reporting the full scope
of
TRALI not known
2015-APL-02503 6
TRALI
MechanismMay be attributable to the presence of Anti-HLA or
Anti-granulocyte antibodies
Once transfused antibodies may cause complement activation
TRALI recipients have no specific demographics
Clinical results may be subtleor significant
Does not always occur through donor transfusions
In either case, there is marked hypoxemia, hypotension, fever,
severe bilateral pulmonary edema
Antibodies implicated are usually of DONOR origin
2015-APL-02503 7
TRALI: Immunologic Mechanism
Activation of complement cascade and/or mobilization of
cytotoxic agents lead to acute lung injury in
approximately 85% of cases
Donor plasma contains Anti-HLA or Anti-Neutrophil antibodies
that react with HLA or Neutrophil antigens on
recipient leukocytes
Antibody-antigen complexes collect in the pulmonary
microvasculature
2015-APL-02503 8
TRALI Non Immune Mechanism
Pre-existing condition activates neutrophils
Stored blood accumulates lipids and/or cytokines and upon
transfusion activate the primed neutrophils
Activated primed neutrophils secrete toxic substances – may
explain the 15% of cases where antibodies are
not detected
2015-APL-02503 9
TRALI RatesEstimated incidence of TRALI is 0.014 – 0.08 %
• 1 in 1271 Units TRALI• 1 in 534 units possible
TRALI
Rana et al Transfusion
2006;46:1478
• 0.02% per unit of blood transfused
• 0.16% per transfused patient
Popovsky et al Am Rev Respir Dis
1983;128:185
2015-APL-02503 10
TRALI: Definition
Hypoxemia (PaO2/FiO2
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TRALI
Common Signs and Symptoms Dyspnea Cyanosis Hypoxemia Fever (low
grade) Chills Hypotension Bilateral pulmonary edema (new onset)
2015-APL-02503 12
TRALI: Diagnosis
This is a clinical diagnosis plus supporting labs/images
Diagnosis of exclusion: rule out other causes of transfusion
associated respiratory distress
Differential diagnosis TACO (increased BP, I & O’s, BNP,
diuresis helps) Anaphylaxis (rash, wheezing) Bacterial
contamination (gram stain/culture) Hemolytic transfusion reaction
(type/screen/cross, DAT)
2015-APL-02503 13
2015-APL-02503 14
TRALI – Management
Respiratory Support
Dictated by clinical picture
Nasal cannula 2L to intubation
Diuretics
Play no role in TRALI
Pathology involves microvascular injury no fluid
overload
2015-APL-02503 15
TRALI Prevention: Donor Selection
AABB Standard 5.4.1.2 Plasma and whole blood for allogeneic
transfusion
shall be from males, females who have not been pregnant or
females who have been tested since their most recent pregnancy and
results interpreted as negative for HLA antibodies
AABB – Donor CentersAABB – Donor Centers
Plasma containing products frequently
implicated
Donors with antibodies should
be deferredUse of male plasma has reduced rates
2015-APL-02503 16
TRALI – Risk ReductionTransfusion Centers
Washed Cellular
Products
Pre-storage Leukoreduction Plasma
Expensive, time consuming Small amounts
of plasma can cause TRALI
Not effective in inhibiting BRM mediated TRALI in-vivo
In Norway – no TRALI reported in the use of solvent-detergent
plasma
2015-APL-02503 17
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Transfusion Related Acute Lung Injury (TRALI)
Preventive Measures: American Red Cross TRALI Mitigation:
Defer donors implicated in a TRALI reaction All Transfusable
plasma
from male donors Women who report a history of no pregnancy
Females who have been tested and found to have an
acceptably low level of HLS antibodies
2015-APL-02503 18
Transfusion Related Acute Lung Injury (TRALI)
Preventive Measures: American Red Cross TRALI Mitigation
Reduce the Risk of TRALI in single donor platelets Defer donors
implicated in TRALI Prevent the manufacture of high volume products
from donors
known to harbor HLA antibodies Leukoreducing all apheresis
platelet products to prevent
interaction with recipient HLA antibodies Increasing the
proportion of donations from male donors Testing female apheresis
donors Ruling out testing of all ever-pregnant females donors
2015-APL-02503 19
Transfusion Related Acute Lung Injury (TRALI)
Preventive Measures: Hospital:
Minimize the inappropriate transfusion of blood products
Minimize AB plasma utilization; group specific plasma should
be given when time permits.
Note: Avoidance of discard is not an indication for use.
2015-APL-02503 20
TRALI Outcomes
• Mortality varies• Reported
between 5% & 25%
Mortality
• 80% recover quickly
• Between 24 to 72 hours
Recovery
2015-APL-02503 21
Immediate steps to take when an adverse reaction to transfusion
is suspected
1. Recognize2. Stop3. Assess4. Notify5. Treat6. Report7.
Document
2015-APL-02503 22
TRALI – Recommendations
Be alert to respiratory
distress
Immediately discontinue transfusion
Begin oxygen and supportive
therapy
Follow your routine
notification sops
Transfusion Service will
notify the Blood Center
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Possible Clinical Interventions
Sig
ns/
S
ymp
tom
sR
eact
ion
T
ype
Man
agem
ent
Fever, Chills/ Rigors
Shock Respiratory Distress Urticaria
Febrile Non-
HemolyticHemolytic Septic TRALI TACO Anaphy-lactic
Mild Allergic
•Antipyretics•Analgesics
•Antipyretics•Analgesics•Fluids•Pressors•Diuretics
•Antipyretics•Analgesics•Broad spectrum antibiotics
•Blood Cultures
•Oxygen•Antipyretics•Intubation•Blood pressure support
•Chest x-ray
•Oxygen•Upright position
•Diuretics
•Oxygen•Feet
up•Fluids•Epinephrine•Intubation•Anti-histamines
•Cortico-steroids
•Beta 2 agonists
•Anti-histamines
2015-APL-02503 24
TRALI: Common Question
Question: Can a patient be transfused after a TRALI
reaction?
Answer: yes The reaction is an issue with the donor, not the
patient Once the transfusion reaction workup has been done
and hemolysis is ruled out, the patient may be transfused
again
2015-APL-02503 25
TRALI: Reporting
Method DetailsE-mail: http://www.fda.gov/medwatchTelephone/voice
mail: 1-800-FDA-1088Fax: 1-800-FDA-0178Express Mail: MedWatch
HF-25600 Fishers LaneRockville, MD 20852
• Fatalities from TRALI should be reported to CBER in accordance
with 21CFR606.170(b)
• FDA encourages voluntary reporting of TRALI as a serious
adverse reaction to transfusions
2015-APL-02503 26
Transfusion Related Fatalities by Complication, FY2009 through
FY2013
2015-APL-02503 27
Transfusion Associated
Circulatory Overload (TACO)
2015-APL-02503 28
TACO History
Historical InformationPhysicians have known transfusion is a
risk factor for circulatory overloadTACO not taken
seriouslyRediscovered now that TRALI is a major focusClinical
impact recognized to be more that giving supplemental oxygen and a
dose of diuretics
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TACO Reports
Massachusetts Medicare Study Popovsky demonstrated TACO patients
required
more intensive care and longer length of care
FDA Data Demonstrate TACO is the second most common cause of
death
from transfusion
2015-APL-02503 30
TACO Reports
Fiscal 2005-2006 Fatal case reports increased from 2-13% of
all
fatalities
French Hemovigilance 6 year period 742 cases identified
resulting in 27
deathsUS Biovigilance Program Undoubtedly more fatalities
identified
2015-APL-02503 31
TACO Mechanism
Inability of circulatory system to tolerate volume or rate of
transfusion
“Cardiogenic pulmonary edema”
ANY patient may get TACO – especially if transfused rapidly
2015-APL-02503 32
TACO Rates
1. Gajic et al Crit Care Med 2006; 34:S1092. Popovsky et al
Immunohematol 1996; 12:873. Rana et al Transfusion 2006;
46:1478
• 0.03%-8% of transfusions depending on criteria
Rate Ranges
• TACO occurred in 1 of 356 transfusions
ICU Patient Study
2015-APL-02503 33
TACO
Patients with the following are most at risk:Diminished cardiac
reserve
Renal failure or dysfunction
Older (85% occur in patients greater than age 60)
Younger (smaller total blood volume)
Chronic anemias (e.g. sickle cell, thallasemias)Those receiving
large amounts of blood products in a short time frame OR receiving
double red cell transfusions
2015-APL-02503 34
Transfusion Associated Circulatory Overload (TACO)
Definition: Infusion volume that cannot be effectively
processed
by the recipient either due to high rate and/or volume of
infusion or an underlying cardiac or pulmonary pathology.
Can occur after only a few ml up to 6 hrs after Fairly Common →
occur in ~1-8% of transfusions
2015-APL-02503 35
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TACO: Diagnosis
Physical exam: lung crackles, rales, elevated JVP, S3 gallop
Chest XR: Alveolar and interstitial edema, Kerley B lines,
pleural effusions, cardiomegaly
Elevated BNP Non-immune mediated, so no antibodies
2015-APL-02503 36
TACO: Signs/Symptoms
Shortness of breath, cough, chest tightness (from fluid
accumulation in the lungs)
Headache (from the increased systolic pressure) Most typically
towards the end of transfusion or
shortly afterwards when the maximum amount of fluid was
transfused
2015-APL-02503 37
Transfusion Associated Circulatory Overload (TACO)
Common Signs and Symptoms Dyspnea Cough Pulmonary edema
Hypertension Tachycardia Elevated brain natriuetic peptide (BNP)
Orthopnea Elevated central venous pressure (CVP) Cyanosis Evidence
of left heart failure Headache Distended neck veins Chest tightness
Pedal edema
2015-APL-02503 38
TACO: Management
Stop the transfusion Follow your facilities routine procedures
for adverse
reactions Evaluate the patient (you may want to sit the
patient
upright to minimize fluid accumulation in the lungs) Give
supplemental oxygen Diuretics to decrease the blood volume Severe
cases may require therapeutic phlebotomy
though typically patients respond to supportive therapy
2015-APL-02503 39
Possible Clinical Interventions
Sig
ns/
S
ymp
tom
sR
eact
ion
T
ype
Man
agem
ent
Fever, Chills/ Rigors
Shock Respiratory Distress Urticaria
Febrile Non-
HemolyticHemolytic Septic TRALI TACO Anaphy-lactic
Mild Allergic
•Antipyretics•Analgesics
•Antipyretics•Analgesics•Fluids•Pressors•Diuretics
•Antipyretics•Analgesics•Broad spectrum antibiotics
•Blood Cultures
•Oxygen•Antipyretics•Intubation•Blood pressure support
•Chest x-ray
•Oxygen•Upright position
•Diuretics
•Oxygen•Feet
up•Fluids•Epinephrine•Intubation•Anti-histamines
•Cortico-steroids
•Beta 2 agonists
•Anti-histamines
2015-APL-02503 40
TACO
PreventionControl rate of infusion (suggest: 1 mL/Kg/hour
Split units in half or use aliquots
Consider lower volume units, or reduced volume units
Some suggest simultaneous administration of furosemide
“critical care level” nursing supervision in high-risk
patients
2015-APL-02503 41
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TACO OutcomesOne study showed the following:
18% (n=98) of pts required transfer to
ICU
8% suffered a major
complication2% died
Early recognition
better clinical outcomes
2015-APL-02503 42
TACO: Outcomes
Andrzejewski and colleagues found at 15 minutes after
transfusion, systolic blood pressure, pulse pressure, and mean
arterial pressure were significantly higher in fluid-challenged
patients than those not overloaded
These patients could benefit from bedside monitoring
2015-APL-02503 43
TACO: Reporting
Report to blood bank as a possible transfusion reaction so the
proper investigation may begin
Contemplate differential diagnosis and encourage appropriate
patient care, laboratory analysis, or other diagnostic measures
Document all details for the EMR and blood bank
2015-APL-02503 44
TACO: Follow-Up
Ask patients if they have any history of previous transfusion
reactions and if so, to please describe
Clinical follow-up—the outcome varies with overall clinical
status of the patient so clinical correlation is recommended to
decide upon what time frame to follow up with the clinician
Ensure all elements are documented
2015-APL-02503 45
TRALI or TACO: Fatality
When the death of a patient is a result of a transfusion
reaction or a complication related to a transfusion current good
manufacturing practice (cGMP) regulations require reporting of the
fatality to the FDA by the facility that performed the
compatibility testing.
The patient’s underlying illness may make determination of the
cause of death difficult.
If there is any clinical suspicion that the transfusion may have
contributed to the patient’s death, an investigation into that
possibility should be performed
2015-APL-02503 46
TRALI or TACO: Reporting
Method DetailsE-mail: http://www.fda.gov/medwatchTelephone/voice
mail: 1-800-FDA-1088Fax: 1-800-FDA-0178Express Mail: MedWatch
HF-25600 Fishers LaneRockville, MD 20852
• Fatalities from any transfusion should be reported to CBER in
accordance with 21CFR606.170(b)
• FDA encourages voluntary reporting of TRALI as a serious
adverse reaction to transfusions
2015-APL-02503 47
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TRALI vs. TACOFeature TRALI TACO
Body Temperature Fever can be present Unchanged
Blood Pressure Hypotension Hypertension
Respiratory Symptoms Acute dyspnea Acute dyspnea
Neck Veins Unchanged Can be distended
Auscultation Rales Rales, S3 may be present
Chest radiograph Diffuse bilateral infiltrates Diffuse bilateral
infiltrates
Ejection fraction Normal, decreased Decreased
PA auscultation pressure 18 mmHg or less Greater than 18
mmHg
Pulmonary edema fluid Exudate Transudate
Fluid balance Positive, even, negative Positive
Response to diuretic Minimal Significant
White count Transient leukopenia Unchanged
BNP 1200 pg/ml
Leukocyte antibodies
Donor leukocyte antibodies present, crossmatch incompatibility
between donor and recipient
Donor leukocyte antibodies may or may not be present, positive
results can suggest TRALI even with true TACO cases
Skeate and Eastlund Curr Opin Hematol 2007; 14:6822015-APL-02503
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Conditions That Mimic Transfusion-Related Acute Lung Injury With
Symptoms and Circumstances That Help Distinguish Them
Condition Hints
Congestive heart failure,† acute left ventricular failure
History of congestive heart failure
Recent bypass surgery
Poor ejection fraction
Peripheral edema
Pleural effusions on chest x-ray or physical examination
Jugular venous distension on physical examination
Dilated superior vena cava on ultrasound
B-natriuretic peptide (BNP) > about 500 pg/mL
Pulmonary capillary wedge pressure > 18 mmHg
Distended pulmonary artery on chest x-ray
Cardiomegaly on chest x-ray
Response to diuresis
†Congestive heart failure is a chronic volume overload state,
because heart failure induces fluid retention as a compensatory
mechanism. The overlap in findings and symptoms with acute volume
overload unrelated to heart failure is therefore not
unexpected.
Table adapted from: Eder and Chambers Arch Pathol Lab Med 2007;
131:708
2015-APL-02503 49
Conditions That Mimic Transfusion-Related Acute Lung Injury With
Symptoms and Circumstances That Help Distinguish Them
Condition Hints*
Acute circulatory (volume) overload
High-volume fluid infusion or transfusion over a short
period
Elderly or very young patient
Increase in systolic blood pressure
Pre-existing chronic volume overload state (e.g.: renal failure,
congestive heart failure)
Severe chronic anemia
Cardiomegaly on chest x-ray
Rales on pulmonary auscultation
Distended pulmonary artery on chest x-ray
Response to diuresis
Pulmonary embolism
Hypercoagulable state (e.g.: pregnancy, known
thrombophiliasyndrome)
Immobility
Disseminated malignancy
No or little pulmonary edema on chest x-rayTable adapted from:
Eder and Chambers Arch Pathol Lab Med 2007; 131:7082015-APL-02503
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Conditions That Mimic Transfusion-Related Acute Lung Injury With
Symptoms and Circumstances That Help Distinguish Them
Condition Hints*
Rapidly progressive pneumonia (especiallyviral or fungal)
Fever
High white blood cell count
Progression of infiltrates on chest x-ray
Patchy or lobar pattern of infiltrates on chest x-ray
Pre-existing diagnosis of pneumonia
Patient at risk for infection (e.g.: Neutropenic)
Adult respiratory distress syndrome (ARDS)/acute lung injury
(ALI)
Underlying illness classically associated with ARDS/ALI such
as:
• Sepsis (especially associated with pneumonia)• Shock•
Disseminated intravascular coagulation• Multiple trauma
Progression or lack of resolution for 1-3 days
High mortality
No or little pulmonary edema on chest x-ray
Table adapted from: Eder and Chambers Arch Pathol Lab Med 2007;
131:708
2015-APL-02503 51
TRALI vs. TACO
Which of the following is not included in the diagnosis of
TACO?A. Elevated JVPB. Increased or new pulmonary edemaC.
Antibodies to HLA or neutrophilsD. Increased BNPE. Cardiomegaly
2015-APL-02503 52
TRALI vs. TACO
Which of the following is not included in the management of
TACO?A. DiureticsB. OxygenC. Hold off on future transfusions for a
whileD. Sitting uprightE. Vasopressors
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TRALI vs. TACO
Which of the following is NOT a symptom of TACO?A. DyspneaB.
Back painC. CoughD. Chest tightnessE. Hypertension
2015-APL-02503 54
TRALI vs. TACO
Which of the following does not support the diagnosis of
TRALI?A. Bilateral infiltrates on CXRB. Symptoms typically begin
1-2 hours after
transfusion and are fully manifest within 1-6 hoursC. Transient
leukopenia, neutropenia,
monocytopenia, hypocomplementemiaD. Decreased BP in response to
diureticsE. Frothy pink secretions from ETT
2015-APL-02503 55
TRALI vs. TACO
Which of the following is not included in the investigation or
prevention of TRALI?A. Determine if donor has HLA or neutrophil
antibodiesB. Determine if recipient has corresponding
antigen
to donor antibodiesC. Remove implicated donor from donor poolD.
Universal leukoreduction of donor productsE. Transfuse male
donor-only plasma
2015-APL-02503 56
TRALI vs. TACO
Which of the following is not included in the definition of
TRALI?A. Hypoxemia B. Occurring 24 hours after transfusionC.
Bilateral infiltrates on chest XRD. No pre-existing acute lung
injury before
transfusionE. No evidence of TACO
2015-APL-02503 57
TRALI vs. TACO
Which of the following is not included in the proposed
mechanisms for TRALI?A. Gram negative cocciB. Anti-HLA antibodiesC.
Anti-neutrophil antibodiesD. Biologically active lipidsE.
Cytokines
2015-APL-02503 58
Adverse Reaction Case Studies
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Case Study – Patient History
• 67 year old female with a history of multiple myeloma and TTP
• Plasma exchange scheduled for next morning
• Transfusion service order received• Type & Screen• 4000 mL
plasma
2015-APL-02503 60
Transfusion Services Result History
2015-APL-02503
Previous History
B positive
Nonreactive Antibody Screen
History of multiple RBC and plasma transfusions
Current Results
B positive
Nonreactive Antibody Screen
16 units B positive plasma prepared
61
Transfusion Event
• The plasma exchange was completed and transportation was
called to return the patient to the room, when the patient said she
did not feel well. She complained of shortness of breath.
• An adverse reaction to the plasma was suspected• Patient’s
Physician was paged• Transfusion Service was called
2015-APL-02503 62
Transfusion Event Timeline
• Post-transfusion nursing clerical check OK:
3)Patient armband
2)Product tag
1) Product label Patient first/last name Unique
identification
number Blood unit number ABO/Rh
1230
Pre-Pooled Plasma (4000 mL)
10101000 125011001030 11301120 1150 1200 1230
2015-APL-02503 63
The nurse sent the following to the lab for investigation…
• all paperwork
• the bags from all 16 units of plasma
• administration set
2015-APL-02503 64
• No abnormalities• All accompanying IV solutions compatible
Adverse Reaction- Laboratory Investigation
Inspect product
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Adverse Reaction- Laboratory Investigation
• Post-transfusion laboratory clerical check OK:
3)Patient armband
2)Product tag
1) Product label Patient first/last name Unique
identification
number Blood unit number ABO/Rh
Clerical check
Inspect product
2015-APL-02503 66
• Patient’s Pre-transfusionspecimen is clear and there is no
evidence of hemolysis or icterus
Adverse Reaction- Laboratory Investigation
• Patient’s Post-transfusionspecimen is clear and there is no
evidence of hemolysis or icterus
Compare specimens
Clerical check
Inspect product
2015-APL-02503 67
Adverse Reaction- Laboratory Investigation
Pre-transfusion Specimen
B positive
Nonreactive Antibody Screen
Polyspecific DAT nonreactive
Post-transfusion specimen
B positive
Nonreactive Antibody Screen
Polyspecific DAT nonreactive
Test specimens
Compare specimens
Clerical check
Inspect product
2015-APL-02503 68
Adverse Reaction Signs and Symptoms: REVIEW
Laboratory investigation: Clerical check (lab/nursing) identical
No visual hemolyisis—serum or urine Pre- and post- sample testing
identical DAT nonreactive
Pre-FFP transfusion
15 min Post-FFP transfusion
Blood Pressure (mmHg) 138/84 139/83 100/68
Pulse (beats/minute) 88 86 115Respirations(breaths/minute) 16 15
25
Temperature (oF/oC) 98.6 98.7 101oF/oCDyspnea and felt
unwell
2015-APL-02503 69
Chest X-Ray
Anesthesia UK Website
Normal Patient
2015-APL-02503 70
Adverse Reaction: Transfusion Event
• After this x-ray was taken: • Patient required Oxygen
• Oxygen saturations 85% on 2L nasal cannula• Patient was
subsequently intubated and admitted to
the ICU• Patient condition continued to deteriorate Patient
expired on day 4
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Reaction Follow-Up
• TRALI reaction reported to blood supplier• Patient received 16
units of thawed plasma exhibiting
a reaction within 6 hours• Blood Supplier
• Determined 4 of 16 donors were at ‘risk’ for developing HLA
antibodies
• All 4 ‘suspect’ donors were tested for HLA antibodies• One
donor tested positive for HLA Granulocyte Class I
and II antibodies• This donor was permanently deferred
2015-APL-02503 72
Summary
TRALI and TACO have been documented for several decades
In the event of a transfusion reaction, the first thing to do is
stop the transfusion
Prevention is best, but also recall that early recognition leads
to better clinical outcomes
Understanding the profiles of TRALI versus TACO can not only
expedite appropriate patient care but also helps the blood bank and
blood provider be aware of transfusion-related complications
2015-APL-02503 73
References Andrzejewski CA, Popovsky MA, Stec TC. Measured and
derived vital sign changes in transfusion reactions
associated with fluid challenges. Transfusion 2008;48 Suppl:204A
Anesthesia UK Website Center for Biologics Evaluation and Research.
Fatalities reported to FDA. Following blood collection &
transfusion.
Annual summary for fiscal years 2005 and 2006. Rockville: CBER;
2008. Available from
http://www.fda.gov/Cber/blood/fatal0506.htm
David B. Haemovigilance: a comparison of three national systems.
27th Congress of the International Society of Blood Transfusion,
24-29 August 2002, Vancouver.
Eder and Chambers Arch Pathol Lab Med 2007; 131:708 Flesland
O.IntensiveCareMed.2007.Jun;33Suppl1S17-21 Gajic et al Crit Care
Med 2006; 34:S109 Lieberman L et al. TransfusMedRev.2013.Oct27(4)
Popovsky MA.Transfusion.1985.Nov25(6):573- 7. Popovsky et al
Immunohematol 1996; 12:87 Popovsky MA, Audet A, Andrzejewski C.
Transfusion-associated circulatory overload in orthopedic
surgery
patients: a multi-institutional study. Immunohematology
1996;12:87-9. Rana et al Transfusion 2006; 46:1478 Rizk A, Gorson
K, Kenny L, and Weinstein R: Transfusion-related acute lung injury
after the infusion of IVIG.
Transfusion 2001; 41:264-268. Skeate and Eastlund Curr Opin
Hematol 2007; 14:682
2015-APL-02503 74