Transfusion-associated circulatory overload in a pediatric intensive care unit: different incidences with different diagnostic criteria.

DeCloedt L, Emeriaud G, Lefebvre E, et al: Transfusion-associated circulatory overload in a pediatric intensive care unit: different incidences with different diagnostic criteria.

Transfusion 2018
Transfusion-associated circulatory overload (TACO) is a frequent and serious transfusion-related adverse reaction in adults. However the diagnostic criteria remain subject of debate, and are not adapted to children. The authors performed a retrospective observational study of consecutively transfused children over a one year period. Only prestorage leukoreduced AS-3 RBC units were used; and patients eligible if they received at least one RBC transfusion during their stay, regardless the volume of the transfusion. Patients were excluded if they were <40 weeks gestation, <3 days or >18 years of age, or had been admitted following labor. The authors’ objectives were to compare different criteria for TACO in the pediatric intensive care unit (PICU) and compared the incidence of TACO using these different criteria.
Data were collected from six hours prior to transfusion (time 0) and in three periods following transfusion: 6, 12 and 24 hours after time 0. The TACO criteria utilized was that of the 2013 International Society of Blood Transfusion (ISBT) which diagnose TACO when any four of five criteria are observed within six hours of transfusion completion: 1) acute respiratory distress, 2) tachycardia, 3) increased blood pressure, 4) acute or worsening pulmonary edema on frontal chest radiograph, and 5) evidence of positive fluid balance. The authors specified meeting these criteria in two ways: 1- use of well-established and published upper limits for vital signs according to age, radiology interpretation of radiographs and >+1mL for positive fluid balance, and 2 – using the patient’s worst values after transfusion compared to their baseline values (observed 6 hours prior transfusion) with 10% and 20% deterioration as thresholds in addition to radiology interpretation and positive fluid balance (> 1+mL). 144 patients received a transfusion, of which 8 were excluded for transfusion on ECMO, transfusion in the OR and death within an hour of transfusion. Data from 136 patients was analyzed.
At six hours post transfusion 63 (46%) of patients met TACO using the first criteria with only 4 (3%) meeting criteria using the 10% threshold and 2 (1.5%) using the 20% threshold. When including data from 12 and 24 hours post transfusion the incidence varied greatly, from 46-76% with the first criteria and from 3-20% and 1.5-12% for 10% and 20% thresholds. This study demonstrates great variability in the incidence of TACO when using different values and different intervals for diagnostic criteria. In this study the TACO incidence was high compared to the adult literature, questioning whether the criteria are too sensitive, and/or that the PICU patient is at higher risk. The wide range in results underscore the need for TACO definitions to be adapted for the pediatric patient.
This study is not without its limitations, however it highlights a critical lack of established criteria for TACO in pediatric patients. The development and validation of a new list of diagnostic criteria for TACO in children is warranted to allow for determination of the real incidence and clinical impact of TACO in critically ill children.

Jill M Cholette MD
Associate Professor of Pediatrics
Medical Director Pediatric Cardiac Care Center
University of Rochester, Golisano Children’s Hospital