C lick to edit Master text styles Test Transfusion Associated - - PowerPoint PPT Presentation

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Transfusion Associated Circulatory Overload

Anna Bartholomew – Specialist Transfusion Practitioner Northumbria Healthcare NHS Foundation Trust Wansbeck General Hospital

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TestTAC

O

• ccurs

when a patient's circulatory system is unable to handle an increase in circulatory volume Leads to pulmonary oedema R isk factors:

C ardiac failure R enal Impairment Hypoalbuminaemia or fluid overload Aged more than 70 years Low body weight

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TestInternational S

• ciety of Blood Transfusion (IS

BT) definition states that TAC O includes any 4 of the following that occur within 6 hours

• f transfusion

Acute respiratory distress Tachycardia Increased blood pressure Acute or worsening pulmonary oedema E vidence of positive fluid balance

2014 S HOT R eport informs us definitions

• f TAC

O are being reviewed

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Masters Level Degree Project to manage TAC O always been of interest C

• llaboration with Denise

Prompt for NC A Decided on an audit R ecognition of transfusion associated circulatory

• verload in patients

aged over 70 years R etrospective audit over a 3 month period in 2012

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To determine:

Incidence of TAC O within the Trust Is under-reporting indicated? Observable links to TAC O in patients aged over 70 years If an framework would assist with the prescribing

• f blood components

for this vulnerable group of patients

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Availability and accessibility of patient s notes Layout of notes and information Multiple volumes

• f notes

Large number of patients Lack of relevant documentation

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Age of patient Male / F emale Weight of patient Location of patient at time of transfusion If a diuretic was prescribed in advance of the transfusion R ecorded on fluid balance chart Any evidence of TAC O if so, was it reported within Trust / S HOT

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247 patients, accounting for 526 blood components 170/247 (69% ) were aged over 80yrs 107 Males 140 F emales

170 29 48 70 - 74 years 75- 79 years

• ver 80 years

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183/247 had a weight recorded (74% ) 110/183 (60% ) weighed less than 70kg Lowest weight recorded was 34kg!

Patient's weight

20 40 60 80 100 120 <70 kg 71 - 80kg >80 kg Weight in kgs Num ber of patients Number of patients

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Location of patient

5 10 15 20 25 30 35 Medicine Respiratory medicine Gynaecology Community day case Surgical assessment unit Ambulatory care Stroke unit Cardiology Intensive Care / HDU Palliative Care Unit Haematology Oncology day unit Community ward Emergency Care (A&E) Medical admissions unit General surgery Theatre / recovery Elderly care Orthopaedics

Number of episodes

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28/247 (11% ) were prescribed a diuretic in advance of the transfusion A further 9 patients (4% ) required a diuretic as a result of the transfusion

100 292 97 20 50 100 150 200 250 300 Number of units < 60 mins 90 mins 120 mins 180 mins Prescription rate

Prescription rate of units

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Only 56/247 episodes, accounting for 92 units were recorded Not all units in the episode were recorded, e.g. one but not the other Many incomplete charts No charts used

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Test8 cases

• f possible TAC

O Not identified at the time, so not reported to S HOT 5/8 weighed less than 70kg; 2/8 had no weight recorded 8/8 aged over 80 years 6 F emales; 2 Males S uggestion of high incidence of under reporting

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Patient ID Units transfused Diuretic in advance Full observations History of cardiac failure History of renal impairment 1

2 x x

2

3 x

3

2 x x

4

2 x x

5

2 x x x

6

3 x x

7

2 x x x

8

2 x x

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Male patient aged 87 Admitted to MAU through A&E Patient weighed 69.8kgs Hb 62 g/ L 2 units RBC’s prescribed Pt developed acute respiratory distress Increased blood pressure Acute/ worsening pulmonary oedema all within 6 hours NO fluid balance chart present History of AF and Hypoalbuminaemia

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Review was requested of ward medical staff after the transfusion had completed IV Furosemide 80mgs given to patient Hb checked and a further unit was given the next day with 2 x Furosemide 40mgs given to the patient before and after No reference to TACO or fluid overload documented following this episode No Datix/ SHOT report

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emale patient aged 86 weight 53.9Kgs

• n Gynae

Prescribed 2 units

• f blood for Hb of 75g/L

actively bleeding Acute respiratory distress Tachycardia Acute/worsening pulmonary oedema E vidence of positive fluid balance Within 6 hours

• f Transfusion

History of C ardiac Failure and F luid Overload

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Units recorded on fluid balance chart Pt reviewed by ward Medics and commenced on 35% O2 and required 40mgs Furosemide after 1st unit and at 3am However not documented in patient s notes

Not reported to Lab/S TP/TTT/HTC No Datix and not reported

to S HOT

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Male pt aged 80+ weight not recorded Haematology Patient admitted with active UGI Bleed Hb 76g/L Pt developed AR D Acute/worsening pulmonary oedema E vidence of positive fluid balance Within 6 hours

• f transfusion

Patient had history of cardiac failure and fluid overload

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Pt reviewed by ward medical staff Transfusion stopped part way through 2nd unit Oxygen commenced unable to determine % given Diuretic administered Documented in the patients notes Not reported to Lab/S TP/TTT/HTC No Datix and not reported to S HOT

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F emale pt aged 85 weighed 70 Kgs Hb 79g/L Orthopaedic pt Given 2 units

• f R

BC 's Pt developed increased S OB Increased BP Acute or worsening pulmonary oedema Had evidence of positive fluid balance not within 6 hours but 2 days later E arlier in 2012 evidence of heart failure on previous admission for pulmonary oedema

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Daily dose of 20mgs furosemide Pt developed post transfusion crackles

• n auscultation
• f the chest with a ?pulmonary oedema diagnosis

Patient had only 1 kidney 2LO2 commenced via nasal cannulae No additional furosemide to daily dose administered Patient had received 2 x 1L N S aline over 12 hours but this had not been recorded on the fluid balance chart and blood was not recorded either Not reported to Lab/S TP/TTT

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nsure staff:

R ecord the patients weight C

• mplete a fluid balance chart

C

• nsider diuretic cover

Monitor for TAC O at all times

Present findings at appropriate meetings S uggest a NC A Develop an algorithm Advocate use of single unit transfusions where appropriate P BM R esources S ize Matters Don t give 2

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Poster presentation at BBTS in 2014 in C linical Transfusion and Hospital Laboratory Practice and Patient Blood Management category Develop algorithm for use P ublish findings NC A to take place in autumn 2016

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F emale Patient 80 years + 34Kgs #NOF Hb (106) reduced due to blood loss in theatre 2.5 Litres positive crystalloid fluid prior to commencement of blood transfusion 2 units

• f blood in Theatre further 6 units

the next day

And Finally...No TACO!

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Any questions?