Lani Lieberman

A Retrospective Review of Patient Factors, Transfusion Practices, and Outcomes in Patients With Transfusion-Associated Circulatory Overload

Transfusion-associated circulatory overload (TACO) is a common yet underrecognized and underreported complication of transfusion associated with significant morbidity and mortality. The objective of this study was to examine patient and transfusion characteristics in a cohort of TACO cases. A retrospective medical record review of 100 consecutive TACO episodes reported at 2 academic centers was performed. Information related to demographics, medical history, radiologic and echocardiographic investigations, infusion practices, reaction features, management, and outcome were collected. Ninety-eight cases were accessible for review. A history of congestive heart failure (41%), renal dysfunction (44%), and age more than 70 years (56%) were common in TACO patients. Suboptimal fluid status management and inappropriate infusion practices were often seen (eg, verbal orders, double red cell transfusions, rapid infusion rates, lack or improper timing of preemptive diuretics). The median volume of blood ordered was 500 mL, and the median volume of crystalloid or colloid (preceding 24 hours) was 2200 mL. A physician order specifying the infusion rate was documented in 50% of transfusion orders. Preemptive diuretics were ordered in only 29% of cases, most commonly introduced midway or after the transfusion at a dose of furosemide 20 mg intravenously. After TACO, 18% of patients required transfer to the intensive care unit, 8% suffered a major complication, and 2% died. Suboptimal ordering and infusion practices may be contributing to the high incidence and severity of TACO. Research in TACO prevention strategies, such as slow rates of infusion and preemptive diuretics, is warranted.

Transfusion-related lung injury in children: a case series and review of the literature

Transfusion‐related acute lung injury (TRALI) is the leading cause of transfusion‐related mortality. The majority of the literature involves adult patients. The main objective of this study was to characterize the demographic features, clinical presentation, patient outcomes, and antibody profiles of TRALI patients reported to the Canadian Blood Service (CBS) and to assess similarities and differences between adult and pediatric TRALI cases.

Platelet transfusions for critically ill patients with thrombocytopenia

#### Continuing Medical Education online This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Medscape, LLC and the American Society of Hematology. Medscape

Antenatal management in fetal and neonatal alloimmune thrombocytopenia: A systematic review

Several strategies can be used to manage fetal or neonatal alloimmune thrombocytopenia (FNAIT) in subsequent pregnancies. Serial fetal blood sampling (FBS) and intrauterine platelet transfusions (IUPT), as well as weekly maternal IV immunoglobulin infusion (IVIG), with or without additional corticosteroid therapy, are common options, but optimal management has not been determined. The aim of this systematic review was to assess antenatal treatment strategies for FNAIT. Four randomized controlled trials and 22 nonrandomized studies were included. Pooling of results was not possible due to considerable heterogeneity. Most studies found comparable outcomes regarding the occurrence of intracranial hemorrhage, regardless of the antenatal management strategy applied; FBS, IUPT, or IVIG with or without corticosteroids. There is no consistent evidence for the value of adding steroids to IVIG. FBS or IUPT resulted in a relatively high complication rate (consisting mainly of preterm emergency cesarean section) of 11% per treated pregnancy in all studies combined. Overall, noninvasive management in pregnant mothers who have had a previous neonate with FNAIT is effective without the relatively high rate of adverse outcomes seen with invasive strategies. This systematic review suggests that first-line antenatal management in FNAIT is weekly IVIG administration, with or without the addition of corticosteroids.

Evaluating appropriate red blood cell transfusions: a quality audit at 10 Ontario hospitals to determine the optimal measure for assessing appropriateness

Evaluating the appropriateness of red blood cell (RBC) transfusion requires labor‐intensive medical chart audits and expert adjudication. We sought to determine the appropriateness of RBC transfusions at 10 hospitals using retrospective chart review and to determine whether simple metrics (proportion of single‐unit transfusions, RBCs/100 acute inpatient days, proportion of transfusions with pretransfusion hemoglobin <80 g/L or posttransfusion hemoglobin <90 g/L) could be used as surrogate markers of appropriateness by comparing their values with the results from the audit.

Prevention of transfusion-transmitted cytomegalovirus (CMV) infection: Standards of care

L. Lieberman, D. V. Devine, H. W. Reesink, S. Panzer, J. Wong, T. Raison, S. Benson, J. Pink, G. C. Leitner, M. Horvath, V. Compernolle, P. S. Prado Scuracchio, S. Wendel, G. Delage, S. Nahirniak, X. Dongfu, T. Krusius, E. Juvonen, S. Sainio, J.-P. Cazenave, P. Guntz, D. Kientz, G. Andreu, P. Morel, E. Seifried, K. Hourfar, C. K. Lin, J. O’Riordan, E. Raspollini, S. Villa, P. Rebulla, P. Flanagan, D. Teo, S. Lam, A. L. Ang, M. Lozano, S. Sauleda, J. Cid, A. Pereira, B. Ekermo, C. Niederhauser, S. Waldvogel, S. Fontana, M. J. Desborough, R. Pawson, M. Li, H. Kamel, M. Busch, L. Qu & D. Triulzi

Consent for blood transfusion: Do patients understand the risks and benefits?

Blood transfusion is a frequent medical intervention in hospitals. The benefits of, risks of and alternatives to blood transfusions are not consistently understood by patients. The objective of this study was to assess gaps in knowledge and comfort with the current process of consenting patients for blood transfusions. A standardised video regarding the risk and benefits of blood transfusions was developed and feedback regarding this tool was assessed.

How to use: the direct antiglobulin test in newborns

The direct antiglobulin test (DAT) detects the presence of immunoglobulin, complement or both bound to the red blood cell membrane. The test, historically called the ‘Coombs test’, was first described in 1945 by Cambridge immunologist Robin Coombs. Suspected haemolytic disease of the newborn, due to either Rhesus disease or ABO incompatibility, is one of most common reasons for requesting a DAT in newborns. In this article, we discuss the physiological background and technological background of the DAT. We also provide a clinical framework for a rational approach to the use and interpretation of the DAT in newborns.

Prothrombin Complex Concentrate for Major Bleeding on Factor Xa Inhibitors: A Prospective Cohort Study

Oral factor Xa inhibitors are increasingly used for anticoagulation, but there is no approved reversal agent. Prothrombin complex concentrate (PCC) for the management of Xa-inhibitor-associated bleeding has been described in small case series and one cohort study. Patients on apixaban or rivaroxaban, suffering a major bleed, were treated at nine Canadian hospitals as per existing hospital protocol with a fixed dose of PCC 2,000 units and subsequently recruited for a 30-day follow-up. The treating physician evaluated the haemostatic effectiveness as observed during the first day as good, moderate or poor/none, using an assessment guide. Safety outcomes were thromboembolism or death. We recruited 66 patients with major bleeding who were treated with PCC and who were receiving rivaroxaban (56%) or apixaban (44%). The effectiveness was assessed as good in 65% (95% confidence interval [CI], 53-77), moderate in 20% (95% CI, 10-30) and poor/none in 15% (95% CI, 6-24). For the 36 patients with intracranial haemorrhage, the corresponding ratings were 67, 17 and 17%, and for 16 patients with gastrointestinal bleeding they were 69, 12 and 19%, respectively. There were nine deaths (14%) by 30 days, and five (8%) major thromboembolic events. In a post hoc analysis, according to International Society on Thrombosis and Haemostasis criteria, reversal was effective in 68% and ineffective in 32%. For major bleeding associated with oral Xa inhibitors, PCC may have a beneficial effect. The risk of thromboembolism after reversal of anticoagulation in patients with a prothrombotic background has to be taken into account.

The association of fever with transfusion-associated circulatory overload.

Fever is described in transfusion‐associated circulatory overload (TACO), reflecting either comprehensive haemovigilance or an inflammatory pathobiology (such as congestion‐associated atheroma disruptions).