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Abu Yousef Y, Bagchee-Clark A, Walters K, Green M, Salib M, Chander A, Law MP, Refaei M. Reducing Unnecessary Transfusions of RBCs in Inpatients Admitted Across Niagara Health Community Hospitals. Qual Manag Health Care 2024:00019514-990000000-00067. [PMID: 38414260 DOI: 10.1097/qmh.0000000000000442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
BACKGROUND AND OBJECTIVES Blood products are scarce resources. Audits on the use of red blood cells (RBCs) in tertiary centers have repeatedly highlighted inappropriate use. Earlier retrospective audit at our local community hospitals has demonstrated that only 85% and 54% of all requests met Choosing Wisely Canada guidelines for pre-transfusion hemoglobin (Hb) of 80 g/L or less and single unit, respectively.We sought to improve RBC utilization by 15% over a period of 12 months (meeting Choosing Wisely Canada criteria of pre-transfusion Hb ≤80g/L by >80% and single-unit transfusion by >65%). METHODS Following repeated PDSA (Plan-Do-Study-Act) cycles, we implemented educational strategies, prospective transfusion medicine (TM) technologist-led screening of orders, and an RBC order set. RESULTS The 3-month median percentages of appropriate RBC use for pre-transfusion Hb and single unit (September-November 2021) across all 3 hospitals were 90% and 71%, respectively. Overall, the rate of appropriate RBCs based on pre-transfusion Hb remained above target (>80%), with minimal improvement across all hospitals (median percentage at pre- and post-technologist screening periods of 87% and 90%, respectively). The median percentage of appropriate RBCs based on single-unit transfusion orders has improved across all Niagara Health hospitals with sustained targets (3-month median percentage at pre- and post-technologist screening and most recent time periods of 54%, 56%, and 71%, respectively). CONCLUSIONS We have taken a collaborative, multifaceted approach to optimizing utilization of RBCs across the Niagara Health hospitals. The rates of appropriate RBC use were comparable with the provincial and national accreditation benchmark standards. In particular, the TM technologist-led screening was effective in producing sustained improvement with respect to single-unit transfusion. One of the balancing outcomes was increasing workload on technologists. Local and provincial efforts are needed to facilitate recruitment and retention of laboratory technologists, especially in community hospitals.
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Affiliation(s)
- Yazan Abu Yousef
- Author Affiliations: Michael G. DeGroote Medical School, McMaster University, Hamilton, Ontario, Canada (Messrs Yousef and Bagchee-Clark); Department of Laboratory Medicine (Mss Walters and Green), Department of Oncology (Dr Salib), Department of Laboratory Medicine & Pathology (Dr Chander), and Division of Hematology and Thrombosis, Department of Oncology (Dr Refaei), Niagara Health, St Catharines, Ontario, Canada; and Department of Health Sciences, Brock University, St Catharines, Ontario, Canada (Dr Law)
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2
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Smith CM. CE: Recognizing Transfusion-Associated Circulatory Overload. Am J Nurs 2023; 123:34-41. [PMID: 37882401 DOI: 10.1097/01.naj.0000995356.33506.f5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
ABSTRACT Transfusion-associated circulatory overload (TACO) is the leading cause of transfusion-related deaths in the United States, accounting for more than 30% of fatalities reported to the Food and Drug Administration between 2016 and 2020. However, TACO is widely considered to be an underdiagnosed and underreported complication of blood transfusions, and its exact incidence is unknown. One of the reasons for this is a lack of recognition of TACO and its signs and symptoms, especially as the definition of TACO has been updated twice since 2018 without full dissemination to nurses, who are responsible for bedside care of patients during and following blood transfusions. This article seeks to bridge this gap by discussing the updated definitions and signs and symptoms of TACO, as well as the management of this treatable blood transfusion reaction.
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Affiliation(s)
- Christy M Smith
- Christy M. Smith is chief nursing executive at Versafusion Medical, a mobile infusion service, in Johnson City, TN. Contact author: . The author and planners have disclosed no potential conflicts of interest, financial or otherwise
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3
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Bulle EB, Klanderman RB, Pendergrast J, Cserti-Gazdewich C, Callum J, Vlaar APJ. The recipe for TACO: A narrative review on the pathophysiology and potential mitigation strategies of transfusion-associated circulatory overload. Blood Rev 2021; 52:100891. [PMID: 34627651 DOI: 10.1016/j.blre.2021.100891] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/24/2021] [Accepted: 09/24/2021] [Indexed: 12/31/2022]
Abstract
Transfusion associated circulatory overload (TACO) is one of the leading causes of transfusion related morbidity and mortality. TACO is the result of hydrostatic pulmonary edema following transfusion. However, up to 50% of all TACO cases appear after transfusion of a single unit, suggesting other factors, aside from volume, play a role in its pathophysiology. TACO follows a two-hit model, in which the first hit is an existing disease or comorbidity that renders patients volume incompliant, and the second hit is the transfusion. First hit factors include, amongst others, cardiac and renal failure. Blood product factors, setting TACO apart from crystalloid overload, include colloid osmotic pressure effects, viscosity, pro-inflammatory mediators and storage lesion byproducts. Differing hemodynamic changes, glycocalyx injury, endothelial damage and inflammatory reactions can all contribute to developing TACO. This narrative review explores pathophysiological mechanisms for TACO, discusses related therapeutic and preventative measures, and identifies areas of interest for future research.
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Affiliation(s)
- Esther B Bulle
- Department of Intensive Care, University of Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands; Laboratory for Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), University of Amsterdam, Amsterdam UMC, the Netherlands.
| | - Robert B Klanderman
- Department of Intensive Care, University of Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands; Laboratory for Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), University of Amsterdam, Amsterdam UMC, the Netherlands.
| | - Jacob Pendergrast
- Laboratory Medicine Program, University Health Network, Toronto, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada.
| | - Christine Cserti-Gazdewich
- Laboratory Medicine Program, University Health Network, Toronto, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada.
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Queen's University and Kingston Health Sciences Centre, Canada.
| | - Alexander P J Vlaar
- Department of Intensive Care, University of Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands; Laboratory for Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), University of Amsterdam, Amsterdam UMC, the Netherlands.
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4
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Rodrigues DM, Djerboua M, Flemming JA. Intravenous Albumin in Patients With Cirrhosis: Evaluation of Practice Patterns and Secular Trends of Usage in Ontario 2000 to 2017. J Can Assoc Gastroenterol 2021; 4:179-185. [PMID: 34337318 PMCID: PMC8320267 DOI: 10.1093/jcag/gwaa027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/20/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Intravenous (IV) albumin has evidence-based indications in cirrhosis that are limited in most guidelines to spontaneous bacterial peritonitis (SBP), type 1 hepatorenal syndrome (HRS) and large volume paracentesis (LVP).This study aimed to describe the trends of IV albumin usage in patients with cirrhosis at the population level and evaluate indications for IV albumin in the hospital setting. METHODS A retrospective study identified albumin infusions in health care data from Ontario, Canada between 2000 and 2017 in those with and without cirrhosis. Annual rates of IV albumin by cirrhosis status were calculated per 10,000 person-years (PY) and described using Poisson regression and rate ratios. Secondly, patients with cirrhosis receiving IV albumin while hospitalized at Kingston Health Sciences Centre (KHSC) in 2017 were identified and underwent detailed chart abstraction to determine the reason for IV albumin administration. RESULTS The overall rate of provincial IV albumin usage doubled over the study period (2000: 8.4/10,000 PY versus 2017: 16.3/10,000 PY; rate ratio 1.94, 95% confidence interval 1.90 to 1.99, P <0.001). The majority of albumin was used during hospitalization (88%) and 22% was used in patients with cirrhosis. At KHSC, there were134 admissions where a patient with cirrhosis received IV albumin. Of these, 49% of prescriptions were for evidence-based indications (LVP 30%, type 1 HRS 10%, SBP 10%), whereas other indications included non-HRS renal failure, hypovolemia and sepsis. CONCLUSION IV albumin use has doubled over two decades and is frequently used in hospitalized patients with cirrhosis with only 50% being prescribed for evidence-based indications. These results highlight the impact of cirrhosis on albumin use and highlight potential quality improvement opportunities.
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Affiliation(s)
| | | | - Jennifer A Flemming
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
- ICES, Queen’s University, Kingston, Ontario, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
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5
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Graham CA, DuBois D, Gleason C, Kumagai J, Sanford J. Identifying and Understanding Transfusion Reactions in the Oncology Population. Semin Oncol Nurs 2021; 37:151137. [PMID: 33745801 DOI: 10.1016/j.soncn.2021.151137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To provide an overview of transfusion reactions, their underlying pathophysiology, clinical presentation, and recommendations for nursing management. DATA SOURCES We researched peer-reviewed journal articles, book chapters, Internet, and lecture proceedings. CONCLUSION Transfusion reactions are adverse reactions to blood products frequently seen in the oncology population and can significantly vary in severity and etiology. Oncology nurses are in a critical position to assist with prevention, early detection, and time-sensitive treatment of transfusion reactions. IMPLICATIONS FOR NURSING PRACTICE The oncology nurse's comprehensive understanding of possible transfusion reactions and management recommendations is key for optimal care of the oncology patient.
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Affiliation(s)
- Carrie A Graham
- Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA.
| | - Danielle DuBois
- Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Christine Gleason
- Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Joy Kumagai
- Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Jeannine Sanford
- Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
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6
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Khandelwal A, Lin Y, Cserti-Gazdewich C, Al Moosawi M, Armali C, Arnold D, Callum J, Dallas KL, Lieberman L, Pavenski K, Rioux-Massé B, Shehata N, Shih AW, Pendergrast J. TACO-BEL-3: a feasibility study and a retrospective audit of diuretics for patients receiving blood transfusion at ten hospitals. Vox Sang 2020; 116:434-439. [PMID: 33103789 DOI: 10.1111/vox.12994] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 07/03/2020] [Accepted: 08/08/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Transfusion-associated circulatory overload (TACO) is the leading cause of transfusion-related morbidity and mortality. A recently completed pilot trial randomized patients to pre-transfusion furosemide versus placebo but had a slower than expected enrollment rate. We sought to determine whether the lack of recruitment was due to a paucity of eligible patients or excessively restrictive eligibility criteria. MATERIALS AND METHODS At 10 sites, eligible patients were retrospectively identified by first screening blood bank databases over one month for all transfusion episodes meeting trial inclusion criteria, defined as non-surgical patients receiving single RBC unit transfusions. The age threshold was decreased from 65 to 50 years. The first 10 patients meeting inclusion criteria then underwent detailed chart review for the exclusion criteria. The incidence of TACO and furosemide use was also recorded. RESULTS At the 10 sites, 11 969 red cell units were transfused over 1 month and 1356 met the inclusion criteria. Of the 100 charts reviewed, 60 (60%) had no exclusion criteria. Active bleeding was the most common reason for ineligibility. There were 813 eligible transfusion episodes. Of the eligible patients, 17 (28·3%) had evidence of congestive heart failure, and furosemide was prescribed in 24 (40%). Despite the use of a lower age threshold, three cases of TACO were detected with an incidence of 3%. CONCLUSION A large number of transfusion episodes met eligibility criteria. With a 3% incidence of TACO, 50% decrease through the use pre-transfusion furosemide and a target consent rate of 30%, a definitive trial of approximately 3000 patients could be completed within 1 year.
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Affiliation(s)
- Aditi Khandelwal
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,Laboratory Medicine Program, University Health Network, Toronto, ON, Canada.,Canadian Blood Services, Toronto, ON, Canada.,Education and Safety in Transfusion (QUEST) Research Program, University of Toronto Quality in Utilization, Toronto, ON, Canada
| | - Yulia Lin
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,Education and Safety in Transfusion (QUEST) Research Program, University of Toronto Quality in Utilization, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Christine Cserti-Gazdewich
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,Laboratory Medicine Program, University Health Network, Toronto, ON, Canada.,Education and Safety in Transfusion (QUEST) Research Program, University of Toronto Quality in Utilization, Toronto, ON, Canada
| | - Muntadhar Al Moosawi
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Chantal Armali
- Education and Safety in Transfusion (QUEST) Research Program, University of Toronto Quality in Utilization, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Donald Arnold
- Hamilton General Hospital, Hamilton, ON, Canada.,Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Jeannie Callum
- Laboratory Medicine Program, University Health Network, Toronto, ON, Canada.,Education and Safety in Transfusion (QUEST) Research Program, University of Toronto Quality in Utilization, Toronto, ON, Canada
| | - Karen L Dallas
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada.,St. Paul Hospital, Vancouver, BC, Canada
| | - Lani Lieberman
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,Laboratory Medicine Program, University Health Network, Toronto, ON, Canada.,Education and Safety in Transfusion (QUEST) Research Program, University of Toronto Quality in Utilization, Toronto, ON, Canada
| | - Katerina Pavenski
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,Education and Safety in Transfusion (QUEST) Research Program, University of Toronto Quality in Utilization, Toronto, ON, Canada.,St Michael's Hospital, Toronto, ON, Canada
| | | | - Nadine Shehata
- Laboratory Medicine Program, University Health Network, Toronto, ON, Canada.,Canadian Blood Services, Toronto, ON, Canada.,Education and Safety in Transfusion (QUEST) Research Program, University of Toronto Quality in Utilization, Toronto, ON, Canada.,Mount Sinai Hospital, Toronto, ON, Canada
| | - Andrew W Shih
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada.,Vancouver General Hospital, Vancouver, BC, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, BC, Canada
| | - Jacob Pendergrast
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,Laboratory Medicine Program, University Health Network, Toronto, ON, Canada.,Education and Safety in Transfusion (QUEST) Research Program, University of Toronto Quality in Utilization, Toronto, ON, Canada
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7
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Bolton‐Maggs PHB, Watt A. Transfusion errors — can they be eliminated? Br J Haematol 2019; 189:9-20. [DOI: 10.1111/bjh.16256] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 09/03/2019] [Accepted: 09/04/2019] [Indexed: 12/14/2022]
Affiliation(s)
| | - Alison Watt
- Serious Hazards of Transfusion Manchester Blood Centre Manchester UK
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8
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Herbert L, Ribar A, Mitchell S, Phillips C. Discovering metformin-induced vitamin B12 deficiency in patients with type 2 diabetes in primary care. J Am Assoc Nurse Pract 2019; 33:174-180. [PMID: 31651584 DOI: 10.1097/jxx.0000000000000312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 07/19/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Although metformin is the preferred initial pharmacological choice in type 2 diabetes, there is evidence that reveals a link between metformin use and vitamin B12 deficiency. The American Diabetes Association (ADA) has recently recommended periodic measurement of B12 levels for all patients on metformin. LOCAL PROBLEM Medical record data collected for the preintervention period showed that only 5% (n = 23) of patients diagnosed with diabetes and on metformin had B12 levels checked at an internal medicine primary care practice. METHODS This was a quasi-experimental project of preintervention and postintervention design using a checklist containing important measures of diabetes control. The project sample population consisted of data of adults with type 2 diabetes aged 18 years and older who were prescribed metformin in the previous year at the primary care practice. INTERVENTIONS The intervention focused on revising an existing diabetes measures checklist to include a prompt for an annual measurement of B12 levels. RESULTS There was significant improvement in monitoring vitamin B12 levels and discovery of low vitamin B12 levels. These data show that the number of B12 levels checked increased from 23 during the preintervention to 155 during the intervention (p ≤ 0.0000). CONCLUSIONS This project supports a conclusion that including a prompt to check B12 levels to an existing checklist increases B12 monitoring in this patient population. Results may encourage other providers to follow the ADA guidelines for monitoring vitamin B12 levels for patients taking metformin.
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Affiliation(s)
- Laura Herbert
- Midlands Internal Medicine, Columbia, South Carolina
- University of South Carolina, College of Nursing, Columbia, South Carolina
| | - Alicia Ribar
- University of South Carolina, College of Nursing, Columbia, South Carolina
| | - Sheryl Mitchell
- University of South Carolina, College of Nursing, Columbia, South Carolina
| | - Cynthia Phillips
- Midlands Internal Medicine, Columbia, South Carolina
- University of South Carolina, College of Pharmacy, Columbia, South Carolina
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9
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Pendergrast J, Armali C, Cserti-Gazdewich C, Hansen M, Kiss A, Lieberman L, Parmar N, Scales D, Skeate R, Callum J, Lin Y. Can furosemide prevent transfusion-associated circulatory overload? Results of a pilot, double-blind, randomized controlled trial. Transfusion 2019; 59:1997-2006. [PMID: 30924166 DOI: 10.1111/trf.15270] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 01/20/2019] [Accepted: 01/20/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Transfusion-associated circulatory overload (TACO) is a leading cause of transfusion-attributable morbidity. It is unclear whether diuretics are safe and effective in preventing this reaction. MATERIALS AND METHODS In a pilot controlled feasibility trial, inpatients 65 years or older ordered a single unit of red blood cells were randomized to pre-transfusion furosemide 20 mg or placebo intravenously. Primary outcome was the ability to enroll 80 patients within a 2-month time period. Secondary feasibility outcomes included proportion of RBC transfusions meeting eligibility criteria, proportion of eligible patients enrolled, and compliance to study protocol. Clinical outcomes included the incidence of TACO and associated complications. RESULTS Nine months of enrollment were required for 80 patients to complete the study, due primarily to fewer transfusions than expected meeting eligibility criteria and lower than anticipated consent rates. Protocol compliance was below target due to missing chart documentation of patient fluid balance, and transfusion infusion time. Blinding was maintained throughout the study and treatment arms were well-balanced. A single case of TACO occurred in each arm, for an overall incidence of 2.5%. No differences in peri-transfusion vital signs, B-natriuretic peptide, or signs of furosemide toxicity were observed. CONCLUSION The study protocol was not feasible as designed, primarily due to challenges in patient enrollment. Modifications to trial design to improve feasibility in future studies have been identified.
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Affiliation(s)
- Jacob Pendergrast
- University Health Network, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | | | | | - Mark Hansen
- University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Alex Kiss
- Institute of Clinical and Evaluative Sciences, Toronto, Ontario, Canada
| | - Lani Lieberman
- University Health Network, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | | | - Damon Scales
- University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Jeannie Callum
- University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Yulia Lin
- University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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10
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Abstract
: In the United States, roughly 4.5 million patients per year receive transfusions of various blood products. Despite the lifesaving benefits of transfusion therapy, it is an independent risk factor for infection, morbidity, and death in critically ill patients. It's important for nurses to understand the potential complications patients face when blood products are administered and to recognize that patients who have received blood products in the past remain at risk for delayed reactions, including immune compromise and infection. Here, the authors review the blood products that are commonly transfused; discuss potential complications of transfusion, as well as their associated signs and symptoms; and outline current recommendations for transfusion therapy that are widely supported in the medical and nursing literature.
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11
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Transfusion-Associated Circulatory Overload: A Clinical Perspective. Transfus Med Rev 2019; 33:69-77. [PMID: 30853167 DOI: 10.1016/j.tmrv.2019.01.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/20/2019] [Accepted: 01/26/2019] [Indexed: 01/28/2023]
Abstract
For 30 years, transfusion-associated circulatory overload (TACO) has been recognized as a serious transfusion complication. Currently, TACO is the leading cause of transfusion-related morbidity and mortality worldwide which occurs in 1% to 12% of at-risk populations. Despite an incomplete understanding of the underlying pathophysiology, TACO is defined as a collection of signs and symptoms of acute pulmonary edema due to circulatory overload occurring within 6 to 12 hours of transfusion. In the past decade, large observational cohort studies resulted in better insight into the associated transfusion risk factors leading to the development of TACO. In this clinical review, we critically analyze the pathogenesis of TACO, associated risk factors, clinical presentation, diagnostic modalities, and treatment options to guide clinicians with early detection of this syndrome and intervention to improve clinical outcomes. Future research should focus on better understanding of the pathogenesis to help advance the field of volume kinetics and endothelial barrier function.
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12
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Soril LJJ, Noseworthy TW, Dowsett LE, Memedovich K, Holitzki HM, Lorenzetti DL, Stelfox HT, Zygun DA, Clement FM. Behaviour modification interventions to optimise red blood cell transfusion practices: a systematic review and meta-analysis. BMJ Open 2018; 8:e019912. [PMID: 29776919 PMCID: PMC5961610 DOI: 10.1136/bmjopen-2017-019912] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To assess the impact of behaviour modification interventions to promote restrictive red blood cell (RBC) transfusion practices. DESIGN Systematic review and meta-analysis. SETTING, PARTICIPANTS, INTERVENTIONS Seven electronic databases were searched to January 2018. Published randomised controlled trials (RCTs) or non-randomised studies examining an intervention to modify healthcare providers' RBC transfusion practice in any healthcare setting were included. PRIMARY AND SECONDARY OUTCOMES The primary outcome was the proportion of patients transfused. Secondary outcomes included the proportion of inappropriate transfusions, RBC units transfused per patient, in-hospital mortality, length of stay (LOS), pretransfusion haemoglobin and healthcare costs. Meta-analysis was conducted using a random-effects model and meta-regression was performed in cases of heterogeneity. Publication bias was assessed by Begg's funnel plot. RESULTS Eighty-four low to moderate quality studies were included: 3 were RCTs and 81 were non-randomised studies. Thirty-one studies evaluated a single intervention, 44 examined a multimodal intervention. The comparator in all studies was standard of care or historical control. In 33 non-randomised studies, use of an intervention was associated with reduced odds of transfusion (OR 0.63 (95% CI 0.56 to 0.71)), odds of inappropriate transfusion (OR 0.46 (95% CI 0.36 to 0.59)), RBC units/patient weighted mean difference (WMD: -0.50 units (95% CI -0.85 to -0.16)), LOS (WMD: -1.14 days (95% CI -2.12 to -0.16)) and pretransfusion haemoglobin (-0.28 g/dL (95% CI -0.48 to -0.08)). There was no difference in odds of mortality (OR 0.90 (95% CI 0.80 to 1.02)). Protocol/algorithm and multimodal interventions were associated with the greatest decreases in the primary outcome. There was high heterogeneity among estimates and evidence for publication bias. CONCLUSIONS The literature examining the impact of interventions on RBC transfusions is extensive, although most studies are non-randomised. Despite this, pooled analysis of 33 studies revealed improvement in the primary outcome. Future work needs to shift from asking, 'does it work?' to 'what works best and at what cost?' PROSPERO REGISTRATION NUMBER CRD42015024757.
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Affiliation(s)
- Lesley J J Soril
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Thomas W Noseworthy
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Laura E Dowsett
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Katherine Memedovich
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Hannah M Holitzki
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Diane L Lorenzetti
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Henry Thomas Stelfox
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - David A Zygun
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, Alberta Health Services and Faculty of Medicine and Dentistry, University of Alberta, Calgary, Alberta, Canada
| | - Fiona M Clement
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
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13
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Lin Y, Cohen R, Armali C, Callum J, Cserti-Gazdewich C, Lieberman L, Pendergrast J. Transfusion-associated circulatory overload prevention: a retrospective observational study of diuretic use. Vox Sang 2018. [DOI: 10.1111/vox.12647] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Y. Lin
- Department of Clinical Pathology; Sunnybrook Health Sciences Centre; Toronto ON Canada
- Department of Laboratory Medicine & Pathobiology; University of Toronto; Toronto ON Canada
- University of Toronto QUEST Research Program; Toronto ON Canada
| | - R. Cohen
- Department of Clinical Pathology; Sunnybrook Health Sciences Centre; Toronto ON Canada
- University of Toronto QUEST Research Program; Toronto ON Canada
- Laboratory Medicine Program; University Health Network; Toronto ON Canada
| | - C. Armali
- Department of Clinical Pathology; Sunnybrook Health Sciences Centre; Toronto ON Canada
- University of Toronto QUEST Research Program; Toronto ON Canada
- Laboratory Medicine Program; University Health Network; Toronto ON Canada
| | - J. Callum
- Department of Clinical Pathology; Sunnybrook Health Sciences Centre; Toronto ON Canada
- Department of Laboratory Medicine & Pathobiology; University of Toronto; Toronto ON Canada
- University of Toronto QUEST Research Program; Toronto ON Canada
| | - C. Cserti-Gazdewich
- Department of Laboratory Medicine & Pathobiology; University of Toronto; Toronto ON Canada
- University of Toronto QUEST Research Program; Toronto ON Canada
- Laboratory Medicine Program; University Health Network; Toronto ON Canada
| | - L. Lieberman
- Department of Laboratory Medicine & Pathobiology; University of Toronto; Toronto ON Canada
- University of Toronto QUEST Research Program; Toronto ON Canada
- Laboratory Medicine Program; University Health Network; Toronto ON Canada
| | - J. Pendergrast
- Department of Laboratory Medicine & Pathobiology; University of Toronto; Toronto ON Canada
- University of Toronto QUEST Research Program; Toronto ON Canada
- Laboratory Medicine Program; University Health Network; Toronto ON Canada
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Roberts DJ. Expanding access to Transfusion Medicine and improving practice: guidelines, patient blood management, protocols and products. Transfus Med 2017; 27 Suppl 5:315-317. [PMID: 29076249 DOI: 10.1111/tme.12484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- D J Roberts
- National Health Service Blood and Transplant, University of Oxford, John Radcliffe Hospital, Oxford, UK
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