CLINICAL FEATURE

KEYWORDS Transfusion associated circulatory overload / TACO / Student operating department practitioner /
Transfusion reaction / Post anaesthetic care unit
Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication August 2013.

Transfusion associated
circulatory overload: a
critical incident
by E Goodall
Correspondence address: c/o The Association for Perioperative Practice, Daisy Ayris House, 42 Freemans Way, Harrogate, HG3 1DH. Email emcgoodall@gmail.com

Transfusion associated circulatory overload (TACO) is a serious but under-recognised

complication of blood transfusion. While the exact incidence rate is unknown the associated
morbidity and mortality make this a transfusion reaction worthy of attention. This article provides
details of a critical incident involving TACO followed by a literature review and discussion written
from the perspective of a student ODP. The goal of this article is to raise awareness of TACO
amongst hospital staff to facilitate faster recognition and earlier intervention in future events.
Introduction
A 39 year old female who had undergone
a mastectomy and lattisimus dorsi flap
reconstruction two days previously was
admitted to theatre for an evacuation
of haematoma from the reconstructed
breast. The evacuation of haematoma
was carried out under general anaesthetic
and the procedure was uneventful and
short, lasting only 35 minutes. During this
procedure the patient sustained minimal
blood loss but was transfused with four
units of fresh frozen plasma (FFP) and two
units of red blood cells (RBC). Following
surgery the patient was admitted into the
post anaesthetic care unit (PACU). An
uncomplicated recovery was expected
and PACU staff were instructed to record
standard postoperative observations with
the addition of observations specific to the
flap reconstruction, such as colour and
temperature. Prescribed analgesia was to
be administered as required in line with
local protocols.

Critical incident
Upon admission to the PACU, standard
non-invasive monitoring equipment was
attached and four litres per minute of
oxygen administered to the patient via a
Hudson face mask. The patient was initially
stable but soon became breathless and
congested with her oxygen saturation,
which had previously been 98%, falling
to 79%. Her blood pressure elevated to

190/120 and heart rate rose to 150 beats

per minute. The patient was transferred to
humidified oxygen, delivered at 40% which
was then increased to 100% with no effect.
The patient was then administered a saline
nebuliser, again with no effect. Medical
help was requested and a full brief given
to the medical team upon their arrival.
The patients chest was auscultated by
medical staff and pulmonary oedema due to
transfusion associated circulatory overload
(TACO) was suspected. A chest x-ray was
obtained, which confirmed a diagnosis of
pulmonary oedema. IV fluids were ceased
and 20mg IV furosemide administered
raising the patients saturation to 84%.
During the time the patients respiratory
distress was being treated, the breast flap
site had darkened and become cold to the
touch. The operating surgeon was informed
and it was decided to return the patient
to theatre. Following theatre the patient
remained ventilated and was transferred to
the intensive care unit.

Literature review
Weinstein (2006) describes TACO as being
pulmonary oedema induced by blood
products being transfused too rapidly or in
excessive volumes. In healthy lungs, fluid
leaks through gaps between endothelial
cells into the interstitial space, where
it is drained by the lymphatic system. If
pulmonary vessel blood volume is greatly
increased, more fluid shifts resulting in

January/February 2014 / Volume 24 / Issue 1 & 2 / ISSN 1750-4589

pulmonary oedema (Ware & Matthay

2005). When transfusions are given to
treat coagulopathies or anaemia there may
be no fluid volume requirement and so
patients circulatory systems can become
overwhelmed, resulting in TACO (Dougherty
& Lamb 2008).
Several pieces of literature discuss the
incidence of TACO. The latest Serious
Hazards of Transfusion (SHOT) report
provides transfusion reaction figures for
2011. Of the reported reactions 3.9% were
attributed to TACO, 5.2% to haemolytic
transfusion reactions (HTRs) and 32.3% to
acute transfusion reactions (ATRs). Of these
reactions, eight resulted in death - four
attributed to TACO and two to ATRs.
The major morbidities resulting from these
reactions numbered 117: ATRs were
responsible for 53, TACO for 24 and HTRs
for 11 (SHOT 2011). However, several
studies suggest that the incidence of TACO
may be far greater than reported, with
results ranging between 1 and 8% of all
transfusions (Gajic et al 2006, Popovsky
2007, Li et al 2011).
The most recent study carried out (Narick
et al 2012) performed a one month
surveillance of all FFP transfusions taking
place in a single hospital. Out of 84
transfusions, no reactions were reported
by staff, but four were identified by the
surveillance.

15

CLINICAL FEATURE

Transfusion associated circulatory overload: a critical incident

Continued

A number of papers comment upon the

causes of TACO. As previously mentioned,
TACO can be triggered by massive
transfusions, although Popovsky (2007)
notes that it can be precipitated by as little
as one unit. Narick et al (2012) suggest
that FFP carries a greater risk of overload
than other components as large volumes
are generally required for adults, even in the
absence of fluid loss. They also note that,
although rapid infusion is cited as inducing
TACO, few studies provide guidance on safe
rates, although Taylor (2008) advises a rate
of <1ml/min for high risk patients.
Having a clinical profile for at risk patients
can aid practitioners with recognition.
Popovsky (2006) and Taylor (2008) both
report that the most at risk patients are
those under the age of three or aged over
60. Popovsky (2009) however disagrees
with this age range, stating that TACO is
not restricted only to the young or elderly,
but can occur at any age. Mealer & Lareau
(2012) add the critically ill, renal failure and
heart failure patients to the at risk category.
But according to Tinegate et al (2012) and
the BCSH (2012), all patients who develop
respiratory distress in the absence of shock,
post-transfusion should be considered for
TACO regardless of demographic.
Many pieces of literature discuss the
symptoms associated with TACO, but in
order to recognise these, care givers must
pay close attention to monitoring and be
able to understand implications of vital
sign changes (Andrzejewski & Mcgirr 2007,
Thompson et al 2008a). The following list of
signs and symptoms are widely agreed upon
within the literature:
Hypertension
Tachycardia
Cyanosis
Jugular venous distension
Rales and crackles upon chest
auscultation
Pulmonary oedema
Raised central venous pressure (CVP)
Nausea and vomiting
Altered pulse pressure
Positive response to diuretics and
Respiratory distress, recognising
the latter as the most indicative
symptom (Andrzejewski & Popovsky
2005, Skeate & Eastlund 2007,
Popovsky 2008, Taylor 2008,
Thompson et al 2008b).
16

Bux & Sachs (2008) illustrate a diagnostic

checklist, stating that TACO should be
considered if four of the following five
symptoms occur within six hours of
transfusion:
Respiratory distress
Tachycardia
Hypertension
Pulmonary oedema and
Evidence of positive fluid balance.
Two papers deal with the subject
of temperature in relation to TACO:
Springhouse (2007) reports that mild
pyrexia is a sign of TACO, whereas Bux
& Sachs (2008) state that temperatures
remain unchanged. Andrzejewski et al
(2012) conducted a study which evaluated
the use of different vital sign trends when
diagnosing TACO, they found a strong
correlation between pulse pressure
variances and the developing stages of
TACO and suggest that an assessment tool
could be devised from these results.
Early treatment for TACO is important
to reduce mortality and morbidity and
several papers provide advice on the topic.
Dougherty and Lamb (2008) and Hillyer et
al (2009) advise:
Sit the patient upright
Cease fluids
Administer supplemental oxygen
Call for medical support
Administer a diuretic and
Obtain a chest x-ray to confirm
pulmonary oedema.
The authors also say that some patients
may require intubation and positive
pressure ventilation. Tinegate et al (2012)
advocate the same treatment but add that,
if a wheeze is present without upper airway
obstruction, consider nebulizing salbutamol.

Discussion
The description of TACO supplied by
Weinstein (2006) aptly sums up the
condition and could easily be used to raise
awareness of the entity, allowing caregivers
to recognise, diagnose and therefore treat
TACO. If the recovery staff involved in this
incident had been aware of TACO and
also aware that transfusions given without
accompanying fluid requirement were a risk
factor, earlier interventions may have been
made for this patient.

When analysing the SHOT (2011) figures,

TACO could be considered the least
influential of the three transfusion reactions
discussed, but it should be noted that
TACO results in a much higher proportion of
morbidity and mortality than the other two
reactions. The figures can be questioned
though, as the lack of awareness of TACO
may mean that it is often undiagnosed
and therefore underreported. Likewise, the
high morbidity and mortality rates could be
due to lack of awareness leading to poorer
management, and not because TACO is
more harmful.
The studies displaying a higher incidence
of TACO can also be questioned. They do
not state the diagnostic criteria used and
they also included all patients exhibiting
TACO symptoms, without taking other comorbidities that could be causing the same
symptoms into account. Narick et al (2012)
also conducted their study only over a one
month period, meaning that their results are
not easily generalised. Although we cannot
be sure of the exact incidence of TACO at
this current time, the reported reactions
demonstrate that TACO is significant and
that care givers should be aware of it.
The combination of TACO being triggered by
even a single unit of FFP and the recovery
room being an area receiving high volumes
of recently transfused patients, make this
a high risk area where staff should be
particularly vigilant. The patient in question
receiving four units of FFP during a short
procedure, corresponds with reports that
FFP transfused too rapidly induces TACO
and this could have been a warning sign
to staff. While the infusion rate advised by
Taylor (2008) is useful, it would not have
aided this patient, who was not in the high
risk category.
The age ranges of high risk patients
illustrated in the literature deviate. The
papers indicating the young and the elderly
to be most at risk do not reference the
source of this data, whereas Popovsky
(2009) gained their data from official
reports in Canada. It could be concluded
that the latter is more reliable, but
considering there is dubiety regarding the
frequency of TACO, it is best not to rule any
age category as low risk until more reliable
data is confirmed. The patient in question
had none of the high risk co-morbidities

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CLINICAL FEATURE

Perhaps the most significant point raised by the literature is the

importance of recognising vital sign changes

cited in the literature so these indicators do

not apply, but if it were standard practice to
consider all patients developing respiratory
distress post-transfusion for TACO, suitable
interventions may have been initiated more
promptly.
The literature discussing the symptoms of
TACO is of varying degrees of usefulness.
The papers examining temperature report
only minimal changes at most, meaning
that pyrexia cannot reliably be considered a
symptom of TACO. The study recommending
pulse pressure as a good diagnostic tool
was carried out in a short time period in
only one institution, meaning that further
research would have to be completed
before these results are generalisable.
The paper indicating a positive response
to diuretics as a good diagnostic tool is
accurate but should be used with caution
as a reduced fluid volume can be harmful
to patients experiencing other pulmonary
transfusion reactions (Tinegate et al 2012).
Perhaps the most significant point raised
by the literature is the importance of
recognising vital sign changes. Much of
the morbidity and mortality associated with
transfusion arises from caregivers failure
to recognise adverse reactions (Higgins &
Jones 2013) and increased awareness of
the symptoms could significantly reduce
this. The list of signs and symptoms of TACO
is useful but extensive and so the shortened
list proposed by Bux & Sachs (2008) is
more workable as a diagnostic checklist.
The patient being discussed exhibited all
five items on this list and if this checklist
had already been in use, the event may
have progressed differently. The treatments
advised in the literature are simple
interventions that can mostly be performed
by non-medical staff. The treatment given
during the critical incident differed only
slightly from the advice of the literature,
with the patient being administered a saline
nebuliser as opposed to the suggested
salbutamol, but as salbutamol requires
a prescription, saline was a practical
substitute until medical help arrived.
Perhaps the most critical treatment cited
by the literature is the cessation of fluids,
which in this case were not stopped until
the patients chest was auscultated by
medical staff. If it were standard practice for
recovery staff to auscultate they may have

identified the pulmonary oedema and halted

fluids earlier. Diuretics could also have been
administered earlier if medical staff had
been alerted to the possibility of oedema
upon arrival at the scene, meaning that the
patient may have suffered less overload
associated trauma.

Conclusion
The literature contains all the knowledge
required to recognise and manage TACO,
but as no official guidelines have been
published, no single source displays all
of this knowledge. One important point
highlighted by the literature is the need
for increased awareness, as recognition is
difficult without a true understanding of the
entity. This need was reflected in clinical
practice as none of the recovery staff caring
for the patient were aware of TACO and
so did not have the knowledge to initiate
appropriate interventions.
This leads to the second important topic
raised in the literature: treatments. Sitting
the patient upright, cessation of fluids and
administration of supplemental oxygen
and diuretics seem to be the most crucial
interventions. All of these treatments were
carried out by staff during this incident
but some were unnecessarily delayed,
highlighting the need for improved TACO
training.
Further research on TACO is required to
ascertain the most common symptoms,
best treatments and implications of
subsequent transfusions for sufferers.
This research should be carried out in
multiple sites over a long time period
to allow the results to be generalised.
Part of this research should address the
unreliability of reported figures. This could
be achieved by supplying a simple audit
form charting vital sign changes with every
unit of blood. Completing this research will
allow diagnostic tools and treatment flow
charts to be developed to facilitate staff
training, which is currently confined to ATRs
and HTRs. This training would be easy and
cost effective to implement using the NHS
learnPro system.
Staff must operate within their scope of
practice, but non-invasive clinical skills like
auscultation can be learnt from medics if
staff are proactive and seek out educational

January/February 2014 / Volume 24 / Issue 1 & 2 / ISSN 1750-4589

opportunities. Skills like these would aid

caregivers in recognising adverse events
to flag to medical staff, thereby increasing
patient safety.

References
Andrzejewski C, McGirr J 2007 Evaluation and
management of suspected transfusion reactions:
nursing perspectives In: Transfusion reactions
Bethesda MD, American Association of Blood
Banks Press
Andrzejewski C, Popovsky MA 2005 Transfusionassociated adverse pulmonary sequelae: widening
our perspective Transfusion 45 (7) 1048-50
Andrzejewski C, Popovsky MA, Stec TC et al 2012
Hemotherapy bedside biovigilance involving
vital sign values and characteristics of patients
with suspected transfusion reactions associated
with fluid challenges: can some cases of
transfusionassociated circulatory overload have
proinflammatory aspects? Transfusion 52 (11)
2310-20
British Committee for Standards in Haematology
2012 Guideline on the investigation and
management of acute transfusion reactions
Available from: www.bcshguidelines.com/
documents/ATR_final_version_to_pdf.pdf
[Accessed September 2013]
Bux J, Sachs UJ 2008 Pulmonary transfusion
reactions Transfusion Medicine and
Hemotherapy 35 (5) 337-45
Dougherty L, Lamb J 2008 Intravenous therapy in
nursing practice Ontario, Wiley-Blackwell
Gajic O, Gropper MA, Hubmayr RD 2006
Pulmonary edema after transfusion: how to
differentiate transfusion-associated circulatory
overload from transfusion related acute lung
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Higgins D, Jones D 2013 Ensuring patient safety in
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Hillyer CD, Abrams CS, Shaz BH et al 2009
Transfusion medicine and hemostasis: clinical
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Li G, Rachmale S, Kojicic M et al 2011 Incidence
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intensive care unit patients Transfusion 51 (2)
338-43
Mealer M, Lareau SC 2012 The lungs in a
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transfusion: TRALI and TACO Transfusion and
Apheresis Science 34 (3) 243-4

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CLINICAL FEATURE

Transfusion associated circulatory overload: a critical incident

Continued

Popovsky MA 2007 Circulatory overload In:

Transfusion reactions Bethesda MD, American
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Thompson CL, Edwards C, Stout L 2008a Blood

transfusions 1: how to monitor for adverse
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About the author

Emma Goodall
2nd Year Operating Department Practitioner Student
Glasgow Caledonian University

No competing interests declared

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Taylor C 2008 Transfusion associated circulatory

overload Manchester, SHOT

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January/February 2014 / Volume 24 / Issue 1 & 2 / ISSN 1750-4589

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