Contemporary Risk Factors and Outcomes of Transfusion-Associated Circulatory Overload

Abstract

Objectives: Transfusion-associated circulatory overload is characterized by hydrostatic pulmonary edema following blood transfusion. Restrictive transfusion practice may affect the occurrence and severity of transfusion-associated circulatory overload in critically ill patients. We sought to examine contemporary risk factors and outcomes for transfusion-associated circulatory overload.

Design: Case-control study.

Setting: Four tertiary care hospitals.

Patients: We prospectively enrolled 200 patients with transfusion-associated circulatory overload identified by active surveillance and 405 controls matched by transfusion intensity.

Interventions: None.

Measurements and main results: Among 20,845 transfused patients who received 128,263 blood components from May 2015 until July 2016, transfusion-associated circulatory overload incidence was one case per 100 transfused patients. In addition to cardiovascular comorbidities, multivariable analysis identified the following independent predictors of transfusion-associated circulatory overload: acute kidney injury, emergency surgery, pretransfusion diuretic use, and plasma transfusion-the latter especially in females. Compared with matched controls, transfusion-associated circulatory overload cases were more likely to require mechanical ventilation (71% vs 49%; p < 0.001), experienced longer intensive care and hospital lengths of stay following transfusion, and had higher mortality (21% vs 11%; p = 0.02) even after adjustment for other potentially confounding variables.

Conclusions: Despite restrictive transfusion practice, transfusion-associated circulatory overload remains a frequent complication of transfusion and is an independent risk factor for in-hospital morbidity and mortality. In addition to cardiovascular and renal risk factors, plasma transfusion was associated with transfusion-associated circulatory overload after controlling for other covariates. Additional research is needed to examine the benefit of reduced erythrocyte or plasma exposure in patients at high risk for transfusion-associated circulatory overload.

Figure 1

Cumulative incidence of in-hospital mortality (Figure 1a), being discharged alive from the intensive care unit (Figure 1b), and being discharged alive from the hospital (Figure 1c) for TACO cases (dotted line) and transfused controls without pulmonary edema (solid line). Analyses counted from the time of transfusion until death or discharge at 50 days.

Figure 1

Cumulative incidence of in-hospital mortality (Figure 1a), being discharged alive from the intensive care unit (Figure 1b), and being discharged alive from the hospital (Figure 1c) for TACO cases (dotted line) and transfused controls without pulmonary edema (solid line). Analyses counted from the time of transfusion until death or discharge at 50 days.

Figure 1

Cumulative incidence of in-hospital mortality (Figure 1a), being discharged alive from the intensive care unit (Figure 1b), and being discharged alive from the hospital (Figure 1c) for TACO cases (dotted line) and transfused controls without pulmonary edema (solid line). Analyses counted from the time of transfusion until death or discharge at 50 days.