Case Study O5: Adverse event following plasma transfusion

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  • Case Study O5 deals with a complication following plasma transfusion, specifically transfusion-associated circulatory overload (TACO).
  • The case has more of a clinical focus than some of the other cases and seemed timely since
    • several recent publications have focused on appropriate evidence-based use of FFP
    • the advent of transfusion safety officers and government regulations and standards for hospital transfusion services, has created an increased impetus to providing transfusion education beyond the laboratory to nurses and medical staff.
  • Because of its increased clinical focus, we especially ask clinical health professionals to improve the case by providing feedback anonymously or with attribution.
  • Case O5 is the fifth in the "Other cases" series of cases initially published elsewhere. The original cases form only the starting point for the TraQ cases and have been significantly altered and combined to illustrate various learning objectives.
  • Like all "Other cases", instead of focusing on serological investigations, Case O5 focuses on best practices and standards related to the case, for example:
    • clinical indications for FFP
    • pretransfusion compatibility testing requirements for plasma products such as FFP
    • monitoring patients being transfused

    • investigating and reporting adverse events.

Case Structure

Learning Outcomes

Upon completion of this exercise, participants should be able to do the following:

  1. List clinical indications for FFP.
  2. Discuss compatibility testing requirements for plasma.
  3. Discuss the role played by patient blood group records in pretransfusion testing, including their importance in preventing misidentification.
  4. Explain precautions related to the use of patient blood group records.
  5. Discuss standards and best practices related to
    1. confirming patient identity prior to administering a transfusion
    2. monitoring patients before, during, and after transfusion.
  6. Discuss best practices for investigating a suspected transfusion reaction.
  7. List transfusion complications that are mainly associated with respiratory distress
  8. Describe regulations and standards forreporting serious adverse events.

Original Cases

This case is a composite derived from 2 cases:

  1. Case study used to teach medical students at the University of Minnesota generously provided by Dr. Ted Eastlund. The case (unpublished) focuses on clinical symptoms and related laboratory data and leads medical students through the process of developing a differential diagnosis. Also included is how to diagnose and treat a transfusion-related complication (TACO) and learning related to appropriate transfusion therapy. The patient characteristics in Case O5 are derived from this case.
  2. Goldy D. Emergency! Circulatory overload secondary to blood transfusion. Am J Nurs 1998 Jul;98(7):33.


Special thanks to the following who kindly provided advice, information, and ideas for the case. The discussion benefits from their valuable input. (Any errors or misstatements are entirely those of the author.)

Thanks to the following hematopathologist for advice on the clinical uses of FFP and investigation of adverse events, including the differential diagnosis of TACO.

  • Gwen Clarke, MD FRCPC (Capital Health, University of Alberta, & Canadian Blood Services, Edmonton, AB)

Thanks to the following Canadian nurses for advice on aspects of administering and investigating transfusions:

  • Shelley Feenstra (Regional Blood Transfusion Clinician, Vancouver Coastal Health, Vancouver, BC)
  • Lina D'Onofrio (Clinical Nurse Specialist, Patient Safety, University Health Network, Toronto, ON)
  • Cindy Hyson (Transfusion Practice Nurse Coordinator, Nova Scotia Provincial Blood Coordinating Program, Halifax, NS)
  • Veronika Pulley (Blood Conservation Program Coordinator [ONTraC], Windsor Regional Hospital, Windsor, ON)
  • Amelie Rivard (Transfusion Safety Nurse, McGill University Health Centre, Montreal, PQ)
  • Bonnie Selcer (Transfusion Safety Nurse, S.M.B.D Jewish General Hospital, Montreal, PQ )
  • Anna Urbanek (Transfusion Safety Nurse, McGill University Health Centre, Montreal, PQ)

This case also benefits from discussions on the Canadian TSO mailing list "transfusion" regarding transfusion practices in Canada.

Case Scenario*

*revised from the originals


A 59 year old unemployed, unmarried, diabetic male (HL) with poor personal hygiene and a 3-year history of mild renal failure (thought to be diabetes-related) was admitted to the hospital because of chronic hemorrhoidal bleeding, inability to get out of bed, poor energy and dyspnea with very little exertion.

Past medical history includes

  • insulin-dependent diabetes since age 17
  • obesity (5 feet 5 inches, 220 lb/100 kg)
  • chronic bronchitis
  • large painful hemorrhoids for 2 years, with bright red bleeding at least weekly and treated with direct pressure, hot soaks, and home remedies. For the past month the hemorrhoids have bled daily.

HL lives alone and has refused to see a physician in the past year. His main diet consists of prepared dinners and junk food such as popcorn, potato chips, and diet cola. He likes his cola in big glasses of ice and chews the ice in bed while watching TV most of the day.

He has gradually become more and more fatigued and bedridden, experiences dyspnea on exertion, spends most days sitting in bed propped up by pillows, and makes numerous trips to the bathroom.HL says that he cannot lie flat in bed, and that every time he does he feels like he cannot get enough air and feels "panicky". Upon further questioning the patient admits that he drinks beer daily.

Medications:HL takes insulin but no medications for heart or kidney disease.

Admission Blood Test Results

Table 1. Admission blood tests (Patient HL)


Value (SI units - see conversion table)
(reference range*)


65 g/L (130-180 g/L)


0.192 (0.37-0.49)


28 pg (25-35 pg)


69 fl (78-100 fl)


320 g/L (310-370 g/L)

Platelet Count

356 x109/L (130-400 x109/L)

White Cell Count

8.2 x109/L (4.5-11x109/L)

Prothrombin Time

20 seconds (10-13 s)

INR 1.6 (0.9-1.2)
Activated Partial Thromboplastin Time 32 seconds (25-35 s)
Blood Urea Nitrogen 25 mmol/L (2.9-8.9 mmol/L)
Creatinine 221 µmol/L (70-120 µmol/L)

*A reminder that reference ranges vary depending on the age, sex, ethnicity and race of the test population, as well as the laboratory methods and instruments used to do the tests. By definition 5% of the population will fall outside the reference range.

Differential Diagnosis

The following process was used to diagnose and treat patient HL.

The peripheral smear showed microcytes, hypochromic red cells, normal lymphocyte, and ample platelets. This smear with the low MCV, combined with pagophagia-a form of pica associated with iron deficiency-and blood loss strongly suggested iron deficiency.

To confirm iron deficiency, the following tests were ordered (reference range):

  • iron: 3.04 µmol/L (10-8 µmol/L)
  • total iron binding capacity: 76.6 µmol/L (38-76 µmol/L)
  • ferritin: 16 µg/L (35 - 300 µg/L)


That evening the attending physician saw HL and scheduled an examination and possible minor hemorrhoid surgery for the next day. After reviewing the liver tests, the physician concluded that HL had alcoholic liver disease and its associated coagulopathy.

Due to the prolonged prothrombin time (20 s) and current mild bleeding, the physician decided to give HL plasma transfusions to correct his coagulopathy prior to surgery and ordered 5 units of FFP.

Transfusion Service Laboratory

HL had been tested once (5 years ago) and was on record as group A Rh positive with a negative antibody screen. The laboratory policy was to require an ABO/Rh typing on each new admission. Accordingly, the lab requested a blood specimen to confirm HL's ABO group before thawing and issuing the FFP. HL's new sample typed as group A Rh positive.

Plasma Transfusion
FFP #1

At 18:30 h the first unit of thawed FFP was brought to the ward by a porter. HL's vital signs had been taken prior to transfusion (20 minutes earlier) and were taken again at the start of the transfusion.

Two nurses verified patient identification information on the FFP unit with the information on HL's wristband and asked HL to state his first and last name. Because the hospital used a Typenex bracelet, they also confirmed that the Typenex number on the bracelet matched the one on the FFP. They verified that the donor unit information on the bag (blood supplier donor number and component type) matched the information on the hospital blood bank label.

Immediately after starting the transfusion, the date and start time were recorded on the Transfusion Record form and both nurses signed the form. One of the nurses stayed with HL for 5 minutes after the transfusion was started.

HL was told to call the nurses if he experienced possible symptoms of a transfusion reaction such as itchiness, feeling warm with a fever, chills, rash or hives, muscle aches, back pain, chest pain, headache, cough, or difficulty breathing.

One of the nurses returned about 15 minutes post-transfusion to take HL's vital signs, which were similar to those at the start of transfusion, and entered them on the Transfusion Record. Vital signs were taken and recorded hourly and upon completion of transfusion, as specified in the facility's transfusion protocol.

FFP #2

The second of the FFP transfusions was started about 15 minutes after completion of the first one at 21:50. Vital signs were not taken, but the nurse planned to take them one hour into the start of the second transfusion.

Approximately 15 minutes after infusion of FFP #2 began, HL began to develop these symptoms:

  • Extreme shortness of breath
  • Heart rate: 136/min.
  • Respiratory rate: 36/min.
  • BP: 180/105
  • Persistent cough, becoming very distressed with blue lips
  • Cold and sweaty
  • Chest pain (tightening sensation) that radiated to his arms and back

HL did not have any chills, fever, rash, hives, red urine, or hypotension. HL felt disoriented and confused but finally called for a nurse about 45 minutes into the transfusion after the chest pain started.

Upon discovering HL in extreme respiratory distress, the nurse quickly

  • stopped the transfusion
  • kept the IV open
  • examined the FFP blood bags and accompanying records to ensure that the plasma was the correct ABO group and was intended for HL
  • paged the on-call resident
  • called the transfusion service to report the reaction

The resident, who was nearing the end of an extended 30-hr. shift, asked the nurse for a portable chest x-ray and ECG STAT, ordered nasal oxygen, and ran from the on-call room to the bedside.

Physical examination revealed

  • widespread pulmonary rales up to his scapulae
  • jugular venous distension
  • large swollen lower legs with pitting edema

The resident concluded that HL was most likely suffering from transfusion-associated circulatory overload (TACO) secondary to the plasma transfusions and may be going into cardiac arrest.

Despite treatment, HL's condition deteriorated. He was intubated for desaturation, tachypnea, and rhonchi and died from myocardial infarction after a failed resuscitation attempt at 04:30 h.

Questions to be Considered

To test your knowledge and as an advance organizer for the discussion section, read and consider these questions:

  1. Can group-specific plasma be issued based on one historical blood group?
  2. What are some well accepted clinical indications for the use of FFP? (list 3 or 4)
  3. Are there standards related to supervising patients after a transfusion has started?
  4. Which types of adverse events require reporting to an external body?


Proceed to Discussion (includes interactive questions with feedback):


This case study presented a scenario of transfusion-associated circulatory overload that led to death. A possible contributing factor was that the nurse incorrectly considered the monitoring of vital signs to apply to the entire transfusion event, as opposed to each unit transfused. Some of the key learning points include:

  1. Determining clinical indications for FFP requires clinical judgement and review of current guidelines.
  2. The benefits of transfusion for each individual must be assessed against the risks.
  3. Policies on using historical blood group records for plasma transfusion are set by individual facilities.
  4. Clinical staff who administer transfusions must be trained and assessed in blood administration.
  5. Monitoring and documentation of vital signs must be done for each blood component transfused.
  6. Recognizing the signs and symptoms of a transfusion reaction and acting promptly and appropriately are critical to reducing serious consequences to transfusion recipients.
  7. Best practice for the immediate actions to take whenever a transfusion complication is suspected include stopping the transfusion-->maintaining IV access-->checking identity and compatibility ("right blood to right patient") -->notifying the physician and transfusion service-->investigating according to hospital policies and procedures.
  8. Blood safety standards exist for
    1. administering transfusions
    2. investigating suspected transfusion complications
    3. reporting suspected transfusion complications

Further Reading

Case study sources

Goldy D. Emergency! Circulatory overload secondary to blood transfusion. Am J Nurs 1998 Jul;98(7):33.


Abdel-Wahab OI, Healy B, Dzik WH. Effect of fresh-frozen plasma transfusion on prothrombin time and bleeding in patients with mild coagulation abnormalities. Transfusion. 2006 Aug;46(8):1279-85.

Andrzejewski C. Transfusion-associated adverse pulmonary sequelae: widening our perspective (editorial). Transfusion 2005 July;45: 1048-50.

Atkinson S. An audit of fresh frozen plasma transfusion use in the Royal Hospitals Trust (RGHT) (poster P12). Transfus Med 2006 Oct;16(s1):30.

BCSH Guidelines: Guidelines for the use of Fresh Frozen Plasma, Cryoprecipitate and Cryosupernatant Br J Haematol 2004; 126, 11-28.

Brunskill S, Doree C, A. Blest A, J. Murdock J, M. Roberts M, and D. Watson D. Bedside practice of blood transfusion - Where is the evidence? (poster P17) Transfus Med October 2006 Oct;16(s1):32.

CSA. Blood and blood components (Z902-04). Mississauga, Ontario Canadian Standards Association, 2004.

CSTM. Standards for Hospital Transfusion Services, v 2

Gajic O, Dzik WH, Toy P. Fresh frozen plasma and platelet transfusion for nonbleeding patients in the intensive care unit: benefit or harm? Crit Care Med. 2006 May;34(5 Suppl):S170?3.

Gajic O, Gropper MA, Hubmayr RD. Pulmonary edema after transfusion: how to differentiate transfusion-associated circulatory overload from transfusion-related acute lung injury. Crit Care Med 2006 May;34(5 Suppl):S109?13.

Holland LL, Brooks JP. Toward rational fresh frozen plasma transfusion: The effect of plasma transfusion on coagulation test results. Am J Clin Pathol. 2006 Jul;126(1):133?9.

Holland LL, Foster TM, Marlar RA, Brooks JP. Fresh frozen plasma is ineffective for correcting minimally elevated international normalized ratios. Transfusion 2005 Jul;45(7):1234?5.

Knippen MA. Transfusion-Related Acute Lung Injury: A rare but potentially lethal result of allogeneic blood transfusion, TRALI resembles acute respiratory distress syndrome. Early intervention can save lives. Am J Nurs 2006 Jun;106(6):61?4.

Luk C, Eckert KM,Barr RM,Chin-Yee IH. Prospective audit of the use of fresh-frozen plasma, based on Canadian Medical Association transfusion guidelines. CMAJ 2002 Jun 11; 166(12): 1539?40.

Lumadue JA, Boyd JS, Ness PM. Adherence to a strict specimen-labeling policy decreases the incidence of erroneous blood grouping of blood bank specimens. Transfusion. 1997 Nov-Dec;37(11-12):1169-72.

Pierce RN, Reich LM, Mayer K. Hemolysis following platelet transfusions from ABO-incompatible donors. Transfusion. 1985 Jan-Feb;25(1):60?2.

Popovsky MA, Audet AM, Andrzejewski C Jr. Transfusion-associated circulatory overload in orthopedic surgery patients: a multi-institutional study. Immunohematol 1996;12(2):87?9.

Shulman IA, Saxena S, Ramer L. Assessing blood administering practices. Arch Pathol Lab Med 1999;123(7):595?8.

Wallis JP, Dzik S. Is fresh frozen plasma overtransfused in the United States? Transfusion. 2004 Nov;44(11):1674?5.

Williamson LM, Lowe S, Love EM, Cohen H, Soldan K, McClelland DB, et al. Serious hazards of transfusion (SHOT) initiative: analysis of the first two annual reports. Br Med J 1999;319:16?9.

Zhou L, Giacherio D, Cooling L, Davenport RD. Use of B-natriuretic peptide as a diagnostic marker in the differential diagnosis of transfusion-associated circulatory overload. Transfusion 2005 Jul;45(7):1056-63.

Online resources

(also see individual discussion sections)

AABB: Composition and use of plasma components - presentation and speaker notes (AABB members only) (May 2006)

ASH and AABB Educational Session (2004): Silliman CC. TRALI


BCSH. The administration of blood and blood components and the management of transfused patients (1999)

Bloody Easy Online Course (Sunnybrook & Women's College HSC, Toronto, Ontario, Canada)Canadian Blood Services:

Case 108 - Transfusion reaction (University of Pittsburgh)

CBBS e-Network Forum

EU directive and haemovigilance (Angela Robinson, UK NBS medical director)

FDA. Guidance for Industry. Notifying FDA of Fatalities Related to Blood Collection or Transfusion

International Haemovigilance Network

Public Health Agency of Canada. User's Manual. Canadian Transfusion Adverse Event Reporting Form (April 2004) | More...

Iron deficiency anaemia (

TraQ: Informed Consent (Resource Library)