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Difficulty: MediumHematology and Oncology

A 72-year-old man is evaluated on postoperative day 2 following a partial colectomy for recurrent diverticulitis. His postoperative course was complicated by surgical site oozing, resulting in a hemoglobin drop to 6.8 g/dL. His past medical history is significant for chronic obstructive pulmonary disease (COPD) and ischemic cardiomyopathy with a left ventricular ejection fraction of 35%. He is currently receiving his second unit of packed red blood cells when he develops sudden-onset severe dyspnea and a dry cough. Temperature is 37.8°C (100.0°F), blood pressure is 175/95 mm Hg, pulse is 115/min, and respirations are 26/min. Pulse oximetry shows 88% on room air. Physical examination reveals an elevated jugular venous pressure of 12 cm H2O. Lung auscultation demonstrates bilateral basilar crackles with scattered expiratory wheezing. Cardiac auscultation reveals a regular tachycardia with a prominent S3 gallop. The transfusion is immediately stopped. Which of the following is the most appropriate next step in management?

  1. A
    Administer inhaled albuterol and systemic corticosteroids
  2. B
    Initiate intravenous broad-spectrum antibiotics
  3. C
    File an incident report regarding the transfusion rate
  4. Administer intravenous furosemideAnswer
  5. E
    Obtain a urinalysis and urine culture

Answer

Administer intravenous furosemide
This patient is experiencing Transfusion-Associated Circulatory Overload (TACO). TACO occurs when a large volume of blood products is administered rapidly, overwhelming the patient's cardiovascular capacity. It is especially common in older patients with underlying left ventricular dysfunction (e.g., ischemic cardiomyopathy with LVEF 35%). The presentation mimics acute decompensated heart failure, characterized by acute dyspnea, hypertension, tachycardia, elevated jugular venous pressure, crackles, and an S3 gallop. The first step in management is to immediately stop the transfusion, provide supplemental oxygen, and administer loop diuretics like intravenous furosemide to reduce preload and clear pulmonary edema.

Step-by-Step Solution

1
Analyze the onset of symptoms and vital signs.
The patient developed acute hypoxia, dyspnea, and hypertension during a blood transfusion.
Timing strongly suggests a transfusion reaction; hypertension narrows the differential toward volume overload.
2
Correlate vital signs with physical examination findings.
Elevated JVP, bilateral crackles, and a prominent S3 gallop in a patient with a low ejection fraction confirm cardiogenic pulmonary edema.
These findings reliably distinguish Transfusion-Associated Circulatory Overload (TACO) from Transfusion-Related Acute Lung Injury (TRALI) or other non-cardiogenic causes of hypoxia.
3
Determine the therapeutic intervention for the diagnosed condition.
The indicated treatment for TACO is intravenous furosemide.
Diuretics rapidly decrease intravascular volume and relieve pulmonary congestion, which is the root cause of the patient's acute respiratory failure.

Key Concept

Diagnosis and management of Transfusion-Associated Circulatory Overload (TACO)
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Topics

Hematology and Oncology

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