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Difficulty: MediumHematology and Oncology

An 81-year-old man is admitted to the medical ward for symptomatic anemia secondary to newly diagnosed myelodysplastic syndrome. He is currently receiving his second unit of packed red blood cells. Approximately two hours after the initiation of the second transfusion, he develops sudden, severe shortness of breath and an upright posture preference.

Vital signs show a temperature of 37.1 °C (98.8 °F), blood pressure of 182/105 mmHg, heart rate of 115/min, and respiratory rate of 28/min. Oxygen saturation is 84% on room air. Physical examination reveals prominent jugular venous distension. Lung auscultation demonstrates bilateral crackles extending to the mid-lung fields. Cardiac auscultation reveals a normal S1 and S2 with a distinct third heart sound (S3).

Which of the following is the most appropriate initial step in the management of this patient's acute symptom onset?

  1. A
    Administer inhaled albuterol and intravenous methylprednisolone
  2. B
    Cease the transfusion and administer intravenous fluid boluses
  3. C
    Cease the transfusion and administer broad-spectrum intravenous antibiotics
  4. Cease the transfusion and administer intravenous furosemideAnswer
  5. E
    Administer intravenous calcium gluconate

Answer

Cease the transfusion and administer intravenous furosemide
This patient is presenting with classic signs of transfusion-associated circulatory overload (TACO). TACO is a form of cardiogenic pulmonary edema that occurs when a patient's cardiovascular system cannot handle the excess fluid volume from a blood product transfusion, particularly in elderly patients or those with underlying cardiac or renal dysfunction. It is characterized by acute respiratory distress, hypertension, tachycardia, jugular venous distension (JVD), and a third heart sound (S3). The presence of hypertension and hypervolemia (JVD, S3) are key distinguishing factors from transfusion-related acute lung injury (TRALI), which typically presents with hypotension and lacks signs of fluid overload. The appropriate initial management of TACO includes immediately ceasing the transfusion, providing supplemental oxygen, and administering a rapid-acting loop diuretic such as intravenous furosemide to reduce intravascular volume.

Step-by-Step Solution

1
Analyze the patient's acute symptoms during a blood transfusion.
The patient developed acute respiratory distress, severe hypertension (182/105 mmHg), jugular venous distension (JVD), and an S3 gallop.
Identifying the specific hemodynamic and respiratory parameters is crucial to distinguish between various types of severe transfusion reactions.
2
Differentiate between TRALI and TACO.
The presence of hypertension, JVD, and an S3 gallop confirms hypervolemia, leading to a diagnosis of Transfusion-Associated Circulatory Overload (TACO) rather than Transfusion-Related Acute Lung Injury (TRALI), which typically features hypotension and no signs of volume overload.
TACO and TRALI both present with acute respiratory distress during or shortly after a transfusion, but their management strategies are completely opposite.
3
Determine the most appropriate initial management for TACO.
The transfusion must be stopped immediately, and intravenous furosemide should be administered.
TACO is a form of cardiogenic pulmonary edema; treatment requires offloading the excess intravascular volume through rapid diuresis and providing respiratory support.

Key Concept

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

Hematology and Oncology

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