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Difficulty: MediumHematology and Oncology

A 76-year-old man is hospitalized for symptomatic anemia. His past medical history is significant for severe chronic obstructive pulmonary disease (COPD), hypertension, and ischemic cardiomyopathy with a left ventricular ejection fraction of 35%. His hemoglobin is 6.4 g/dL. A transfusion of packed red blood cells is initiated. Two hours later, he develops acute shortness of breath and a cough producing frothy sputum.

Vital signs:
Temperature: 37.2°C (99.0°F)
Blood pressure: 170/95 mmHg
Pulse: 115/min
Respiratory rate: 26/min
Pulse oximetry: 88% on room air

Physical examination reveals markedly elevated jugular venous pressure. Lung auscultation demonstrates bilateral basilar crackles and diffuse expiratory wheezes. Cardiac auscultation reveals an S3 gallop and a regular tachycardia.

Which of the following is the most appropriate next step in management?

  1. A
    Discontinue the transfusion and administer inhaled albuterol
  2. B
    Pause the transfusion and administer oral acetaminophen
  3. Discontinue the transfusion and administer intravenous furosemideAnswer
  4. D
    Discontinue the transfusion and administer intravenous normal saline
  5. E
    Discontinue the transfusion and administer intravenous piperacillin-tazobactam

Answer

Discontinue the transfusion and administer intravenous furosemide
The correct answer addresses the patient's Transfusion-Associated Circulatory Overload (TACO). TACO is characterized by acute respiratory distress, hypertension, tachycardia, elevated jugular venous pressure, and pulmonary edema (manifesting as crackles and an S3 gallop) occurring during or within 6 hours of a blood transfusion. Patients with underlying cardiopulmonary disease (such as this patient's ischemic cardiomyopathy) are at the highest risk due to an inability to handle the rapid expansion of intravascular volume. The most appropriate initial step is to immediately discontinue the transfusion and administer a diuretic, such as intravenous furosemide, along with supplemental oxygen and ventilatory support if necessary.

Step-by-Step Solution

1
Analyze the patient's acute presentation during the blood transfusion.
The patient developed acute respiratory distress, hypertension, elevated jugular venous pressure, pulmonary crackles, wheezing, and an S3 gallop.
Identifying the specific clinical signs and vital sign derangements is essential to differentiate between the types of acute transfusion reactions.
2
Differentiate Transfusion-Associated Circulatory Overload (TACO) from other cardiopulmonary etiologies.
The combination of volume overload signs (elevated JVP, S3 gallop, severe hypertension) strongly points to TACO. This rules out Transfusion-Related Acute Lung Injury (TRALI), which typically presents with hypotension and no JVD, as well as a COPD exacerbation, which would lack the signs of acute heart failure.
Accurate diagnosis based on hemodynamics dictates the specific intervention required.
3
Determine the most appropriate next step in management.
The immediate required steps are to stop the transfusion, provide respiratory support (oxygen), and administer diuretics such as intravenous furosemide to reduce the excess intravascular volume.
Stopping the offending agent and addressing the profound volume overload are life-saving measures in TACO.

Key Concept

Transfusion-Associated Circulatory Overload (TACO) typically presents with acute respiratory distress, hypertension, tachycardia, and signs of cardiogenic pulmonary edema (elevated JVP, S3 gallop) during or shortly after a blood transfusion. Management involves stopping the transfusion, providing supplemental oxygen, and administering diuretics.
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Topics

Hematology and Oncology

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