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A 15-month old toddler is seen in the ED with pallor and decrease in activity. History reveals that the child eats very little solid food and receives most of his nutrition from drinking six 8-ounce bottles of whole milk daily. His hemoglobin is found to be 3.1 g/dL, and he is given a transfusion of PRBCs 10 mL/kg over 2 hours. He is discharged home to follow up with his PCP but returns 3 hours later with shortness of breath. Exam now reveals: lung exam – rales and wheezes. Cardiac exam: tachycardia and an S3 gallop rhythm but no hypotension. Abdominal exam: liver 3cm below right subcostal margin. CXR shows bilateral patchy infiltrates and mild cardiomegaly. There is no rash or angioedema. He is afebrile. O2 sat is 90% on room air.
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July 23, 2024 at 9:18 pm
A) Transfusion-associated circulatory overload (TACO)
TACO is more commonly seen in young children who receive a larger volume at a faster rate. It presents with respiratory distress within 12 hours of the transfusion, and there may be physical exam signs of fluid overload, pulmonary edema on CXR, and elevated BNP. An exclusive cow’s milk diet can lead to iron deficiency anemia. Anemia develops chronically, and transfusion should be in smaller aliquots – read more here. TRALI is ARDS-like, develops within 6 hours of transfusion, and is not related to the volume of transfusion. Anaphylactic reactions typically rapid onset soon after the transfusion is initiated, and may include urticaria, respiratory distress, wheezing, angioedema, and hypotension. Acute hemolytic transfusion reactions occur within 24 hours of the transfusion and may present with fever, hypotension, back or flank pain, bleeding, and evidence of hemolysis on labs. If the transfused product is contaminated, transfusion-associated sepsis can occur, which presents similar to other sources of sepsis.