An 18-month-old girl is brought to the emergency department due to decreased energy. Over the last 2 months, the parents have noticed that she tires easily after play, and the fatigue has steadily worsened. The patient has been drinking 1,080 mL (36.5 oz) of cow's milk daily since transitioning from breast milk at age 12 months. She is a picky eater. Examination is unremarkable other than notable pallor. Hemoglobin is 2.3 g/dL. Stool occult blood is negative. The patient is admitted to the hospital for iron deficiency anemia due to poor dietary intake and receives 20 mL/kg of packed red blood cells over 3 hours. An hour after completion, she develops respiratory distress. Temperature is 37.1 C (98.8 F), blood pressure is 130/60 mm Hg, pulse is 160/min, and respirations are 44/min. Pulse oximetry is 89% on room air. The patient is grunting with retractions. Cardiac examination shows tachycardia with an S3 gallop but no friction rub. Lung examination shows diffuse crackles bilaterally. She is placed on oxygen. Which of the following is the best next step in management of this patient?
Transfusion-associated circulatory overload | |
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Transfusion-associated circulatory overload (TACO) is a reaction that occurs when a large volume of blood product is rapidly transfused, leading to fluid overload. Patients with cardiac or renal disorders, as well as children age <3 and patients age >60 with chronic anemia, are at increased risk. For instance, toddlers with severe, chronic iron deficiency anemia due to excessive milk consumption (>24 oz/day) and poor intake of iron-rich foods are susceptible to TACO, as seen in this patient.
Symptoms of TACO develop within 6 hours of transfusion initiation and include respiratory distress (eg, dyspnea, tachypnea), hypertension, tachycardia, and/or pulmonary edema (eg, bilateral crackles). Signs of heart failure, including S3 gallop and jugular venous distension, may be present. Chest x-ray is often performed to confirm pulmonary edema and exclude other causes of respiratory distress (eg, pneumothorax).
Treatment includes respiratory support (eg, supplemental oxygen) and diuresis with furosemide (ie, loop diuretic). In high-risk patients, preventive measures may include limiting transfusion volumes, transfusing slowly, and administering pretransfusion diuretics.
(Choice A) Antibiotic therapy is used to treat transfusion-transmitted bacterial infections, which typically present with fever, rigors, and tachycardia. These infections most commonly occur after platelet transfusions and are unlikely in an afebrile child.
(Choice B) Epinephrine is given for anaphylaxis, which presents with hypotension, respiratory distress, and angioedema within minutes of transfusion initiation. The timing of this patient's symptoms and presence of hypertension make anaphylaxis unlikely.
(Choice D) Iron chelation therapy (eg, deferoxamine) is used to treat iron overload in patients who require chronic transfusions (eg, those with thalassemia). This treatment would not be appropriate for this iron-deficient child who has received only 20 mL/kg of blood.
(Choice E) Respiratory support alone is the treatment for transfusion-related acute lung injury, a transfusion reaction characterized by respiratory distress caused by noncardiogenic pulmonary edema. This condition often presents with hypotension and does not cause circulatory overload (eg, S3 gallop, diffuse crackles).
(Choice F) Heparin infusion is appropriate for respiratory distress due to pulmonary embolism (PE). However, the presence of an S3 gallop and diffuse crackles is suggestive of volume overload. In addition, this patient has no PE risk factors (eg, coagulopathy, immobilization).
Educational objective:
Transfusion-associated circulatory overload can occur when a large volume of blood product is rapidly transfused, particularly in children age <3 with chronic anemia. Signs include respiratory distress, hypertension, tachycardia, and pulmonary edema within 6 hours of transfusion initiation. Management includes diuresis (eg, furosemide).