What to do for a patient who develops hypertension and breathlessness after receiving a packed red blood cell (PRBC) transfusion?

Management of Transfusion-Related Acute Hypertension and Breathlessness

For a patient who develops hypertension and breathlessness after receiving a packed red blood cell (PRBC) transfusion, immediately stop the transfusion and provide supportive care including oxygen, upright positioning, and diuretic therapy.

Immediate Management

1. Stop the transfusion immediately 1

   • Preserve the blood bag and tubing for later investigation
   • Document the time and volume transfused

2. Position the patient upright to improve respiratory mechanics 1

3. Administer oxygen to maintain SpO2 > 92% 1

   • Start with nasal cannula or face mask
   • Escalate to high-flow oxygen or non-invasive ventilation if needed

4. Administer IV diuretics 1

   • Furosemide 20-40mg IV (adult dose)
   • This addresses the likely Transfusion-Associated Circulatory Overload (TACO)

5. Monitor vital signs closely

   • Blood pressure, heart rate, respiratory rate, oxygen saturation
   • Continuous cardiac monitoring if available

Differential Diagnosis

The clinical presentation suggests Transfusion-Associated Circulatory Overload (TACO), which is characterized by:

• Hypertension (distinguishing feature)
• Breathlessness
• Onset during or within 12 hours of transfusion
• Cardiogenic pulmonary edema pattern 1

This must be distinguished from Transfusion-Related Acute Lung Injury (TRALI), which typically presents with:

• Normal blood pressure or hypotension (not hypertension)
• Non-cardiogenic pulmonary edema
• Onset within 6 hours of transfusion 1

Secondary Management

1. Consider IV antihypertensive therapy if hypertension persists despite diuretics

   • Nicardipine: Start at 5 mg/hr IV infusion, titrate by 2.5 mg/hr every 15 minutes up to maximum 15 mg/hr 2
   • Monitor for hypotension during treatment

2. Obtain chest imaging (chest X-ray)

   • Look for cardiogenic pulmonary edema pattern with vascular redistribution 1

3. Laboratory assessment

   • BNP/NT-proBNP (will be elevated in TACO)
   • Complete blood count
   • Basic metabolic panel to assess renal function

4. Consider echocardiography if available to assess cardiac function

Prevention of Future Episodes

For future transfusions, implement these preventive measures:

1. Pre-transfusion risk assessment 1

   • Identify risk factors: advanced age, heart failure, renal failure, hypoalbuminemia

2. Slower transfusion rate for high-risk patients 1

   • Maximum 1 mL/kg/hour in high-risk patients

3. Consider prophylactic diuretics before transfusion in high-risk patients 1

4. Weight-based dosing for blood products 1

5. Split units over longer periods for patients with history of TACO

Monitoring Response

• Reassess vital signs and respiratory status every 15-30 minutes
• Expect improvement in symptoms within hours with appropriate management
• Consider ICU transfer if respiratory status deteriorates despite initial management

Reporting

• Document the transfusion reaction in the patient's medical record
• Report to blood bank and transfusion service for investigation
• Complete transfusion reaction form as per institutional protocol

This approach prioritizes immediate cessation of the transfusion and supportive care, focusing on treating the likely diagnosis of TACO, which presents with the characteristic hypertension and breathlessness after transfusion.