What is the best course of action for a post-transfusion patient exhibiting behavioral changes?

Behavioral Changes in Post-Transfusion Patients

Immediately stop any ongoing transfusion and assess for transfusion-associated circulatory overload (TACO), transfusion-related acute lung injury (TRALI), or acute hemolytic reaction—these are life-threatening complications that can present with neurological symptoms including confusion and behavioral changes. 1

Immediate Assessment and Management

Stop Transfusion and Stabilize

• Discontinue the transfusion immediately at the first sign of behavioral changes—this is the single most critical intervention to prevent progression to severe morbidity or mortality 1
• Maintain IV access with normal saline for medication administration and potential fluid resuscitation 1, 2
• Monitor vital signs every 5-15 minutes: heart rate, blood pressure, temperature, respiratory rate, and oxygen saturation 1, 3
• Administer high-flow oxygen to address potential hypoxemia 1

Differentiate the Underlying Cause

TACO (Most Common Cause of Transfusion-Related Mortality):

• Look for acute respiratory distress, tachycardia (>100 bpm), hypertension (>100 mmHg), and evidence of volume overload (edema, jugular venous distension) occurring during or up to 12 hours post-transfusion 3
• Behavioral changes in TACO result from cerebral hypoxia secondary to pulmonary edema and impaired gas exchange 1
• Elevated BNP (>300 pg/mL) or NT-proBNP (>2000 pg/mL) supports TACO diagnosis 3
• Treatment: Administer diuretics immediately and slow future transfusion rates 3

TRALI:

• Presents with severe hypoxemia, bilateral pulmonary infiltrates, and non-cardiogenic pulmonary edema within 1-6 hours of transfusion 1
• Unlike TACO, TRALI shows no evidence of volume overload and does not respond to diuretics 1, 3
• Fresh frozen plasma and apheresis platelets carry the highest TRALI risk 1
• Treatment: Critical care supportive measures and oxygen therapy—avoid diuretics as they are ineffective 1, 3

Acute Hemolytic Transfusion Reaction:

• Classic triad: pain at IV site, difficulty breathing, and fever within 10 minutes of transfusion 2
• Behavioral changes result from systemic inflammatory response and hemodynamic instability 2
• Risk is approximately 1:70,000 per unit transfused 2
• Treatment: Maintain MAP >65-70 mmHg with IV fluids, monitor for hemoglobinuria and DIC 2

Posterior Reversible Encephalopathy Syndrome (PRES):

• Rare complication presenting with confusion, headache, and seizures days after transfusion (typically day 6) 4
• More common in middle-aged women with chronic anemia from menorrhagia who receive rapid transfusion 4
• Mechanism: abrupt hemoglobin increase causes rapid rise in blood viscosity, loss of hypoxic vasodilation, endothelial damage, and brain capillary leakage 4
• MRI shows characteristic T2-weighted lesions that resolve with supportive care 4

Essential Laboratory Workup

Immediate Labs:

• Complete blood count, PT, aPTT, Clauss fibrinogen 1
• Direct antiglobulin test (DAT/Coombs test) and repeat cross-match 1, 2
• Visual inspection of plasma for hemolysis 2
• Urine analysis for hemoglobinuria 2
• BNP or NT-proBNP if TACO suspected 3

Send Blood Component Back:

• Return the blood bag with administration set to transfusion laboratory immediately 1, 2

Critical Pitfalls to Avoid

• Do not wait to confirm reaction type before stopping transfusion—immediate cessation is paramount 1
• Do not administer diuretics for TRALI—they are ineffective and may worsen the condition 1, 3
• Do not overlook TACO in elderly patients (>70 years) or those with heart failure, renal failure, or hypoalbuminemia—these are high-risk populations 1, 3
• Do not assume behavioral changes are purely psychiatric—the case report describes a patient initially treated with haloperidol and diazepam for presumed alcohol withdrawal when pulmonary embolism was the actual cause 5

Reporting Requirements

• Contact the transfusion laboratory immediately to report the reaction and initiate investigation 1
• Notify the patient's general practitioner 1
• Report to the blood bank and hemovigilance system—transfusion reactions are underdiagnosed and underreported despite being a leading cause of transfusion-related mortality 1, 3
• Document all findings with 100% traceability as this is a legal requirement 1

Prevention for Future Transfusions

• Use single-unit transfusions in non-hemorrhaging patients and reassess before giving additional units 1
• Transfuse slowly in high-risk patients (elderly, cardiac disease, renal failure) 3
• Monitor closely during the first 10 minutes—immediate reactions typically occur within the first minute 1
• Ensure positive patient identification with four core identifiers before every transfusion 1