What is the management for a 1-month-old patient with severe anemia (hemoglobin level of 56) suspected of having Transfusion-Related Circulatory Overload (TACO)?

Management of Transfusion-Associated Circulatory Overload (TACO) in a 1-Month-Old with Severe Anemia

Immediately stop the transfusion, administer IV furosemide 1 mg/kg, provide 100% oxygen support, and prepare for potential intubation if respiratory distress is severe. 1

Immediate Recognition and Intervention

Stop the transfusion immediately upon recognizing signs of TACO, which include respiratory distress, increased oxygen requirements, tachypnea, dyspnea, or evidence of pulmonary edema. 2, 1 Maintain IV access with normal saline to preserve vascular access for medication administration. 3

Pharmacologic Management

• Administer IV furosemide 1 mg/kg immediately in this 1-month-old infant presenting with TACO. 1 The onset of diuresis occurs within 5 minutes of IV administration, making it the most rapid intervention for volume overload. 4

• Important caveat: Furosemide has reduced clearance and prolonged half-life in neonates, making dosing unpredictable and increasing risks of ototoxicity and nephrocalcinosis with repeated doses. 2 Monitor carefully for adverse effects including electrolyte disturbances (hypokalemia, hyponatremia) and renal function deterioration. 2, 4

• Do NOT use furosemide if: The infant has hyperkalemia (furosemide causes metabolic alkalosis that paradoxically worsens intracellular potassium shifts), hemodynamic instability, or inadequate intravascular volume. 2

Respiratory Support

• Provide 100% oxygen via non-rebreather mask or high-flow nasal cannula appropriate for neonatal use. 1, 3

• Prepare for early intubation if the infant demonstrates severe respiratory distress, inability to maintain oxygenation despite supplemental oxygen, or altered mental status. 1 Positive pressure ventilation reduces preload and improves oxygenation in cardiogenic pulmonary edema. 1

Critical Distinction: TACO vs TRALI

This clinical scenario requires distinguishing TACO from transfusion-related acute lung injury (TRALI), as management differs significantly:

• TACO presents with cardiogenic pulmonary edema and responds to diuretics. 2, 5 Clinical signs include elevated jugular venous pressure, pulmonary edema on examination, and volume overload. 2

• TRALI presents with non-cardiogenic pulmonary edema within 1-2 hours of transfusion, often with hypotension, and diuretics are ineffective and potentially harmful. 3, 5 TRALI requires supportive care with oxygen therapy, not volume removal. 3

Key diagnostic point: The presence of hemoglobin 56 g/L (5.6 g/dL) indicates severe anemia requiring transfusion, but the timing of symptom onset during/after transfusion and presence of volume overload signs favor TACO over TRALI. 5

Monitoring Requirements

Continuous monitoring is essential and should include: 1

• Continuous ECG and pulse oximetry
• Respiratory rate (tachypnea is an early TACO symptom) 2
• Blood pressure monitoring (intra-arterial if available)
• Urine output (target >1 mL/kg/h) 1
• Core temperature
• Electrolytes (particularly potassium and sodium given furosemide administration) 2

Addressing the Underlying Severe Anemia

Once TACO is stabilized, the severe anemia (hemoglobin 56 g/L) still requires correction:

• Transfusion threshold: With hemoglobin <5 g/dL, transfusion is indicated even in stable infants. 6 The World Health Organization recommends transfusion for severe anemia with hemoglobin <5 g/dL. 6

• Slow transfusion rate: When resuming transfusion after TACO resolution, use 4-5 mL/kg/h or slower for patients with reduced cardiac output. 2, 1 This is more important than prophylactic diuretics for preventing fluid overload. 2

• Volume considerations: A typical 15 mL/kg RBC transfusion over 3-4 hours minimizes risks of hyperkalemia and fluid shifts. 1 For a 1-month-old (approximately 4 kg), this represents 60 mL transfused over 3-4 hours.

Common Pitfalls to Avoid

• Do not use furosemide prophylactically in all neonatal transfusions—it should only be used when TACO develops or in very high-risk patients. 2 The evidence base for prophylactic furosemide is weak and it does not prevent acute kidney injury. 2

• Do not confuse TACO with TRALI—giving diuretics for TRALI is harmful. 3, 5 TRALI requires supportive care without volume removal.

• Do not avoid transfusion entirely due to TACO risk—with hemoglobin 56 g/L, the mortality risk from severe anemia exceeds the risk of properly managed transfusion. 6

• Monitor for furosemide adverse effects including ototoxicity (tinnitus, hearing loss), electrolyte disturbances, and renal dysfunction, particularly in neonates where drug clearance is reduced. 2, 4

Transfer to Higher Level of Care

Transfer to intensive care for continued monitoring and mechanical ventilation if needed, as TACO can evolve over the first 6-12 hours post-transfusion. 1, 3 Continue observation for at least 24 hours. 3