A 78-year-old man receives 2 units of packed red cells over 4 hours for anaemia. Six hours later he is orthopnoeic with BP 165/95 mmHg, HR 105/min, bilateral basal crepitations, and frothy sputum. Chest radiograph shows pulmonary congestion with a normal-sized heart border. BNP is markedly elevated. What is the best immediate treatment?

• A Non-invasive ventilation alone without further intervention
• B Empirical broad-spectrum antibiotics
• C Intravenous calcium gluconate
• D Intravenous furosemide with upright positioning and oxygen ✓

Explanation

Transfusion-associated circulatory overload (TACO) occurs within hours of transfusion, typically in elderly patients, with hypertension, raised BNP, and hydrostatic pulmonary oedema. Treatment is stopping the transfusion, sitting the patient up, oxygen, and loop diuretics. The key discriminator from TRALI is haemodynamic profile: TACO gives hypertension and elevated BNP, whereas TRALI gives hypotension and normal BNP. Non-invasive ventilation may be adjunctive but diuresis is the definitive step.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.