Transfusion Medicine — Written Clinical Reasoning

Model answer — Part A: post-transfusion dyspnoea

Frame the problem first. New respiratory distress within 6 hours of transfusion is TACO or TRALI until proven otherwise; both are reportable to the blood bank. The first moves are identical: stop the transfusion, keep the line open with saline, check the unit against the patient's identity, assess ABC and call for review ^[1].

The discrimination is hydrostatic versus permeability oedema. For TACO: hypertension, raised JVP, positive fluid balance, elevated BNP, response to diuretics, and a vulnerable heart (age, HFpEF, renal impairment). For TRALI: normal or low blood pressure, no volume overload, often fever, normal BNP, and no diuretic response ^[1].

Investigations: chest X-ray (both show bilateral infiltrates — it does not discriminate), BNP, fluid balance chart, ECG and troponin if ischaemia is plausible, FBC/coagulation/DAT and haemolysis markers to exclude a haemolytic reaction, and cultures if febrile ^[1].

Management: sit up, oxygen; for TACO — IV diuretic, and future transfusions restricted to single units at slow rates with diuretic cover; for suspected TRALI — supportive respiratory care (escalate to ICU if hypoxaemia progresses), no diuretics, and blood-bank notification for donor investigation. Close with the report: both reactions require formal documentation and haemovigilance reporting ^[1].