Synopsis
Differentiate the principal respiratory transfusion emergencies, deliver syndrome-specific oxygen, diuresis or adrenaline and preserve evidence for transfusion investigation.
- First-line shared action is stop the transfusion, keep access with new saline tubing, perform ABCDE and contact the transfusion laboratory.
- TRALI causes non-cardiogenic pulmonary oedema during or within six hours, with hypoxaemia and bilateral infiltrates not mainly explained by hydrostatic pressure.
- TRALI often features fever or hypotension with normal or low JVP; treat with oxygen and lung-protective ventilatory support, not routine diuresis.
- TACO causes hydrostatic pulmonary oedema during or up to 12 hours after transfusion, supported by hypertension, raised JVP, positive balance, cardiomegaly, natriuretic-peptide rise and response to diuresis.
- First-line TACO treatment is stop transfusion, sit upright, give oxygen, assess for intravenous loop diuretic and escalate to CPAP or critical care when necessary.
- Prevent TACO by verifying indication, prescribing one unit or weight-adjusted volume, using an appropriate slower rate and reassessing before further components.
- Anaphylaxis is defined clinically by sudden airway, breathing or circulation compromise; skin or mucosal change supports it but can be absent.
- First-line anaphylaxis medicine is intramuscular adrenaline 500 micrograms from 1 mg/mL solution into the anterolateral thigh, repeated after five minutes if needed.
- Give rapid intravenous crystalloid for anaphylactic shock, call the resuscitation team and use intravenous adrenaline only in an expert monitored setting.
- A mild isolated rash may respond to an antihistamine after stopping and assessment, but antihistamines do not treat airway compromise or shock.
- Chest radiography, blood gas, ECG, fluid balance, cardiac assessment and natriuretic peptides help distinguish TACO from TRALI but no single test is a gold standard.
- Return the implicated component, complete reaction samples and document timing, volume, rate and total fluid because classification drives donor and future-recipient safety.
Key red flags
Stridor, tongue or airway swelling, wheeze, persistent hypotension or collapse indicates anaphylaxis even when urticaria is absent.
New hypoxaemia with bilateral pulmonary oedema during or within six hours of transfusion and no dominant left-atrial hypertension suggests TRALI.
Dyspnoea, orthopnoea, hypertension, raised JVP and positive fluid balance during or up to 12 hours after transfusion suggests TACO.
Severe chronic anaemia, low body weight, cardiac or renal impairment and multiple rapid components create a high-risk TACO phenotype requiring prevention before transfusion starts.
Fever, rigors, shock, pain or haemoglobinuria widens the emergency differential to contaminated component and acute haemolysis and requires cultures and compatibility investigation.
Investigation priorities
Separate airway allergy, permeability oedema and hydrostatic overload quickly.
Management branches
Breathlessness, hypoxia, wheeze or collapse begins during or shortly after transfusion.
- Stop the component, maintain access through new tubing, give oxygen, call senior help and notify the transfusion laboratory.
- Look immediately for airway swelling, wheeze, rash, JVP, hypertension, fever, fluid excess, pain and dark urine.
- Treat anaphylaxis, TACO or TRALI physiology immediately while sending reaction tests and imaging; do not await a final label.