Series of errors leading to life-threatening transfusion-associated circulatory overload

Dear Editor, We would like to present a case of a 65-year-old female admitted to a gastroenterology and hepatolo­gy department for the optimization of Crohn’s disease treatment – the patient developed antibodies to inflixi­mab. The patient was malnourished, with body mass index 17.5 kg m^–2 (body weight 45 kg). Haemoglobin (Hb) concentration at admission was 110 g L^–1 and over 4 days it dropped to 100 g L^–1. The following day the Hb concentration was 66 g L^–1 (error 1). There were no signs of bleeding. The patient did not present any signs or symptoms of anaemia (error 2). The decision to transfuse the patient with 2 (error 3) units of red blood cell (RBC) without buffy coat (error 4) was made. The RBC transfusion was carried out over approximately 3 hours (error 5) in the evening hours (error 6). Shortly after completion of transfusion of the second RBC, the patient developed acute respiratory failure. Urgent anaesthesiology consultation was requested. The patient was found with dyspnoea, tachypnoea (40 breaths min^–1), peripheral oxygen saturation (SpO₂) 88% on an oxygen mask with a reservoir (15 L min^–1), and crackles audible over the entire chest. The patient had tachycardia (120 bpm) and hypertension (blood pressure 160/90 mmHg). Lung ultrasound revealed B profile in all lung points and fluid in the pleural cavities (4 cm on the right side, 1 cm on the left side). The arterial blood gas analysis revealed pH 7.44, pCO2 31.8 mmHg, pO2 54 mmHg, HCO3 22.9 mmol L^–1, BE –2.6 mmol L^–1, Hb 134 g L^–1. Considering the patient’s low body weight, the large volume of transfused RBC (600 mL), age (suspicion of heart failure), and absence of symptoms suggesting alternative post-transfusion reaction, transfusion-associated circulatory overload (TACO) was diagnosed. Furosemide was given (20 mg IV), and the patient was cathe­terized with a resulting urine output of 1000 mL. The patient’s respiratory status improved within 30 min., oxygen therapy was reduced to 5 L min^–1, SpO₂ was 97%, and the respiratory rate dropped to 18 min^–1. After stabilization of the patient the following examinations were ordered: brain natriuretic peptide (pro-BNP) (4293 pg mL^–1), C-reactive protein (36.4 mg L^–1), haemoglobin (129 g L^–1), and computed tomography examination of the chest (Figure 1).
After 3 h...


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