On the morning after hospital admission, a decision was made to transfuse the patient with 1 U of packed RBCs for a hematocrit of 25.8%. Before transfusion, her temperature was 98°C; BP, 132/60 mm Hg; pulse rate, 72 beats/min, and oxygen saturation, 97% (room air). After receiving approximately 200 mL of the unit of blood over 40 min, she became short of breath, confused, and agitated, and was initially found to be hypertensive to 200/100 mm Hg, with an oxygen saturation of 77% (3 L/min). On further examination, her lungs were clear but her oxygen saturation subsequently fell to approximately 65% despite breathing 100% oxygen. She was administered nitropaste to reduce her BP and 120 mg of furosemide to treat what was presumed to be flash pulmonary edema even though the initial posttransfusion chest radiograph (Fig 1
, top) was not consistent with pulmonary edema, nor were there crackles on physical examination. She was placed on continuous positive airway pressure, but shortly afterwards hemoptysis developed and she was intubated. A chest radiograph obtained just before intubation and 1.5 h after the initiation of the transfusion revealed the development of new patchy infiltrates (Fig 1, bottom). Given the elevated INR of 13.1 from her hospital admission laboratory work and the development of hemoptysis, she received transfusion with the first of 4 U of fresh frozen plasma. A CBC count performed at this time revealed a stable hematocrit but development of leukopenia, with WBC count of 2.0 × 103/μL (down from 10.8 × 103/μL earlier). The BP was 100/44 mm Hg without vasopressors; however, within minutes after transfer to the ICU, cardiac arrest developed and resuscitation was unsuccessful.