An 78-year-old man is evaluated for sudden-onset shortness of breath. He was admitted to t… — USMLE Step 2 CK

An 78-year-old man is evaluated for sudden-onset shortness of breath. He was admitted to the hospital earlier today for symptomatic anemia secondary to chronic gastrointestinal blood loss. His medical history is significant for ischemic heart disease, hypertension, and chronic obstructive pulmonary disease. Two hours ago, a transfusion of packed red blood cells was initiated. Current vital signs include a temperature of $37.2^\circ\text{C}$ ( $99.0^\circ\text{F}$ ), blood pressure of $172/96 \text{ mmHg}$ , pulse of $114/\text{min}$ , and respiratory rate of $28/\text{min}$ . Pulse oximetry shows an oxygen saturation of $85\%$ on room air. Physical examination reveals visibly distended neck veins. Lung auscultation demonstrates bilateral bibasilar crackles extending to the mid-lung fields, as well as scattered expiratory wheezes. Cardiac auscultation reveals a regular rhythm with an audible S3 gallop. The transfusion is immediately stopped and supplemental oxygen is provided. Which of the following is the most appropriate next step in management?

A
Administer nebulized albuterol and ipratropium
B
Obtain a computed tomography pulmonary angiogram
Administer intravenous furosemideAnswer
D
Administer intravenous piperacillin-tazobactam
E
Administer intravenous methylprednisolone

Answer

The most appropriate next step is to administer intravenous furosemide to manage the acute volume overload.

The patient is experiencing Transfusion-Associated Circulatory Overload (TACO), a common complication in elderly patients or those with underlying cardiopulmonary disease receiving blood products. The presentation is characterized by acute respiratory distress, hypertension, tachycardia, and signs of fluid overload such as jugular venous distension, an S3 gallop, and pulmonary crackles. The definitive initial management is to stop the transfusion, provide supplemental oxygen, and administer loop diuretics, such as intravenous furosemide, to rapidly reduce intravascular volume.

Step-by-Step Solution

Analyze the timing and context of the patient's respiratory distress.

The acute dyspnea and hypoxia occurred directly during the transfusion of a blood product.

Establishing the temporal relationship strongly indicates an acute transfusion reaction.

Evaluate vital signs and physical examination findings to distinguish the specific type of transfusion reaction.

The patient exhibits marked hypertension (

172/96 \text{ mmHg}

), jugular venous distension, an S3 gallop, and bilateral pulmonary crackles.

These findings specifically indicate a cardiogenic cause of pulmonary edema and volume overload, ruling out Transfusion-Related Acute Lung Injury (TRALI), which typically presents with hypotension and no signs of right-sided heart strain.

Determine the most appropriate immediate medical intervention based on the diagnosis of Transfusion-Associated Circulatory Overload (TACO).

The standard of care requires immediate cessation of the transfusion and administration of intravenous loop diuretics.

Loop diuretics rapidly decrease intravascular volume and alleviate pulmonary congestion, correcting the underlying hydrostatic pressure derangement.

Key Concept

Diagnosis and management of Transfusion-Associated Circulatory Overload (TACO)

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