A 68-year-old woman is evaluated in the hospital for severe shortness of breath. She has a… — USMLE Step 2 CK

A $68$ -year-old woman is evaluated in the hospital for severe shortness of breath. She has a history of diffuse large B-cell lymphoma and chronic obstructive pulmonary disease. Two days ago, she underwent uncomplicated placement of a right internal jugular venous port. Today, she was admitted for symptomatic anemia and was prescribed two units of packed red blood cells. Toward the end of the second unit's infusion, she acutely developed dyspnea, orthopnea, and a cough productive of pink, frothy sputum.

Her temperature is $37.6^\circ\text{C}$ ( $99.7^\circ\text{F}$ ), blood pressure is $178/92\text{ mmHg}$ , pulse is $112/\text{min}$ , and respirations are $28/\text{min}$ . Pulse oximetry shows $88\%$ on room air.

Physical examination reveals elevated jugular venous pressure. The port site is clean and without erythema. Cardiopulmonary auscultation reveals an S3 gallop, bilateral basilar crackles, and scattered expiratory wheezes.

Laboratory studies show:
Hemoglobin: $8.9\text{ g/dL}$ (up from $6.8\text{ g/dL}$ before transfusion)
Leukocyte count: $8,400/\text{mm}^3$
Platelet count: $145,000/\text{mm}^3$
Brain natriuretic peptide (BNP): $850\text{ pg/mL}$
Creatinine: $1.1\text{ mg/dL}$

Which of the following is the most appropriate next step in management?

Discontinue the transfusion and administer intravenous furosemideAnswer
B
Discontinue the transfusion and administer inhaled albuterol and systemic glucocorticoids
C
Discontinue the transfusion and administer intravenous vancomycin and cefepime
D
Discontinue the transfusion and obtain a duplex ultrasound of the lower extremities
E
Discontinue the transfusion and initiate disciplinary action against the administering nurse

Answer

The most appropriate next step is to stop the transfusion and administer intravenous furosemide to manage the volume overload.

This patient is experiencing Transfusion-Associated Circulatory Overload (TACO), a known complication of blood product administration, particularly in older patients or those with underlying cardiopulmonary disease. The rapid expansion of intravascular volume leads to acute decompensated heart failure and cardiogenic pulmonary edema. Classic signs include severe respiratory distress, hypertension, tachycardia, elevated jugular venous pressure (JVP), an S3 gallop, and bilateral pulmonary crackles. Laboratory testing often reveals an elevated BNP. The most appropriate next step in management is to immediately discontinue the transfusion to prevent further volume expansion, provide supplemental oxygen, and administer intravenous loop diuretics (e.g., furosemide) to reduce intravascular volume.

Step-by-Step Solution

Analyze the patient's acute symptoms and physical exam findings during a blood transfusion.

The patient developed acute dyspnea, hypertension, hypoxia, JVD, crackles, and an S3 gallop.

Identifying the constellation of symptoms helps differentiate between various transfusion reactions.

Differentiate between TRALI (Transfusion-Related Acute Lung Injury) and TACO (Transfusion-Associated Circulatory Overload).

The presence of hypertension, JVD, an S3 gallop, and markedly elevated BNP confirms TACO. TRALI typically presents with hypotension and normal cardiac filling pressures.

TRALI and TACO are the two most common causes of severe respiratory distress following transfusion, but their treatments differ significantly.

Determine the best management step for TACO.

The correct management is immediate cessation of the transfusion, respiratory support (oxygen), and diuresis (intravenous furosemide).

TACO is a form of acute decompensated heart failure; reducing intravascular volume is essential for recovery.

Key Concept

Transfusion-Associated Circulatory Overload (TACO)

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