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Difficulty: MediumPulmonary and Critical Care

A 74-year-old man is hospitalized for the management of melena and severe symptomatic anemia. He has a notable medical history of essential hypertension, type 2 diabetes mellitus, and stage 3 chronic kidney disease. Upon admission, his hemoglobin level is 5.8 g/dL5.8 \text{ g/dL}, and he is prescribed three units of packed red blood cells. Approximately 30 minutes into the transfusion of the third unit, the patient reports sudden-onset shortness of breath and a dry cough.

Current vital signs include a temperature of 37.2∘C37.2^\circ\text{C} (99.0∘F99.0^\circ\text{F}), blood pressure of 178/96 mm Hg178/96 \text{ mm Hg}, heart rate of 115/min115/\text{min}, and respiratory rate of 26/min26/\text{min}. Pulse oximetry displays an oxygen saturation of 86%86\% while breathing room air.

Physical examination shows prominent jugular venous distention when the patient is seated at a 45-degree angle. Auscultation of the lungs reveals bilateral basilar crackles without any audible wheezing. Cardiac examination demonstrates a regular tachycardia with a prominent S3 gallop.

An arterial blood gas analysis on room air yields the following results:

pH: 7.287.28
PaCO 2_2: 56 mm Hg56 \text{ mm Hg}
PaO 2_2: 52 mm Hg52 \text{ mm Hg}
HCO 3−_3^-: 25 mEq/L25 \text{ mEq/L}

A portable chest radiograph displays bilateral pulmonary infiltrates, an enlarged cardiac silhouette, and widening of the vascular pedicle.

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

  1. A
    Initiate empiric piperacillin-tazobactam
  2. B
    Administer intravenous sodium bicarbonate
  3. Administer intravenous furosemideAnswer
  4. D
    Administer intravenous methylprednisolone and nebulized albuterol
  5. E
    Submit a disciplinary report against the nursing staff

Answer

The most appropriate next step in management is to administer intravenous furosemide to treat Transfusion-Associated Circulatory Overload (TACO).
The correct answer is to administer intravenous furosemide. This patient is experiencing Transfusion-Associated Circulatory Overload (TACO), a common complication of blood product administration, particularly in patients with underlying cardiac or renal disease (such as this patient's chronic kidney disease). TACO is characterized by acute respiratory distress, hypertension, tachycardia, and classic signs of volume overload, including jugular venous distention, an S3 gallop, and pulmonary crackles. Arterial blood gas analysis typically reveals hypoxemia and, in severe or fatiguing cases, an acute respiratory acidosis due to poor ventilation. Management involves immediately stopping the transfusion, providing supplemental oxygen or noninvasive ventilatory support, and administering loop diuretics like furosemide to reduce intravascular volume.

Step-by-Step Solution

1
Analyze the patient's presentation and vital signs during the blood transfusion.
The patient developed acute respiratory distress, hypoxemia, and significant hypertension (178/96 mm Hg178/96 \text{ mm Hg}) during the third unit of packed red blood cells.
Identifying the timeline and vital sign changes is critical for differentiating between types of acute transfusion reactions.
2
Evaluate the physical examination and radiographic findings.
The presence of jugular venous distention, an S3 gallop, bibasilar crackles, cardiomegaly, and a widened vascular pedicle indicates cardiogenic volume overload.
These findings distinguish volume overload from other pulmonary pathologies like ARDS, TRALI, or pneumonia.
3
Determine the optimal therapeutic intervention.
The patient is experiencing Transfusion-Associated Circulatory Overload (TACO) and requires immediate diuresis with intravenous furosemide.
Diuretics reduce the intravascular volume and hydrostatic pressure, rapidly resolving the pulmonary edema.

Key Concept

Transfusion-Associated Circulatory Overload (TACO) presents with respiratory distress, hypertension, and signs of cardiogenic pulmonary edema (JVD, S3 gallop) during or shortly after a blood transfusion, and is managed primarily with diuretics and respiratory support.
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Topics

Pulmonary and Critical Care

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