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Difficulty: MediumHematology and Oncology

A 72-year-old man is evaluated for severe shortness of breath on postoperative day 3 following a right hemicolectomy for colon cancer. Yesterday, his hemoglobin was 6.5 g/dL, and he was prescribed 2 units of packed red blood cells. The infusion of the second unit was completed 30 minutes ago. He has a history of essential hypertension, diet-controlled type 2 diabetes mellitus, and osteoarthritis. His temperature is 37.1°C (98.8°F), blood pressure is 168/94 mm Hg, pulse is 112/min, and respirations are 24/min. Pulse oximetry shows 88% on room air. Physical examination reveals distended jugular veins evaluated at 9 cm above the sternal angle. Cardiac auscultation shows a regular tachycardia with a prominent S3 gallop. Lung auscultation reveals bilateral crackles at the lung bases. Trace bilateral pedal edema is present. What is the most appropriate next step in management?

  1. Intravenous furosemideAnswer
  2. B
    Inhaled albuterol and ipratropium
  3. C
    Intravenous broad-spectrum antibiotics
  4. D
    Removal of central venous catheter and blood cultures
  5. E
    Rapid infusion of 0.9% normal saline

Answer

Intravenous furosemide
The correct intervention is the administration of a loop diuretic. This patient is presenting with Transfusion-Associated Circulatory Overload (TACO), characterized by respiratory distress, hypertension, tachycardia, and signs of cardiogenic pulmonary edema (JVD, S3 gallop, basilar crackles) occurring within 6 hours of a blood transfusion. Patients at extremes of age or with underlying cardiac/renal dysfunction are at highest risk. Management involves immediate cessation of the transfusion, respiratory support (supplemental oxygen or positive pressure ventilation), and diuresis (e.g., intravenous furosemide).

Step-by-Step Solution

1
Analyze the patient's vital signs and timing of symptom onset.
The patient developed acute dyspnea, hypoxia (88%), and hypertension (168/94 mm Hg) within 30 minutes of receiving a second unit of packed red blood cells.
Establishing the temporal relationship to the transfusion helps narrow the differential to acute transfusion reactions.
2
Evaluate the physical examination findings.
The patient has jugular venous distention, an S3 gallop, and bilateral basilar crackles.
These findings are pathognomonic for left-sided heart failure and systemic volume overload.
3
Synthesize data to determine the specific transfusion reaction and select the appropriate intervention.
The combination of respiratory distress, hypertension, and cardiogenic pulmonary edema following a transfusion indicates Transfusion-Associated Circulatory Overload (TACO). The correct management is diuresis.
TACO is caused by fluid volume excess overwhelming the cardiovascular system, requiring loop diuretics like furosemide alongside supplemental oxygen.

Key Concept

Transfusion-Associated Circulatory Overload (TACO) management
Estimated Time:1m 30s
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Topics

Hematology and Oncology

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