During a hospital observation, an 82-year-old male with a history of moderate chronic obst… — USMLE Step 2 CK

During a hospital observation, an 82-year-old male with a history of moderate chronic obstructive pulmonary disease and diet-controlled hypertension is receiving a blood transfusion. He was admitted earlier today for severe fatigue and was found to have a hemoglobin level of $6.2 \text{ g/dL}$ due to suspected chronic gastrointestinal blood loss. While receiving his second unit of packed red blood cells, he suddenly develops worsening shortness of breath and a dry cough. His blood pressure is $168/94 \text{ mmHg}$ , pulse is $112/\text{min}$ , and respiratory rate is $26/\text{min}$ . Oxygen saturation is $88\%$ on room air. Physical examination reveals distended neck veins and bilateral crackles at the lung bases. There is no fever, rash, or wheezing. Which of the following is the most appropriate next step in management?

Administer intravenous furosemideCevap
B
Administer inhaled albuterol and ipratropium
C
Stop the transfusion and administer a bolus of intravenous normal saline
D
Transfer the patient to radiology for a computed tomography pulmonary angiogram
E
Initiate empiric treatment with intravenous vancomycin and cefepime

Cevap

Administer intravenous furosemide

The correct intervention is to administer intravenous furosemide. This patient is experiencing transfusion-associated circulatory overload (TACO), a known complication when blood products are administered rapidly or to patients vulnerable to volume expansion (such as the elderly). The classic presentation includes acute respiratory distress, hypertension, tachycardia, and physical exam findings of pulmonary edema (bibasilar crackles) and central volume overload (elevated jugular venous pressure). Management consists of immediately stopping the transfusion, providing supplemental oxygen, and aggressively diuresing the patient with an intravenous loop diuretic like furosemide.

Adım Adım Çözüm

Analyze the patient's vital signs and physical examination findings during the transfusion.

The patient exhibits hypertension (

168/94 \text{ mmHg}

), tachycardia, hypoxia, distended neck veins, and bibasilar crackles without fever.

Identifying the hemodynamic status and presence of fluid overload is crucial to differentiate between various transfusion reactions.

Correlate the clinical findings with potential transfusion complications.

The combination of rapid blood product administration in an elderly patient leading to acute respiratory distress, hypertension, and signs of pulmonary edema (crackles, elevated jugular venous pressure) strongly indicates transfusion-associated circulatory overload (TACO).

Differentiating TACO from transfusion-related acute lung injury (TRALI) is key; TACO presents with hypertension and signs of volume overload, whereas TRALI typically presents with hypotension and no signs of left heart failure.

Determine the appropriate bedside intervention for TACO.

The correct management is to immediately stop the transfusion, provide respiratory support, and administer a diuretic (intravenous furosemide).

Diuresis rapidly decreases intravascular volume, reducing the hydrostatic pressure in the pulmonary capillaries and alleviating the pulmonary edema.

Anahtar Kavram

Recognition and management of transfusion-associated circulatory overload (TACO) using loop diuretics.

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Cevap

Adım Adım Çözüm

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