An 82-year-old woman is evaluated in the progressive care unit due to sudden-onset difficu… — USMLE Step 2 CK

An $82$ -year-old woman is evaluated in the progressive care unit due to sudden-onset difficulty breathing. She was admitted yesterday for a lower gastrointestinal bleed secondary to diverticulosis. Her medical history is significant for hypertension and heart failure with preserved ejection fraction. Two hours ago, her hemoglobin was noted to be $6.4 \text{ g/dL}$ , and a transfusion of two units of packed red blood cells was initiated. She is currently receiving the second unit. Her temperature is $37.0^\circ\text{C}$ ( $98.6^\circ\text{F}$ ), blood pressure is $172/92 \text{ mmHg}$ , heart rate is $112/\text{min}$ , and respiratory rate is $28/\text{min}$ . Pulse oximetry shows $87\%$ on ambient air. Physical examination reveals distended jugular veins and bounding peripheral pulses. Auscultation of the lungs demonstrates bibasilar crackles extending to the mid-lung fields. A new S3 gallop is appreciated on cardiac auscultation. Which of the following is the most appropriate next step in the management of this patient's respiratory distress?

A
Discontinue the transfusion and administer intravenous diphenhydramine
B
Discontinue the transfusion and administer broad-spectrum antibiotics
C
Discontinue the transfusion and prepare for emergent endotracheal intubation
Discontinue the transfusion and initiate intravenous diuresisCevap
E
Discontinue the transfusion and administer an intravenous fluid bolus

Cevap

The most appropriate next step is to discontinue the transfusion and initiate intravenous diuresis.

This patient's presentation of acute dyspnea, hypertension, jugular venous distension, and an S3 gallop during a blood transfusion is highly characteristic of transfusion-associated circulatory overload (TACO). TACO occurs when a blood product is transfused rapidly or in high volumes, overwhelming the patient's cardiovascular capacity, particularly in those with pre-existing conditions like heart failure with preserved ejection fraction (HFpEF). The definitive management is to immediately halt the transfusion, provide supportive oxygen therapy, and administer intravenous loop diuretics to rapidly reduce intravascular volume.

Adım Adım Çözüm

Identify the acute complication.

The patient developed sudden-onset dyspnea, hypoxemia, hypertension, JVD, and pulmonary crackles during a blood transfusion.

These findings represent acute cardiopulmonary compromise temporally related to blood product administration.

Differentiate the type of transfusion reaction.

The presence of significant hypertension, JVD, and an S3 gallop points to Transfusion-Associated Circulatory Overload (TACO) rather than Transfusion-Related Acute Lung Injury (TRALI) or anaphylaxis.

TACO is a cardiogenic pulmonary edema caused by volume overload, whereas TRALI presents with hypotension and lacks signs of left heart failure.

Determine the most appropriate management.

Halt the transfusion and administer a loop diuretic.

Removing the volume stress and offloading the heart is the definitive medical treatment for TACO.

Anahtar Kavram

Transfusion-Associated Circulatory Overload (TACO) diagnosis and management

Alternatif Yöntem

In addition to loop diuretics, patients with severe hypoxemia from TACO may benefit from non-invasive positive pressure ventilation (NIPPV) to decrease preload and improve oxygenation.

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Cevap

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Anahtar Kavram

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Alternatif Yöntem

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