Examkin

Soru

Zorluk: OrtaHematology and Oncology

A 74-year-old man is hospitalized for symptomatic anemia secondary to newly diagnosed myelodysplastic syndrome. His medical history includes chronic obstructive pulmonary disease (COPD) and essential hypertension. His pre-transfusion hemoglobin is 6.1 g/dL.

A transfusion of two units of packed red blood cells is ordered. Thirty minutes into the transfusion of the second unit, the patient reports acute-onset shortness of breath and a dry cough. A urine culture sent on admission for mild dysuria has just resulted, showing >100,000 CFU/mL of *Escherichia coli* that is susceptible to nitrofurantoin and cephalexin, but resistant to ciprofloxacin.

Temperature is 37.1°C (98.8°F), blood pressure is 185/95 mm Hg, pulse is 112/min, and respirations are 28/min. Pulse oximetry shows an oxygen saturation of 85% on room air. Physical examination reveals prominent jugular venous distention. Cardiac examination shows regular tachycardia with a loud S3 gallop. Pulmonary examination reveals bilateral crackles extending halfway up the lung fields, with scattered expiratory wheezes.

Arterial blood gas analysis on room air shows:

ParameterValueReference Range
pH7.317.35 - 7.45
pCO2pCO_249 mm Hg35 - 45 mm Hg
pO2pO_252 mm Hg75 - 105 mm Hg
HCO3−HCO_3^-24 mEq/L22 - 28 mEq/L

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

  1. Discontinue the transfusion and administer intravenous furosemideCevap
  2. B
    Discontinue the transfusion and administer inhaled albuterol and intravenous methylprednisolone
  3. C
    Discontinue the transfusion and administer an intravenous sodium bicarbonate infusion
  4. D
    Discontinue the transfusion and administer intravenous meropenem
  5. E
    Discontinue the transfusion and file a punitive incident report against the transfusion nursing staff

Cevap

The most appropriate next step is to discontinue the transfusion and administer intravenous furosemide to manage Transfusion-Associated Circulatory Overload (TACO).
The patient's presentation of acute dyspnea, hypertension, elevated jugular venous pressure, an S3 gallop, and basilar crackles during a blood transfusion is pathognomonic for Transfusion-Associated Circulatory Overload (TACO). TACO occurs when a large volume of blood products is administered rapidly, particularly in patients with underlying cardiopulmonary disease or advanced age (such as this elderly man with COPD and hypertension). The hydrostatic pressure in the pulmonary capillaries increases, leading to acute cardiogenic pulmonary edema. The ABG demonstrates an acute respiratory acidosis secondary to impaired gas exchange. The immediate and most critical steps in management are to discontinue the transfusion, provide supplemental oxygen, and administer intravenous loop diuretics (e.g., furosemide) to reduce intravascular volume and cardiac preload.

Adım Adım Çözüm

1
Analyze the patient's acute symptoms and physical examination findings.
The patient developed acute dyspnea, hypertension, tachycardia, hypoxia, elevated JVP, an S3 gallop, and pulmonary crackles during a blood transfusion.
Identifying the constellation of cardiogenic pulmonary edema signs helps differentiate TACO from TRALI (which typically presents with hypotension and no JVD).
2
Interpret the arterial blood gas results.
The ABG shows a low pH (7.31), elevated pCO2 (49 mm Hg), and normal HCO3 (24 mEq/L), indicating an acute, uncompensated respiratory acidosis.
This confirms respiratory failure due to fluid overload (pulmonary edema) rather than a primary metabolic derangement.
3
Determine the optimal immediate management strategy.
The correct action is to immediately stop the transfusion to prevent further fluid administration, provide supplemental oxygen, and administer loop diuretics (intravenous furosemide).
Diuresis rapidly decreases intravascular volume, reducing cardiac preload and relieving the hydrostatic pulmonary edema associated with TACO.

Anahtar Kavram

Transfusion-Associated Circulatory Overload (TACO) presents with signs of volume overload (hypertension, elevated JVP, S3 gallop, pulmonary edema) and is managed by stopping the transfusion and administering loop diuretics and oxygen.
Tahmini Süre:1m 15s
Bu soruyu puanla

Konular

Hematology and Oncology

Bu konudan daha fazla soru