A 72-year-old man is admitted to the hospital due to fatigue, dark stools, and symptomatic… — USMLE Step 2 CK

A 72-year-old man is admitted to the hospital due to fatigue, dark stools, and symptomatic anemia. His medical history includes hypertension and chronic kidney disease. Laboratory studies on admission show a hemoglobin level of $6.2 \text{ g/dL}$ . A transfusion of packed red blood cells is initiated. One hour into the transfusion, the patient reports the sudden onset of shortness of breath and a dry cough. The transfusion is immediately stopped. Temperature is $37.2^\circ\text{C}$ ( $99.0^\circ\text{F}$ ), blood pressure is $172/96 \text{ mm Hg}$ , pulse is $112/\text{min}$ , and respirations are $24/\text{min}$ . Pulse oximetry shows an oxygen saturation of $89\%$ on room air. Physical examination reveals elevated jugular venous pressure. Pulmonary auscultation reveals bilateral basilar crackles. Cardiac auscultation reveals an S3 gallop. There is no rash, wheezing, or stridor. Which of the following is the most appropriate next step in management?

Administer intravenous furosemideCevap
B
Analyze donor plasma for anti-leukocyte antibodies
C
Administer intravenous diphenhydramine and hydrocortisone
D
Obtain blood cultures and administer broad-spectrum antibiotics
E
Administer oral acetaminophen and resume the transfusion at a slower rate

Cevap

Administer intravenous furosemide

The correct next step is to administer intravenous furosemide. This patient is experiencing Transfusion-Associated Circulatory Overload (TACO). TACO occurs when a blood product is transfused rapidly or in a large volume, leading to volume overload and cardiogenic pulmonary edema. It is characterized by acute dyspnea, hypoxia, hypertension, tachycardia, and physical exam findings of fluid overload, such as elevated jugular venous pressure (JVP), an S3 gallop, and bilateral basilar lung crackles. The first step in management is always to stop the transfusion. Subsequent management involves respiratory support (oxygen, positive pressure ventilation if necessary) and aggressive diuresis with loop diuretics (e.g., intravenous furosemide) to reduce intravascular volume.

Adım Adım Çözüm

Analyze the patient's symptoms and vital signs that developed during the blood transfusion.

The patient developed acute dyspnea, hypoxia, hypertension (

172/96 \text{ mm Hg}

), elevated jugular venous pressure, basilar crackles, and an S3 gallop.

Identifying the specific symptom cluster and hemodynamic status is necessary to differentiate between the various types of acute transfusion reactions.

Differentiate between Transfusion-Associated Circulatory Overload (TACO) and Transfusion-Related Acute Lung Injury (TRALI).

The presence of hypertension, elevated JVP, and an S3 gallop strongly points to cardiogenic pulmonary edema due to volume overload (TACO), rather than noncardiogenic pulmonary edema (TRALI), which would typically present with hypotension.

Both TACO and TRALI cause respiratory distress during or shortly after transfusion, but their pathophysiology and definitive management differ completely.

Determine the most appropriate management for TACO.

Management includes stopping the transfusion, providing supplemental oxygen, and administering loop diuretics like intravenous furosemide.

Loop diuretics rapidly reduce intravascular volume, alleviating the hydrostatic pressure that causes cardiogenic pulmonary edema.

Anahtar Kavram

Transfusion-associated circulatory overload (TACO) presents with respiratory distress, hypertension, and signs of volume overload (elevated JVP, S3 gallop, crackles) during or within 6 hours of a blood transfusion. Management includes respiratory support and diuresis.

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