A 30-year-old man is admitted for observation following a motorcycle collision. He was hemodynamically stable at presentation, and the initial workup revealed an isolated liver laceration. The patient has no chronic medical conditions and takes no medications. He consumes 3-4 alcoholic drinks daily and has been smoking 1 pack of cigarettes daily for the past 10 years. Overnight, his hemoglobin levels acutely decreased, and a packed red blood cell transfusion was ordered. An hour after the transfusion starts, the patient develops difficulty breathing. The transfusion is stopped. Temperature is 36.9 C (98.4 F), blood pressure is 86/42 mm Hg, pulse is 110/min, and respirations are 26/min. Pulse oximetry shows 88% on room air. Lung examination reveals bilateral crackles. Skin examination is normal. Chest x-ray reveals bilateral pulmonary infiltrates. Which of the following is the best next step in management of this patient's respiratory distress?

Question

A 30-year-old man is admitted for observation following a motorcycle collision.  He was hemodynamically stable at presentation, and the initial workup revealed an isolated liver laceration.  The patient has no chronic medical conditions and takes no medications.  He consumes 3-4 alcoholic drinks daily and has been smoking 1 pack of cigarettes daily for the past 10 years.  Overnight, his hemoglobin levels acutely decreased, and a packed red blood cell transfusion was ordered.  An hour after the transfusion starts, the patient develops difficulty breathing.  The transfusion is stopped.  Temperature is 36.9 C (98.4 F), blood pressure is 86/42 mm Hg, pulse is 110/min, and respirations are 26/min.  Pulse oximetry shows 88% on room air.  Lung examination reveals bilateral crackles.  Skin examination is normal.  Chest x-ray reveals bilateral pulmonary infiltrates.  Which of the following is the best next step in management of this patient's respiratory distress?

Quizplus · Accepted Answer

11ec25c8_d914_f924_bc81_e5c3fa0cd56e_MD0003_00 This patient developed respiratory distress, hypotension, and pulmonary infiltrates during blood transfusion, findings concerning for transfusion-related acute lung injury (TRALI). TRALI is an uncommon but potentially fatal transfusion reaction in which neutrophils activated by a component in the transfused blood (eg, anti-leukocyte antibodies) cause damage to pulmonary microvasculature. Risk factors for TRALI include smoking, alcohol abuse, and critical illness. Damage to the capillary endothelium results in inflammatory pulmonary edema. Hypoxia and dyspnea develop within 6 hours after transfusion initiation. Tachycardia, hypotension, and fever may also be present. Chest x-ray reveals bilateral pulmonary infiltrates. Treatment of TRALI includes immediate transfusion cessation and respiratory supportive care; most patients require ventilatory support. Some patients recover within 24-48 hours, but up to 50% of previously critically ill patients expire. (Choice A) Anticoagulation is indicated for pulmonary embolism, which causes tachycardia and hypoxia. Bilateral pulmonary infiltrates would be unusual, and the temporal association with transfusion makes TRALI more likely. (Choice B) Broad-spectrum antibiotics are administered for transfusion-transmitted bacterial infection, which most commonly occurs after platelet transfusion and presents with fever, rigors, tachycardia, and hypotension. This patient's pulmonary findings and lack of fever make this diagnosis unlikely. (Choice C) Diuretic therapy is the treatment for transfusion-associated circulatory overload (TACO). Patients have respiratory distress within 6 hours after transfusion initiation; however, hypertension due to fluid overload is typically present. In addition, this patient has not received a significant amount of fluid, making TACO less likely. (Choice D) In addition to intramuscular epinephrine, intravenous antihistamine administration is indicated in anaphylactic transfusion reactions, which can present with respiratory distress and hypotension. However, anaphylaxis occurs within minutes after transfusion initiation. Moreover, examination typically reveals wheezing (not crackles), and pulmonary infiltrates would not be seen. Educational objective: Transfusion-related acute lung injury is a potentially fatal transfusion reaction, presenting with acute dyspnea and hypoxia, bilateral pulmonary infiltrates, and possible hypotension. Management involves transfusion cessation and respiratory supportive care. References: Blood transfusion associated lung injury. (http://www.ncbi.nlm.nih.gov/pubmed/31559068)

A 30-Year-Old Man Is Admitted for Observation Following a Motorcycle