Today, we’re examining a clinical case of a patient who’s undergoing a red blood cell transfusion. Thirty minutes into the transfusion, he suddenly develops dyspnea, cough, and chest tightness. What’s the next step in management?
A 58-year-old man is undergoing a red blood cell transfusion. Thirty minutes into the transfusion, he suddenly develops dyspnea, cough, and chest tightness. Past medical history is significant for hypertension and type 2 diabetes mellitus. Temperature is 38.7°C (101.7°F), heart rate is 110/min, blood pressure is 90/50 mmHg, respiratory rate is 28/min, and oxygen saturation is 88% on room air. On physical examination, he appears anxious and tachypneic. There is no rash or urticaria. Auscultation of the lungs reveals bilateral rales without wheezing. There is no lower extremity edema.
Which of the following is the best next step in management?
A. Stop the blood transfusion and provide respiratory support
B. Stop the blood transfusion and administer intravenous (IV) methylprednisolone
C. Stop the blood transfusion and administer intravenous (IV) furosemide
D. Continue the blood transfusion and administer intramuscular (IM) epinephrine
E. Continue the blood transfusion and initiate intravenous (IV) broad-spectrum antibiotics
Scroll down for the correct answer!
The correct answer to today’s USMLE® Step 2 Question is…
A. Stop the blood transfusion and provide respiratory support
Correct: See Main Explanation.
Incorrect Answer Explanations
B. Stop the blood transfusion and administer intravenous (IV) methylprednisolone
Incorrect: This patient likely has transfusion-related acute lung injury (TRALI). While the transfusion should be stopped, corticosteroids are not generally recommended for the treatment of TRALI. The immediate focus should be on providing respiratory support.
C. Stop the blood transfusion and administer intravenous (IV) furosemide
Incorrect: This patient likely has transfusion-related acute lung injury (TRALI). Stopping the transfusion is appropriate, but administering IV furosemide is not an appropriate treatment of TRALI. It is indicated for transfusion-associated circulatory overload (TACO), which is characterized by volume overload; whereas TRALI involves noncardiogenic pulmonary edema.
D. Continue the blood transfusion and administer intramuscular (IM) epinephrine
Incorrect: Continuing the transfusion is contraindicated in the context of a suspected transfusion reaction. Epinephrine is used for anaphylactic reactions, not for transfusion-related acute lung injury (TRALI), and continuing the transfusion could worsen the patient’s condition.
E. Continue the blood transfusion and initiate intravenous (IV) broad-spectrum antibiotics
Incorrect: This patient likely has transfusion-related acute lung injury (TRALI). Continuing the blood transfusion in the presence of acute respiratory symptoms suggestive of a transfusion reaction is inappropriate. While the symptoms may mimic sepsis, the temporal relation to the transfusion is more suggestive of TRALI, and antibiotics are not indicated.
Main Explanation
This patient exhibits sudden onset dyspnea, cough, chest tightness, hypotension, and hypoxemia during a blood transfusion and most likely has transfusion-related acute lung injury (TRALI). TRALI is a life-threatening complication of blood transfusions that is characterized by acute respiratory distress and noncardiogenic pulmonary edema. It typically occurs during or shortly after a blood transfusion. Management of TRALI involves immediate cessation of the blood transfusion and immediate airway and hemodynamic stabilization.
TRALI is caused by donor antibodies reacting against the recipient’s leukocytes, leading to capillary leak and pulmonary edema. The first step in management involves stopping the blood transfusion to prevent further exposure to donor antibodies. Next, patients should receive supportive care with oxygen and mechanical ventilation if needed. This condition can rapidly progress to severe hypoxemia and respiratory failure.
Major Takeaway
TRALI is characterized by acute respiratory distress and noncardiogenic pulmonary edema. In cases of transfusion-related acute lung injury (TRALI), critical steps in management include stopping the blood transfusion and providing respiratory support.
Want to learn more about this topic?
Watch the Osmosis video: Pulmonary transfusion reactions: Clinical sciences
References
- Semple JW, Rebetz J, Kapur R. Transfusion-associated circulatory overload and transfusion-related acute lung injury. Blood. 2019;133(17):1840-1853. doi:10.1182/blood-2018-10-860809
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