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A 32-year-old woman is admitted to the trauma intensive care unit after a motor vehicle accident. She requires 13 units of packed RBCs and 7 L of crystalloid during resuscitation. Although she has been stable for several hours, she suddenly develops shortness of breath. Her vital signs are notable for oxygen saturation of 91% on 4 L oxygen via nasal cannula and fever to 39°C (102.2°F). An x-ray of the chest performed shows diffuse bilateral pulmonary infiltrates, and a bedside echocardiogram is reportedly normal.
What is the best initial treatment for her condition?
A.Continuous furosemide infusion
B.Corticosteroids
C.Extracorporeal membrane oxygenation
D.Immediate intubation
E.Trial of furosemide and supportive treatment
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so its not D, E or B, try again
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The correct answer is E. 41% chose this.
The patient in the clinical vignette had acute-onset fever, hypoxia, and diffuse pulmonary infiltrates several hours after a blood transfusion, suggesting a diagnosis of transfusion-related acute lung injury (TRALI). TRALI is characterized by the development of symptoms including tachypnea, hypoxia, hypotension, and fever during or shortly after transfusion. The patient should be given a trial of diuresis and supportive measures initiated. Because it is difficult to distinguish TRALI from volume overload (transfusion-associated circulatory overload) in the setting of aggressive resuscitation, a trial of diuresis is often indicated.
A is not correct. 6% chose this.
Continuous furosemide infusions may be helpful for rapid diuresis in the setting of volume overload. Differentiating between TRALI and transfusion-associated circulatory overload can be difficult, but, given this patient's normal echocardiogram, TRALI is the most likely diagnosis, and a continuous furosemide infusion is not indicated.
B is not correct. 9% chose this.
Most cases of TRALI will resolve rapidly and completely with only supportive measures, and the routine use of corticosteroids is not recommended.
C is not correct. 7% chose this.
Extracorporeal membrane oxygenation (ECMO) has been shown to be successful in treating TRALI in one case study following coronary artery bypass grafting. Clearly, ECMO is an extreme intervention and should be reserved for consideration only for the most severe, refractory cases of TRALI.
D is not correct. 37% chose this.
Many cases of TRALI require only supplemental oxygen and will resolve within 48 hours. Therefore immediate intubation may be premature and overly aggressive.
