A 55-Year-Old Man Is Evaluated for Acute Onset of Respiratory

question 67

Multiple Choice

A 55-year-old man is evaluated for acute onset of respiratory distress.  He was admitted to the hospital after a highway traffic accident, which resulted in a left femur and wrist fracture.  He was immediately taken to the operating room and underwent open reduction and internal fixation.  The total blood loss was estimated at 1.1 liters and he was given 2 liters of intravenous normal saline and one unit of packed red blood cells intraoperatively.  He was extubated and transferred to the postoperative recovery room.  One hour following extubation, he developed acute respiratory distress requiring reintubation.  His other medical problems include inferior wall myocardial infarction with right coronary artery stent placement 3 years ago, hypertension, hyperlipidemia, and type 2 diabetes mellitus.  His home medications include aspirin, metoprolol, lisinopril, metformin, and rosuvastatin.
His temperature is 38.1 C (100.6 F) , blood pressure is 110/70 mm Hg, pulse is 110/min, respirations are 30/min, and oxygen saturation is 90% on 100% FiO₂ and 10 mm Hg of PEEP.  He is drowsy from the sedation and intravenous hydromorphone infusion.  There is no jugular venous distention or lower extremity edema.  Pulmonary examination reveals diffuse crackles throughout the lungs.  There are no heart murmurs.  Skin examination reveals no rashes.
Arterial blood gas shows a pH of 7.47, PaCO₂ of 32 mm Hg, and PaO₂ of 65 mm Hg.
ECG shows sinus tachycardia.  His preoperative chest x-ray was within normal limits.  Repeat chest x-ray taken before reintubation is shown below.

Which of the following is the most likely cause of his current condition?

• A)Anaphylactic transfusion reaction
• B)Aspiration pneumonia
• C)Fat embolism
• D)Transfusion-associated acute lung injury
• E)Volume overload

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