A 52-Year-Old Man With Pulmonary Edema Following Large-Volume Transfusion

Abstract

A 52-year-old man with a history of mild hepatitis C cirrhosis presented with a chief complaint of several weeks of postprandial abdominal pain and anorexia. He had no history of coagulopathy, ascites, varices, or hepatic encephalopathy. Evaluation revealed portal venous thromboses, and he underwent catheter-directed thrombolysis with tissue plasminogen activator (tPA). He was admitted to the medical ICU for routine postprocedure monitoring while receiving continuous tPA. On admission, he was alert and oriented, jaundiced, and the examination was otherwise unremarkable. The hemoglobin level prior to the procedure was 12.5 g/dL. Following the procedure, hemoglobin was stable on two serial measurements. Platelet count was 126,000/ L, and renal function, electrolytes, and international normalized ratio were normal. Portal venous flow was restored after 30 h of tPA infusion and angioplasty. The tPA was discontinued, and heparin infusion was begun. His abdominal examination revealed slight right upper quadrant tenderness without guarding or rebound tenderness. Several hours later, he became tachycardic and febrile to 38.4°C. His hemoglobin fell to 10.3 g/dL. Abdominal CT scan revealed a hemoperitoneum. Heparin was discontinued, blood culture specimens were drawn, and cefepime and metronidazole were begun. Because he had already had no food for several days, 10% dextrose solution was ordered as a temporary calorie source. Through the following day, hemoglobin fell to 7.4 g/dL, and his platelet count decreased to 65,000/ L. The international normalized ratio remained normal, and the activated partial thrombin time corrected after heparin was discontinued. His renal function remained normal. He received transfusions of packed RBCs, platelets, and fresh-frozen plasma. Over the course of the next day, progressive dyspnea and tachypnea developed, with an increased oxygen requirement. His BP was normal, although his pulse was elevated to 112 beats/min. Physical examination showed jugular venous distension and coarse bilateral rales. Blood gas on a 100% oxygen mask showed pH 7.36, Paco2 of 43 mm Hg, and Pao2 of 63 mm Hg. ECG was normal. Chest radiography revealed new diffuse bilateral alveolar infiltrates (Fig 1, 2). IV fluids were decreased, and he was treated with furosemide but nevertheless required intubation for hypoxemia. Two days after intubation, his nurse discovered that the patient was receiving 10% low-molecular-weight dextran 40 in 5% dextrose solution, instead of the 10% dextrose that had been ordered.