TRALI You May Lose, If You Transfuse.
Haney A. Mallemat, MDDepartment of Critical CareDartmouth-Hitchcock Medical Center
Clinical Case• 77 M• AAA repair• POD #3
• Extubated• Stable vitals• Hb 8.1
Evening Vascular Rounds…
• 2U PRBC• No indication documented
3 hours later…• Respiratory distress
• 85% sat• 85/50 • P: 125
• STAT Airway• Levophed
OUTLINE• Definition• Epidemiology• Pathogenesis• Diagnosis• Treatment• Prognosis
Definition• Epidemiology• Pathogenesis• Diagnosis• Treatment• Prognosis
1951• Pulmonary Hypersensitivity Reaction
• Allergic Pulmonary Edema
• Non-Cardiogenic Pulmonary Edema
• Pulmonary Leucoagglutinin Reaction
1983: Dr. Popovosky
Transfusion-Associated Popovoskitis
•TRansfusion
•Associated
•Lung
•Injury
Definition
• No formal definition
TRALI Consensus Conference
• ALI from blood products• P/F ratio <300• B/L infiltrates• No circulatory overload• No previous ALI• No causes ALI
TRALI“Classic” TRALI
< 6 h ▪~30-120 min
“Delayed” TRALI6 – 72 h
• DefinitionEpidemiology• Pathogenesis• Diagnosis• Treatment• Prognosis
Epidemiology• #1 transfusion-related mortality• >Infection• >ABO mismatch
• Under recognized / reported
• Mortality 5-10%
Epidemiology• PRBC 1 in 5000• Plasma 1 in 2000• Platelets 1 in 2000
• IVIG• Cryoprecipitate• Stem cells
Risk FactorsHOST
• M = F• Recent surgery• Active infections• Recent transfusion• Cytokine treatment• Thrombocytopenia• Increased age• Ethanol use• Tobacco• Severe illness
DONOR
• Multi-parous female donors• Prolonged blood storage
• Definition• EpidemiologyPathogenesis• Diagnosis• Treatment• Prognosis
3 Theories…1. Anti-granulocyte antibody
2. Endothelial-cell priming
3. “Two-hit” hypothesis
• Definition• Epidemiology• PathogenesisDiagnosis• Treatment• Prognosis
Clinical Presentation• Mild symptoms• • •
• • Death
Non-Specific Si/Sx• Fever• Dyspnea• Tachypnea• Tachycardia• Hypotension• Hypertension• No lung findings• Crackles• Retractions
• No S3• Frothy sputum• Cough• No JVD• No cardiomegaly• Non-cardiac edema• Leukopenia• Thrombocytpoenia• Hyponatremia
Question 1: Recent Transfusion?
Question 2: Acute Lung Injury
• <6 hours
• Hypoxemia• P/F <300• O2sat <90%
• B/l infiltrates
• No evidence of HF
Bilateral pulmonary infiltrates
Question 3: R/o other causes of ALI
• Aspiration• Pneumonia• Toxic inhalation• Lung contusion• Near drowning• Severe sepsis
• Shock• Trauma• Burns• Pancreatitis• Bypass surgery• Drug overdose
Question 4: R/o volume overload
• CHF• Nephrotic syndrome• Fluid overload• Post-sepsis• ESRD• AKI
Diagnosis: Physical Exam
• Frothy sputum•Hypoxia• Tachycardia•Hypotension• Fever
Diagnosis: Radiology
• CXR
Diagnosis: Lab Tests
Diagnosis: Nursing
• Rare and subtle diagnosis
• Subtlety is your specialty• Notice changes first
• Key to diagnosis• Stick to your guns
• Definition• Pathogenesis• Epidemiology• DiagnosisTreatment• Prognosis
Treatment• Stop transfusion!• Report reaction
• Supportive Care
Treatment• Hemodynamic support• Fluids +/- pressors• No diuresis!• “Wet” CXR confusing
• Ventilatory support• NIPPV vs. Intubate • Lung protective strategy
Treatment• Need transfusion?• Single donor units• Leukodepleted blood• Newer blood
• Definition• Pathogenesis• Epidemiology• Diagnosis• TreatmentPrognosis
Prognosis
Live
Prognosis
Die
Live?• Recovery 24 – 96
• No long-term sequelae
• CXR lingers
Practice Guidelines
Bottom LineTransfusion + Clinical decline =
TRALI
Summary Questions• What is the #1 cause of #1 transfusion related
mortality?• What transfusion reaction is very under
reported and under-recognized?• What can any blood product cause?• What should you think about if there is any
clinical change within 6 hours of transfusion? • Who is the most important person to
recognize TRALI?
• Supportive Good prognosis
• Question all transfusions!
Thank you DHMC!