TRANSFUSION-RELATED ACUTE LUNG
INJURY( TRALI)
DR VEERESH
MMC RI MYSORE
Introduction
bull Transfusion-related acute lung injury (TRALI)
represents Acute Lung Injury(ALI) after transfusion of
one or more plasma-containing blood products
developing within 6 hours of completion of transfusion
bull Though not uncommon it is difficult to prove as the cause
for the ALI as there is lack of knowledge about it
bull It has emerged as the most important cause of morbidity
and mortality resulting from blood transfusion
bull
bull Transfusion-related acute lung injury (TRALI) is a rare
complication of blood transfusion
bull The incidence reported in 1985 was 1 in 5000 U transfused But
recent studies shows that incidence is 1 in1000 to 2400 units
bull Plasma containing blood components such as whole blood
platelet concentrates fresh frozen plasma packed red cells
granulocytes cryoprecipitate and intravenous
immunoglobulin have all been implicated as a possible cause of
TRALI
Clinical features of transfusion-related acute lung injury
Dyspnoearespiratory distress requiring oxygen support Virtually all
Requiring mechanical ventilation 70
Documented hypoxemia Virtually all
Cyanosis Very common
Hypotension Majority
Fever Very common
Hypertension Unusual
DEFINITION
bull A Working Party on Definitions of Adverse Transfusion Events
was established by the European Haemovigilance Network
(EHN) This group has suggested that the following be the
minimum requirements for a clinical diagnosis of TRALI
bull 1) the occurrence of acute respiratory distress during or within 6
hrs of transfusion
bull 2) absence of signs of circulatory overload
bull 3) radiographic evidence of bilateral pulmonary infiltrates
bull Also has been defined by the Canadian Consensus Conference
Panel on TRALI and by National Heart Lung and Blood
Institute (NHLBI) Working Group on TRALI as new acute lung
injury (ALI) within six hours of a completed transfusion
bull Applying this definition TRALI is a clinical syndrome rather than
a disease with a single aetiology
Canadian Consensus Conference Proposed Criteria for
Transfusion -Related Acute Lung Injury (TRALI)
Criteria for TRALI
Acute lung injury (ALI)Acute onset Hypoxemia
In research setting
Ratio of PaO2FiO2 lt300 or
SpO2 lt90 at room air
Non research settingRatio of PaO2FiO2 lt300 or
SpO2 lt90 at room air
Other clinical evidence of hypoxia
Bilateral infiltrates on frontal chest radiograph
No evidence of left atrial hypertension (ie circulatory overload)
No preexisting AL I before transfus ion d uring or within 6 h of transfusion andNo temporal relationship to an alternative risk factor for ALI
Criteria for possible TRALI
Acute lung injury (ALI )
No preexisting ALI before transfusion
During or within 6 h of transfusion andA clear tempora l rela tionship to an alternative risk factor for ALI
The National Heart Lung and Blood Institute (NHLBI) Working
Group recognized that ALI in patients with other recognized risk
factor (such as trauma sepsis) would be difficult to classify as
TRALI and such cases would be designated as indeterminate
bull The Consensus Panel designates these indeterminate cases
as possible TRALI a category used by the Consensus Panel
for cases in which ALI is temporally related to a transfusion in
the presence of one other risk factor for ALI
bull The guidelines recommend classifying each suspected case in
one of the following 3 categories (1) TRALI(2) Possible
TRALI or (3) Not TRALI
bull Laboratory tests which strongly support but are not required for
the clinical diagnosis of TRALI include the
bull Demonstration of human leukocyte antigen (HLA) class I or class
II or
bull Neutrophil-specific antibodies in donor plasma
PATHOGENESIS
bull The exact pathogenesis of TRALI is not known thus several
theories have been proposed Two basic mechanisms have
been proposed for the pathogenesis of TRALI for
immune competent hosts
(1) single event hypothesis
(2) Two-event model
bull Other possible mechanisms - Several other explanations for
TRALI have been suggested but these are not supported by
clinical and experimental evidence
bull These include direct injury to pulmonary endothelium
bull Immune complex formation with complement activation and
bull Cytokine network activation
RISK FACTORS
Multiparous donors
Blood components platelet Concentratesgtfresh frozen
plasmagtpacked red cellsgtgranulocytesgtcryoprecipitategt
intravenous immunoglobulin
Massive transfusion
bull Stored blood products Inflammatory mediators like cytokines
and lipid soluble substances accumulate during storage of blood
products
bull Underlying clinical condition Factors such as trauma major
surgery sepsis may serve as initial priming event in the
development of TRALI (Two event hypothesis)
MANAGEMENT
Immediate Actions When Considering the
Diagnosis of Transfusion -Related Acute Lung Injury
1 Stop the transfusion immediately
2 Support the patient
3 If the patient is intubated obtain undiluted edema fluid as soon as possible
(preferably within 15 min) and simultaneous plasma for determination of total protein
concentrations
4 Obtain a complete blood count with differential and chest radiograph
5 Notify the blood bank of possible transfusion-related acute lung injury request a
different unit and quarantine other units from the same donor
6 Follow institutional policies for a trans fusion reaction workup and send blood
bank
bull A patient blood specimenbull Bags from units of blood transfused in the last 6 h
bull A copy of transfus ion record forms
bull Indicate the last unit transfused if possible
bull Results of the patient rsquos human leukocyte antigen type if available
bull For mild TRALI cases supplemental oxygen and supportive
care may be sufficient
bull For the most severe cases IV fluids mechanical or non-
invasive ventilation and invasive cardiovascular monitoring
may be required A low tidal volume strategy with low plateau
pressures should be employed when ventilating TRALI
patients just like other causes of ALIARDS
bull Extracorporeal membrane oxygenation has been used
successfully in a severe case of TRALI
bull Other less well-documented and unproven therapies (eg
diuretics corticosteroids prostaglandin E1) have also been
used
PREVENTION
bull Avoiding blood from multiparous women these women are at the
risk of producing anti-leucocyte antibodies during previous
pregnancies
bull Donors whose blood has resulted in TRALI like reaction
previously
bull Blood which has been stored for long duration long storage
results in production of anti-leucocyte antibodies
bull Not using whole blood
bull Leukoreduction can be done by ɤ - irradiation of the blood
componentor by using micro filters in the transfusion setsor by
using centrifuged blood component which has reduced leucocytes
Transfusion Associated Circulatory
Overload(TACO)
bull There is no universally agreed-upon definition for what
constitutes TACO
bull During or within several hours of transfusion If patients
develop respiratory distress orthopnea cyanosis
tachycardia and hypertension
bull Rales on auscultation
bull Some patients may have raised JVP an S3 on cardiac
auscultation or lower limb edema A chest radiograph can
reveal cardiomegaly and interstitial infiltrates
All patients with TACO may not have all these
abnormalities
Highest risk for TACO include those younger than 3 and
those older than 60 years of age particularly those with
underlying cardiac dysfunction
The pathogenesis of TACO is similar to other
causes of acute congestive heart failure an increase in
central venous pressure and pulmonary blood volume
causes an increase in hydrostatic pressure leading to fluid
extravasation into the alveolar space
Treatment of TACO starts with discontinuing any
ongoing transfusion
Respiratory distress is treated with
the degree of respiratory support needed to maintain the
patientrsquos oxygenation
Diuretics are administered to
remove excess fluid
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
Introduction
bull Transfusion-related acute lung injury (TRALI)
represents Acute Lung Injury(ALI) after transfusion of
one or more plasma-containing blood products
developing within 6 hours of completion of transfusion
bull Though not uncommon it is difficult to prove as the cause
for the ALI as there is lack of knowledge about it
bull It has emerged as the most important cause of morbidity
and mortality resulting from blood transfusion
bull
bull Transfusion-related acute lung injury (TRALI) is a rare
complication of blood transfusion
bull The incidence reported in 1985 was 1 in 5000 U transfused But
recent studies shows that incidence is 1 in1000 to 2400 units
bull Plasma containing blood components such as whole blood
platelet concentrates fresh frozen plasma packed red cells
granulocytes cryoprecipitate and intravenous
immunoglobulin have all been implicated as a possible cause of
TRALI
Clinical features of transfusion-related acute lung injury
Dyspnoearespiratory distress requiring oxygen support Virtually all
Requiring mechanical ventilation 70
Documented hypoxemia Virtually all
Cyanosis Very common
Hypotension Majority
Fever Very common
Hypertension Unusual
DEFINITION
bull A Working Party on Definitions of Adverse Transfusion Events
was established by the European Haemovigilance Network
(EHN) This group has suggested that the following be the
minimum requirements for a clinical diagnosis of TRALI
bull 1) the occurrence of acute respiratory distress during or within 6
hrs of transfusion
bull 2) absence of signs of circulatory overload
bull 3) radiographic evidence of bilateral pulmonary infiltrates
bull Also has been defined by the Canadian Consensus Conference
Panel on TRALI and by National Heart Lung and Blood
Institute (NHLBI) Working Group on TRALI as new acute lung
injury (ALI) within six hours of a completed transfusion
bull Applying this definition TRALI is a clinical syndrome rather than
a disease with a single aetiology
Canadian Consensus Conference Proposed Criteria for
Transfusion -Related Acute Lung Injury (TRALI)
Criteria for TRALI
Acute lung injury (ALI)Acute onset Hypoxemia
In research setting
Ratio of PaO2FiO2 lt300 or
SpO2 lt90 at room air
Non research settingRatio of PaO2FiO2 lt300 or
SpO2 lt90 at room air
Other clinical evidence of hypoxia
Bilateral infiltrates on frontal chest radiograph
No evidence of left atrial hypertension (ie circulatory overload)
No preexisting AL I before transfus ion d uring or within 6 h of transfusion andNo temporal relationship to an alternative risk factor for ALI
Criteria for possible TRALI
Acute lung injury (ALI )
No preexisting ALI before transfusion
During or within 6 h of transfusion andA clear tempora l rela tionship to an alternative risk factor for ALI
The National Heart Lung and Blood Institute (NHLBI) Working
Group recognized that ALI in patients with other recognized risk
factor (such as trauma sepsis) would be difficult to classify as
TRALI and such cases would be designated as indeterminate
bull The Consensus Panel designates these indeterminate cases
as possible TRALI a category used by the Consensus Panel
for cases in which ALI is temporally related to a transfusion in
the presence of one other risk factor for ALI
bull The guidelines recommend classifying each suspected case in
one of the following 3 categories (1) TRALI(2) Possible
TRALI or (3) Not TRALI
bull Laboratory tests which strongly support but are not required for
the clinical diagnosis of TRALI include the
bull Demonstration of human leukocyte antigen (HLA) class I or class
II or
bull Neutrophil-specific antibodies in donor plasma
PATHOGENESIS
bull The exact pathogenesis of TRALI is not known thus several
theories have been proposed Two basic mechanisms have
been proposed for the pathogenesis of TRALI for
immune competent hosts
(1) single event hypothesis
(2) Two-event model
bull Other possible mechanisms - Several other explanations for
TRALI have been suggested but these are not supported by
clinical and experimental evidence
bull These include direct injury to pulmonary endothelium
bull Immune complex formation with complement activation and
bull Cytokine network activation
RISK FACTORS
Multiparous donors
Blood components platelet Concentratesgtfresh frozen
plasmagtpacked red cellsgtgranulocytesgtcryoprecipitategt
intravenous immunoglobulin
Massive transfusion
bull Stored blood products Inflammatory mediators like cytokines
and lipid soluble substances accumulate during storage of blood
products
bull Underlying clinical condition Factors such as trauma major
surgery sepsis may serve as initial priming event in the
development of TRALI (Two event hypothesis)
MANAGEMENT
Immediate Actions When Considering the
Diagnosis of Transfusion -Related Acute Lung Injury
1 Stop the transfusion immediately
2 Support the patient
3 If the patient is intubated obtain undiluted edema fluid as soon as possible
(preferably within 15 min) and simultaneous plasma for determination of total protein
concentrations
4 Obtain a complete blood count with differential and chest radiograph
5 Notify the blood bank of possible transfusion-related acute lung injury request a
different unit and quarantine other units from the same donor
6 Follow institutional policies for a trans fusion reaction workup and send blood
bank
bull A patient blood specimenbull Bags from units of blood transfused in the last 6 h
bull A copy of transfus ion record forms
bull Indicate the last unit transfused if possible
bull Results of the patient rsquos human leukocyte antigen type if available
bull For mild TRALI cases supplemental oxygen and supportive
care may be sufficient
bull For the most severe cases IV fluids mechanical or non-
invasive ventilation and invasive cardiovascular monitoring
may be required A low tidal volume strategy with low plateau
pressures should be employed when ventilating TRALI
patients just like other causes of ALIARDS
bull Extracorporeal membrane oxygenation has been used
successfully in a severe case of TRALI
bull Other less well-documented and unproven therapies (eg
diuretics corticosteroids prostaglandin E1) have also been
used
PREVENTION
bull Avoiding blood from multiparous women these women are at the
risk of producing anti-leucocyte antibodies during previous
pregnancies
bull Donors whose blood has resulted in TRALI like reaction
previously
bull Blood which has been stored for long duration long storage
results in production of anti-leucocyte antibodies
bull Not using whole blood
bull Leukoreduction can be done by ɤ - irradiation of the blood
componentor by using micro filters in the transfusion setsor by
using centrifuged blood component which has reduced leucocytes
Transfusion Associated Circulatory
Overload(TACO)
bull There is no universally agreed-upon definition for what
constitutes TACO
bull During or within several hours of transfusion If patients
develop respiratory distress orthopnea cyanosis
tachycardia and hypertension
bull Rales on auscultation
bull Some patients may have raised JVP an S3 on cardiac
auscultation or lower limb edema A chest radiograph can
reveal cardiomegaly and interstitial infiltrates
All patients with TACO may not have all these
abnormalities
Highest risk for TACO include those younger than 3 and
those older than 60 years of age particularly those with
underlying cardiac dysfunction
The pathogenesis of TACO is similar to other
causes of acute congestive heart failure an increase in
central venous pressure and pulmonary blood volume
causes an increase in hydrostatic pressure leading to fluid
extravasation into the alveolar space
Treatment of TACO starts with discontinuing any
ongoing transfusion
Respiratory distress is treated with
the degree of respiratory support needed to maintain the
patientrsquos oxygenation
Diuretics are administered to
remove excess fluid
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
bull Transfusion-related acute lung injury (TRALI) is a rare
complication of blood transfusion
bull The incidence reported in 1985 was 1 in 5000 U transfused But
recent studies shows that incidence is 1 in1000 to 2400 units
bull Plasma containing blood components such as whole blood
platelet concentrates fresh frozen plasma packed red cells
granulocytes cryoprecipitate and intravenous
immunoglobulin have all been implicated as a possible cause of
TRALI
Clinical features of transfusion-related acute lung injury
Dyspnoearespiratory distress requiring oxygen support Virtually all
Requiring mechanical ventilation 70
Documented hypoxemia Virtually all
Cyanosis Very common
Hypotension Majority
Fever Very common
Hypertension Unusual
DEFINITION
bull A Working Party on Definitions of Adverse Transfusion Events
was established by the European Haemovigilance Network
(EHN) This group has suggested that the following be the
minimum requirements for a clinical diagnosis of TRALI
bull 1) the occurrence of acute respiratory distress during or within 6
hrs of transfusion
bull 2) absence of signs of circulatory overload
bull 3) radiographic evidence of bilateral pulmonary infiltrates
bull Also has been defined by the Canadian Consensus Conference
Panel on TRALI and by National Heart Lung and Blood
Institute (NHLBI) Working Group on TRALI as new acute lung
injury (ALI) within six hours of a completed transfusion
bull Applying this definition TRALI is a clinical syndrome rather than
a disease with a single aetiology
Canadian Consensus Conference Proposed Criteria for
Transfusion -Related Acute Lung Injury (TRALI)
Criteria for TRALI
Acute lung injury (ALI)Acute onset Hypoxemia
In research setting
Ratio of PaO2FiO2 lt300 or
SpO2 lt90 at room air
Non research settingRatio of PaO2FiO2 lt300 or
SpO2 lt90 at room air
Other clinical evidence of hypoxia
Bilateral infiltrates on frontal chest radiograph
No evidence of left atrial hypertension (ie circulatory overload)
No preexisting AL I before transfus ion d uring or within 6 h of transfusion andNo temporal relationship to an alternative risk factor for ALI
Criteria for possible TRALI
Acute lung injury (ALI )
No preexisting ALI before transfusion
During or within 6 h of transfusion andA clear tempora l rela tionship to an alternative risk factor for ALI
The National Heart Lung and Blood Institute (NHLBI) Working
Group recognized that ALI in patients with other recognized risk
factor (such as trauma sepsis) would be difficult to classify as
TRALI and such cases would be designated as indeterminate
bull The Consensus Panel designates these indeterminate cases
as possible TRALI a category used by the Consensus Panel
for cases in which ALI is temporally related to a transfusion in
the presence of one other risk factor for ALI
bull The guidelines recommend classifying each suspected case in
one of the following 3 categories (1) TRALI(2) Possible
TRALI or (3) Not TRALI
bull Laboratory tests which strongly support but are not required for
the clinical diagnosis of TRALI include the
bull Demonstration of human leukocyte antigen (HLA) class I or class
II or
bull Neutrophil-specific antibodies in donor plasma
PATHOGENESIS
bull The exact pathogenesis of TRALI is not known thus several
theories have been proposed Two basic mechanisms have
been proposed for the pathogenesis of TRALI for
immune competent hosts
(1) single event hypothesis
(2) Two-event model
bull Other possible mechanisms - Several other explanations for
TRALI have been suggested but these are not supported by
clinical and experimental evidence
bull These include direct injury to pulmonary endothelium
bull Immune complex formation with complement activation and
bull Cytokine network activation
RISK FACTORS
Multiparous donors
Blood components platelet Concentratesgtfresh frozen
plasmagtpacked red cellsgtgranulocytesgtcryoprecipitategt
intravenous immunoglobulin
Massive transfusion
bull Stored blood products Inflammatory mediators like cytokines
and lipid soluble substances accumulate during storage of blood
products
bull Underlying clinical condition Factors such as trauma major
surgery sepsis may serve as initial priming event in the
development of TRALI (Two event hypothesis)
MANAGEMENT
Immediate Actions When Considering the
Diagnosis of Transfusion -Related Acute Lung Injury
1 Stop the transfusion immediately
2 Support the patient
3 If the patient is intubated obtain undiluted edema fluid as soon as possible
(preferably within 15 min) and simultaneous plasma for determination of total protein
concentrations
4 Obtain a complete blood count with differential and chest radiograph
5 Notify the blood bank of possible transfusion-related acute lung injury request a
different unit and quarantine other units from the same donor
6 Follow institutional policies for a trans fusion reaction workup and send blood
bank
bull A patient blood specimenbull Bags from units of blood transfused in the last 6 h
bull A copy of transfus ion record forms
bull Indicate the last unit transfused if possible
bull Results of the patient rsquos human leukocyte antigen type if available
bull For mild TRALI cases supplemental oxygen and supportive
care may be sufficient
bull For the most severe cases IV fluids mechanical or non-
invasive ventilation and invasive cardiovascular monitoring
may be required A low tidal volume strategy with low plateau
pressures should be employed when ventilating TRALI
patients just like other causes of ALIARDS
bull Extracorporeal membrane oxygenation has been used
successfully in a severe case of TRALI
bull Other less well-documented and unproven therapies (eg
diuretics corticosteroids prostaglandin E1) have also been
used
PREVENTION
bull Avoiding blood from multiparous women these women are at the
risk of producing anti-leucocyte antibodies during previous
pregnancies
bull Donors whose blood has resulted in TRALI like reaction
previously
bull Blood which has been stored for long duration long storage
results in production of anti-leucocyte antibodies
bull Not using whole blood
bull Leukoreduction can be done by ɤ - irradiation of the blood
componentor by using micro filters in the transfusion setsor by
using centrifuged blood component which has reduced leucocytes
Transfusion Associated Circulatory
Overload(TACO)
bull There is no universally agreed-upon definition for what
constitutes TACO
bull During or within several hours of transfusion If patients
develop respiratory distress orthopnea cyanosis
tachycardia and hypertension
bull Rales on auscultation
bull Some patients may have raised JVP an S3 on cardiac
auscultation or lower limb edema A chest radiograph can
reveal cardiomegaly and interstitial infiltrates
All patients with TACO may not have all these
abnormalities
Highest risk for TACO include those younger than 3 and
those older than 60 years of age particularly those with
underlying cardiac dysfunction
The pathogenesis of TACO is similar to other
causes of acute congestive heart failure an increase in
central venous pressure and pulmonary blood volume
causes an increase in hydrostatic pressure leading to fluid
extravasation into the alveolar space
Treatment of TACO starts with discontinuing any
ongoing transfusion
Respiratory distress is treated with
the degree of respiratory support needed to maintain the
patientrsquos oxygenation
Diuretics are administered to
remove excess fluid
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
Clinical features of transfusion-related acute lung injury
Dyspnoearespiratory distress requiring oxygen support Virtually all
Requiring mechanical ventilation 70
Documented hypoxemia Virtually all
Cyanosis Very common
Hypotension Majority
Fever Very common
Hypertension Unusual
DEFINITION
bull A Working Party on Definitions of Adverse Transfusion Events
was established by the European Haemovigilance Network
(EHN) This group has suggested that the following be the
minimum requirements for a clinical diagnosis of TRALI
bull 1) the occurrence of acute respiratory distress during or within 6
hrs of transfusion
bull 2) absence of signs of circulatory overload
bull 3) radiographic evidence of bilateral pulmonary infiltrates
bull Also has been defined by the Canadian Consensus Conference
Panel on TRALI and by National Heart Lung and Blood
Institute (NHLBI) Working Group on TRALI as new acute lung
injury (ALI) within six hours of a completed transfusion
bull Applying this definition TRALI is a clinical syndrome rather than
a disease with a single aetiology
Canadian Consensus Conference Proposed Criteria for
Transfusion -Related Acute Lung Injury (TRALI)
Criteria for TRALI
Acute lung injury (ALI)Acute onset Hypoxemia
In research setting
Ratio of PaO2FiO2 lt300 or
SpO2 lt90 at room air
Non research settingRatio of PaO2FiO2 lt300 or
SpO2 lt90 at room air
Other clinical evidence of hypoxia
Bilateral infiltrates on frontal chest radiograph
No evidence of left atrial hypertension (ie circulatory overload)
No preexisting AL I before transfus ion d uring or within 6 h of transfusion andNo temporal relationship to an alternative risk factor for ALI
Criteria for possible TRALI
Acute lung injury (ALI )
No preexisting ALI before transfusion
During or within 6 h of transfusion andA clear tempora l rela tionship to an alternative risk factor for ALI
The National Heart Lung and Blood Institute (NHLBI) Working
Group recognized that ALI in patients with other recognized risk
factor (such as trauma sepsis) would be difficult to classify as
TRALI and such cases would be designated as indeterminate
bull The Consensus Panel designates these indeterminate cases
as possible TRALI a category used by the Consensus Panel
for cases in which ALI is temporally related to a transfusion in
the presence of one other risk factor for ALI
bull The guidelines recommend classifying each suspected case in
one of the following 3 categories (1) TRALI(2) Possible
TRALI or (3) Not TRALI
bull Laboratory tests which strongly support but are not required for
the clinical diagnosis of TRALI include the
bull Demonstration of human leukocyte antigen (HLA) class I or class
II or
bull Neutrophil-specific antibodies in donor plasma
PATHOGENESIS
bull The exact pathogenesis of TRALI is not known thus several
theories have been proposed Two basic mechanisms have
been proposed for the pathogenesis of TRALI for
immune competent hosts
(1) single event hypothesis
(2) Two-event model
bull Other possible mechanisms - Several other explanations for
TRALI have been suggested but these are not supported by
clinical and experimental evidence
bull These include direct injury to pulmonary endothelium
bull Immune complex formation with complement activation and
bull Cytokine network activation
RISK FACTORS
Multiparous donors
Blood components platelet Concentratesgtfresh frozen
plasmagtpacked red cellsgtgranulocytesgtcryoprecipitategt
intravenous immunoglobulin
Massive transfusion
bull Stored blood products Inflammatory mediators like cytokines
and lipid soluble substances accumulate during storage of blood
products
bull Underlying clinical condition Factors such as trauma major
surgery sepsis may serve as initial priming event in the
development of TRALI (Two event hypothesis)
MANAGEMENT
Immediate Actions When Considering the
Diagnosis of Transfusion -Related Acute Lung Injury
1 Stop the transfusion immediately
2 Support the patient
3 If the patient is intubated obtain undiluted edema fluid as soon as possible
(preferably within 15 min) and simultaneous plasma for determination of total protein
concentrations
4 Obtain a complete blood count with differential and chest radiograph
5 Notify the blood bank of possible transfusion-related acute lung injury request a
different unit and quarantine other units from the same donor
6 Follow institutional policies for a trans fusion reaction workup and send blood
bank
bull A patient blood specimenbull Bags from units of blood transfused in the last 6 h
bull A copy of transfus ion record forms
bull Indicate the last unit transfused if possible
bull Results of the patient rsquos human leukocyte antigen type if available
bull For mild TRALI cases supplemental oxygen and supportive
care may be sufficient
bull For the most severe cases IV fluids mechanical or non-
invasive ventilation and invasive cardiovascular monitoring
may be required A low tidal volume strategy with low plateau
pressures should be employed when ventilating TRALI
patients just like other causes of ALIARDS
bull Extracorporeal membrane oxygenation has been used
successfully in a severe case of TRALI
bull Other less well-documented and unproven therapies (eg
diuretics corticosteroids prostaglandin E1) have also been
used
PREVENTION
bull Avoiding blood from multiparous women these women are at the
risk of producing anti-leucocyte antibodies during previous
pregnancies
bull Donors whose blood has resulted in TRALI like reaction
previously
bull Blood which has been stored for long duration long storage
results in production of anti-leucocyte antibodies
bull Not using whole blood
bull Leukoreduction can be done by ɤ - irradiation of the blood
componentor by using micro filters in the transfusion setsor by
using centrifuged blood component which has reduced leucocytes
Transfusion Associated Circulatory
Overload(TACO)
bull There is no universally agreed-upon definition for what
constitutes TACO
bull During or within several hours of transfusion If patients
develop respiratory distress orthopnea cyanosis
tachycardia and hypertension
bull Rales on auscultation
bull Some patients may have raised JVP an S3 on cardiac
auscultation or lower limb edema A chest radiograph can
reveal cardiomegaly and interstitial infiltrates
All patients with TACO may not have all these
abnormalities
Highest risk for TACO include those younger than 3 and
those older than 60 years of age particularly those with
underlying cardiac dysfunction
The pathogenesis of TACO is similar to other
causes of acute congestive heart failure an increase in
central venous pressure and pulmonary blood volume
causes an increase in hydrostatic pressure leading to fluid
extravasation into the alveolar space
Treatment of TACO starts with discontinuing any
ongoing transfusion
Respiratory distress is treated with
the degree of respiratory support needed to maintain the
patientrsquos oxygenation
Diuretics are administered to
remove excess fluid
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
DEFINITION
bull A Working Party on Definitions of Adverse Transfusion Events
was established by the European Haemovigilance Network
(EHN) This group has suggested that the following be the
minimum requirements for a clinical diagnosis of TRALI
bull 1) the occurrence of acute respiratory distress during or within 6
hrs of transfusion
bull 2) absence of signs of circulatory overload
bull 3) radiographic evidence of bilateral pulmonary infiltrates
bull Also has been defined by the Canadian Consensus Conference
Panel on TRALI and by National Heart Lung and Blood
Institute (NHLBI) Working Group on TRALI as new acute lung
injury (ALI) within six hours of a completed transfusion
bull Applying this definition TRALI is a clinical syndrome rather than
a disease with a single aetiology
Canadian Consensus Conference Proposed Criteria for
Transfusion -Related Acute Lung Injury (TRALI)
Criteria for TRALI
Acute lung injury (ALI)Acute onset Hypoxemia
In research setting
Ratio of PaO2FiO2 lt300 or
SpO2 lt90 at room air
Non research settingRatio of PaO2FiO2 lt300 or
SpO2 lt90 at room air
Other clinical evidence of hypoxia
Bilateral infiltrates on frontal chest radiograph
No evidence of left atrial hypertension (ie circulatory overload)
No preexisting AL I before transfus ion d uring or within 6 h of transfusion andNo temporal relationship to an alternative risk factor for ALI
Criteria for possible TRALI
Acute lung injury (ALI )
No preexisting ALI before transfusion
During or within 6 h of transfusion andA clear tempora l rela tionship to an alternative risk factor for ALI
The National Heart Lung and Blood Institute (NHLBI) Working
Group recognized that ALI in patients with other recognized risk
factor (such as trauma sepsis) would be difficult to classify as
TRALI and such cases would be designated as indeterminate
bull The Consensus Panel designates these indeterminate cases
as possible TRALI a category used by the Consensus Panel
for cases in which ALI is temporally related to a transfusion in
the presence of one other risk factor for ALI
bull The guidelines recommend classifying each suspected case in
one of the following 3 categories (1) TRALI(2) Possible
TRALI or (3) Not TRALI
bull Laboratory tests which strongly support but are not required for
the clinical diagnosis of TRALI include the
bull Demonstration of human leukocyte antigen (HLA) class I or class
II or
bull Neutrophil-specific antibodies in donor plasma
PATHOGENESIS
bull The exact pathogenesis of TRALI is not known thus several
theories have been proposed Two basic mechanisms have
been proposed for the pathogenesis of TRALI for
immune competent hosts
(1) single event hypothesis
(2) Two-event model
bull Other possible mechanisms - Several other explanations for
TRALI have been suggested but these are not supported by
clinical and experimental evidence
bull These include direct injury to pulmonary endothelium
bull Immune complex formation with complement activation and
bull Cytokine network activation
RISK FACTORS
Multiparous donors
Blood components platelet Concentratesgtfresh frozen
plasmagtpacked red cellsgtgranulocytesgtcryoprecipitategt
intravenous immunoglobulin
Massive transfusion
bull Stored blood products Inflammatory mediators like cytokines
and lipid soluble substances accumulate during storage of blood
products
bull Underlying clinical condition Factors such as trauma major
surgery sepsis may serve as initial priming event in the
development of TRALI (Two event hypothesis)
MANAGEMENT
Immediate Actions When Considering the
Diagnosis of Transfusion -Related Acute Lung Injury
1 Stop the transfusion immediately
2 Support the patient
3 If the patient is intubated obtain undiluted edema fluid as soon as possible
(preferably within 15 min) and simultaneous plasma for determination of total protein
concentrations
4 Obtain a complete blood count with differential and chest radiograph
5 Notify the blood bank of possible transfusion-related acute lung injury request a
different unit and quarantine other units from the same donor
6 Follow institutional policies for a trans fusion reaction workup and send blood
bank
bull A patient blood specimenbull Bags from units of blood transfused in the last 6 h
bull A copy of transfus ion record forms
bull Indicate the last unit transfused if possible
bull Results of the patient rsquos human leukocyte antigen type if available
bull For mild TRALI cases supplemental oxygen and supportive
care may be sufficient
bull For the most severe cases IV fluids mechanical or non-
invasive ventilation and invasive cardiovascular monitoring
may be required A low tidal volume strategy with low plateau
pressures should be employed when ventilating TRALI
patients just like other causes of ALIARDS
bull Extracorporeal membrane oxygenation has been used
successfully in a severe case of TRALI
bull Other less well-documented and unproven therapies (eg
diuretics corticosteroids prostaglandin E1) have also been
used
PREVENTION
bull Avoiding blood from multiparous women these women are at the
risk of producing anti-leucocyte antibodies during previous
pregnancies
bull Donors whose blood has resulted in TRALI like reaction
previously
bull Blood which has been stored for long duration long storage
results in production of anti-leucocyte antibodies
bull Not using whole blood
bull Leukoreduction can be done by ɤ - irradiation of the blood
componentor by using micro filters in the transfusion setsor by
using centrifuged blood component which has reduced leucocytes
Transfusion Associated Circulatory
Overload(TACO)
bull There is no universally agreed-upon definition for what
constitutes TACO
bull During or within several hours of transfusion If patients
develop respiratory distress orthopnea cyanosis
tachycardia and hypertension
bull Rales on auscultation
bull Some patients may have raised JVP an S3 on cardiac
auscultation or lower limb edema A chest radiograph can
reveal cardiomegaly and interstitial infiltrates
All patients with TACO may not have all these
abnormalities
Highest risk for TACO include those younger than 3 and
those older than 60 years of age particularly those with
underlying cardiac dysfunction
The pathogenesis of TACO is similar to other
causes of acute congestive heart failure an increase in
central venous pressure and pulmonary blood volume
causes an increase in hydrostatic pressure leading to fluid
extravasation into the alveolar space
Treatment of TACO starts with discontinuing any
ongoing transfusion
Respiratory distress is treated with
the degree of respiratory support needed to maintain the
patientrsquos oxygenation
Diuretics are administered to
remove excess fluid
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
bull A Working Party on Definitions of Adverse Transfusion Events
was established by the European Haemovigilance Network
(EHN) This group has suggested that the following be the
minimum requirements for a clinical diagnosis of TRALI
bull 1) the occurrence of acute respiratory distress during or within 6
hrs of transfusion
bull 2) absence of signs of circulatory overload
bull 3) radiographic evidence of bilateral pulmonary infiltrates
bull Also has been defined by the Canadian Consensus Conference
Panel on TRALI and by National Heart Lung and Blood
Institute (NHLBI) Working Group on TRALI as new acute lung
injury (ALI) within six hours of a completed transfusion
bull Applying this definition TRALI is a clinical syndrome rather than
a disease with a single aetiology
Canadian Consensus Conference Proposed Criteria for
Transfusion -Related Acute Lung Injury (TRALI)
Criteria for TRALI
Acute lung injury (ALI)Acute onset Hypoxemia
In research setting
Ratio of PaO2FiO2 lt300 or
SpO2 lt90 at room air
Non research settingRatio of PaO2FiO2 lt300 or
SpO2 lt90 at room air
Other clinical evidence of hypoxia
Bilateral infiltrates on frontal chest radiograph
No evidence of left atrial hypertension (ie circulatory overload)
No preexisting AL I before transfus ion d uring or within 6 h of transfusion andNo temporal relationship to an alternative risk factor for ALI
Criteria for possible TRALI
Acute lung injury (ALI )
No preexisting ALI before transfusion
During or within 6 h of transfusion andA clear tempora l rela tionship to an alternative risk factor for ALI
The National Heart Lung and Blood Institute (NHLBI) Working
Group recognized that ALI in patients with other recognized risk
factor (such as trauma sepsis) would be difficult to classify as
TRALI and such cases would be designated as indeterminate
bull The Consensus Panel designates these indeterminate cases
as possible TRALI a category used by the Consensus Panel
for cases in which ALI is temporally related to a transfusion in
the presence of one other risk factor for ALI
bull The guidelines recommend classifying each suspected case in
one of the following 3 categories (1) TRALI(2) Possible
TRALI or (3) Not TRALI
bull Laboratory tests which strongly support but are not required for
the clinical diagnosis of TRALI include the
bull Demonstration of human leukocyte antigen (HLA) class I or class
II or
bull Neutrophil-specific antibodies in donor plasma
PATHOGENESIS
bull The exact pathogenesis of TRALI is not known thus several
theories have been proposed Two basic mechanisms have
been proposed for the pathogenesis of TRALI for
immune competent hosts
(1) single event hypothesis
(2) Two-event model
bull Other possible mechanisms - Several other explanations for
TRALI have been suggested but these are not supported by
clinical and experimental evidence
bull These include direct injury to pulmonary endothelium
bull Immune complex formation with complement activation and
bull Cytokine network activation
RISK FACTORS
Multiparous donors
Blood components platelet Concentratesgtfresh frozen
plasmagtpacked red cellsgtgranulocytesgtcryoprecipitategt
intravenous immunoglobulin
Massive transfusion
bull Stored blood products Inflammatory mediators like cytokines
and lipid soluble substances accumulate during storage of blood
products
bull Underlying clinical condition Factors such as trauma major
surgery sepsis may serve as initial priming event in the
development of TRALI (Two event hypothesis)
MANAGEMENT
Immediate Actions When Considering the
Diagnosis of Transfusion -Related Acute Lung Injury
1 Stop the transfusion immediately
2 Support the patient
3 If the patient is intubated obtain undiluted edema fluid as soon as possible
(preferably within 15 min) and simultaneous plasma for determination of total protein
concentrations
4 Obtain a complete blood count with differential and chest radiograph
5 Notify the blood bank of possible transfusion-related acute lung injury request a
different unit and quarantine other units from the same donor
6 Follow institutional policies for a trans fusion reaction workup and send blood
bank
bull A patient blood specimenbull Bags from units of blood transfused in the last 6 h
bull A copy of transfus ion record forms
bull Indicate the last unit transfused if possible
bull Results of the patient rsquos human leukocyte antigen type if available
bull For mild TRALI cases supplemental oxygen and supportive
care may be sufficient
bull For the most severe cases IV fluids mechanical or non-
invasive ventilation and invasive cardiovascular monitoring
may be required A low tidal volume strategy with low plateau
pressures should be employed when ventilating TRALI
patients just like other causes of ALIARDS
bull Extracorporeal membrane oxygenation has been used
successfully in a severe case of TRALI
bull Other less well-documented and unproven therapies (eg
diuretics corticosteroids prostaglandin E1) have also been
used
PREVENTION
bull Avoiding blood from multiparous women these women are at the
risk of producing anti-leucocyte antibodies during previous
pregnancies
bull Donors whose blood has resulted in TRALI like reaction
previously
bull Blood which has been stored for long duration long storage
results in production of anti-leucocyte antibodies
bull Not using whole blood
bull Leukoreduction can be done by ɤ - irradiation of the blood
componentor by using micro filters in the transfusion setsor by
using centrifuged blood component which has reduced leucocytes
Transfusion Associated Circulatory
Overload(TACO)
bull There is no universally agreed-upon definition for what
constitutes TACO
bull During or within several hours of transfusion If patients
develop respiratory distress orthopnea cyanosis
tachycardia and hypertension
bull Rales on auscultation
bull Some patients may have raised JVP an S3 on cardiac
auscultation or lower limb edema A chest radiograph can
reveal cardiomegaly and interstitial infiltrates
All patients with TACO may not have all these
abnormalities
Highest risk for TACO include those younger than 3 and
those older than 60 years of age particularly those with
underlying cardiac dysfunction
The pathogenesis of TACO is similar to other
causes of acute congestive heart failure an increase in
central venous pressure and pulmonary blood volume
causes an increase in hydrostatic pressure leading to fluid
extravasation into the alveolar space
Treatment of TACO starts with discontinuing any
ongoing transfusion
Respiratory distress is treated with
the degree of respiratory support needed to maintain the
patientrsquos oxygenation
Diuretics are administered to
remove excess fluid
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
bull Also has been defined by the Canadian Consensus Conference
Panel on TRALI and by National Heart Lung and Blood
Institute (NHLBI) Working Group on TRALI as new acute lung
injury (ALI) within six hours of a completed transfusion
bull Applying this definition TRALI is a clinical syndrome rather than
a disease with a single aetiology
Canadian Consensus Conference Proposed Criteria for
Transfusion -Related Acute Lung Injury (TRALI)
Criteria for TRALI
Acute lung injury (ALI)Acute onset Hypoxemia
In research setting
Ratio of PaO2FiO2 lt300 or
SpO2 lt90 at room air
Non research settingRatio of PaO2FiO2 lt300 or
SpO2 lt90 at room air
Other clinical evidence of hypoxia
Bilateral infiltrates on frontal chest radiograph
No evidence of left atrial hypertension (ie circulatory overload)
No preexisting AL I before transfus ion d uring or within 6 h of transfusion andNo temporal relationship to an alternative risk factor for ALI
Criteria for possible TRALI
Acute lung injury (ALI )
No preexisting ALI before transfusion
During or within 6 h of transfusion andA clear tempora l rela tionship to an alternative risk factor for ALI
The National Heart Lung and Blood Institute (NHLBI) Working
Group recognized that ALI in patients with other recognized risk
factor (such as trauma sepsis) would be difficult to classify as
TRALI and such cases would be designated as indeterminate
bull The Consensus Panel designates these indeterminate cases
as possible TRALI a category used by the Consensus Panel
for cases in which ALI is temporally related to a transfusion in
the presence of one other risk factor for ALI
bull The guidelines recommend classifying each suspected case in
one of the following 3 categories (1) TRALI(2) Possible
TRALI or (3) Not TRALI
bull Laboratory tests which strongly support but are not required for
the clinical diagnosis of TRALI include the
bull Demonstration of human leukocyte antigen (HLA) class I or class
II or
bull Neutrophil-specific antibodies in donor plasma
PATHOGENESIS
bull The exact pathogenesis of TRALI is not known thus several
theories have been proposed Two basic mechanisms have
been proposed for the pathogenesis of TRALI for
immune competent hosts
(1) single event hypothesis
(2) Two-event model
bull Other possible mechanisms - Several other explanations for
TRALI have been suggested but these are not supported by
clinical and experimental evidence
bull These include direct injury to pulmonary endothelium
bull Immune complex formation with complement activation and
bull Cytokine network activation
RISK FACTORS
Multiparous donors
Blood components platelet Concentratesgtfresh frozen
plasmagtpacked red cellsgtgranulocytesgtcryoprecipitategt
intravenous immunoglobulin
Massive transfusion
bull Stored blood products Inflammatory mediators like cytokines
and lipid soluble substances accumulate during storage of blood
products
bull Underlying clinical condition Factors such as trauma major
surgery sepsis may serve as initial priming event in the
development of TRALI (Two event hypothesis)
MANAGEMENT
Immediate Actions When Considering the
Diagnosis of Transfusion -Related Acute Lung Injury
1 Stop the transfusion immediately
2 Support the patient
3 If the patient is intubated obtain undiluted edema fluid as soon as possible
(preferably within 15 min) and simultaneous plasma for determination of total protein
concentrations
4 Obtain a complete blood count with differential and chest radiograph
5 Notify the blood bank of possible transfusion-related acute lung injury request a
different unit and quarantine other units from the same donor
6 Follow institutional policies for a trans fusion reaction workup and send blood
bank
bull A patient blood specimenbull Bags from units of blood transfused in the last 6 h
bull A copy of transfus ion record forms
bull Indicate the last unit transfused if possible
bull Results of the patient rsquos human leukocyte antigen type if available
bull For mild TRALI cases supplemental oxygen and supportive
care may be sufficient
bull For the most severe cases IV fluids mechanical or non-
invasive ventilation and invasive cardiovascular monitoring
may be required A low tidal volume strategy with low plateau
pressures should be employed when ventilating TRALI
patients just like other causes of ALIARDS
bull Extracorporeal membrane oxygenation has been used
successfully in a severe case of TRALI
bull Other less well-documented and unproven therapies (eg
diuretics corticosteroids prostaglandin E1) have also been
used
PREVENTION
bull Avoiding blood from multiparous women these women are at the
risk of producing anti-leucocyte antibodies during previous
pregnancies
bull Donors whose blood has resulted in TRALI like reaction
previously
bull Blood which has been stored for long duration long storage
results in production of anti-leucocyte antibodies
bull Not using whole blood
bull Leukoreduction can be done by ɤ - irradiation of the blood
componentor by using micro filters in the transfusion setsor by
using centrifuged blood component which has reduced leucocytes
Transfusion Associated Circulatory
Overload(TACO)
bull There is no universally agreed-upon definition for what
constitutes TACO
bull During or within several hours of transfusion If patients
develop respiratory distress orthopnea cyanosis
tachycardia and hypertension
bull Rales on auscultation
bull Some patients may have raised JVP an S3 on cardiac
auscultation or lower limb edema A chest radiograph can
reveal cardiomegaly and interstitial infiltrates
All patients with TACO may not have all these
abnormalities
Highest risk for TACO include those younger than 3 and
those older than 60 years of age particularly those with
underlying cardiac dysfunction
The pathogenesis of TACO is similar to other
causes of acute congestive heart failure an increase in
central venous pressure and pulmonary blood volume
causes an increase in hydrostatic pressure leading to fluid
extravasation into the alveolar space
Treatment of TACO starts with discontinuing any
ongoing transfusion
Respiratory distress is treated with
the degree of respiratory support needed to maintain the
patientrsquos oxygenation
Diuretics are administered to
remove excess fluid
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
Canadian Consensus Conference Proposed Criteria for
Transfusion -Related Acute Lung Injury (TRALI)
Criteria for TRALI
Acute lung injury (ALI)Acute onset Hypoxemia
In research setting
Ratio of PaO2FiO2 lt300 or
SpO2 lt90 at room air
Non research settingRatio of PaO2FiO2 lt300 or
SpO2 lt90 at room air
Other clinical evidence of hypoxia
Bilateral infiltrates on frontal chest radiograph
No evidence of left atrial hypertension (ie circulatory overload)
No preexisting AL I before transfus ion d uring or within 6 h of transfusion andNo temporal relationship to an alternative risk factor for ALI
Criteria for possible TRALI
Acute lung injury (ALI )
No preexisting ALI before transfusion
During or within 6 h of transfusion andA clear tempora l rela tionship to an alternative risk factor for ALI
The National Heart Lung and Blood Institute (NHLBI) Working
Group recognized that ALI in patients with other recognized risk
factor (such as trauma sepsis) would be difficult to classify as
TRALI and such cases would be designated as indeterminate
bull The Consensus Panel designates these indeterminate cases
as possible TRALI a category used by the Consensus Panel
for cases in which ALI is temporally related to a transfusion in
the presence of one other risk factor for ALI
bull The guidelines recommend classifying each suspected case in
one of the following 3 categories (1) TRALI(2) Possible
TRALI or (3) Not TRALI
bull Laboratory tests which strongly support but are not required for
the clinical diagnosis of TRALI include the
bull Demonstration of human leukocyte antigen (HLA) class I or class
II or
bull Neutrophil-specific antibodies in donor plasma
PATHOGENESIS
bull The exact pathogenesis of TRALI is not known thus several
theories have been proposed Two basic mechanisms have
been proposed for the pathogenesis of TRALI for
immune competent hosts
(1) single event hypothesis
(2) Two-event model
bull Other possible mechanisms - Several other explanations for
TRALI have been suggested but these are not supported by
clinical and experimental evidence
bull These include direct injury to pulmonary endothelium
bull Immune complex formation with complement activation and
bull Cytokine network activation
RISK FACTORS
Multiparous donors
Blood components platelet Concentratesgtfresh frozen
plasmagtpacked red cellsgtgranulocytesgtcryoprecipitategt
intravenous immunoglobulin
Massive transfusion
bull Stored blood products Inflammatory mediators like cytokines
and lipid soluble substances accumulate during storage of blood
products
bull Underlying clinical condition Factors such as trauma major
surgery sepsis may serve as initial priming event in the
development of TRALI (Two event hypothesis)
MANAGEMENT
Immediate Actions When Considering the
Diagnosis of Transfusion -Related Acute Lung Injury
1 Stop the transfusion immediately
2 Support the patient
3 If the patient is intubated obtain undiluted edema fluid as soon as possible
(preferably within 15 min) and simultaneous plasma for determination of total protein
concentrations
4 Obtain a complete blood count with differential and chest radiograph
5 Notify the blood bank of possible transfusion-related acute lung injury request a
different unit and quarantine other units from the same donor
6 Follow institutional policies for a trans fusion reaction workup and send blood
bank
bull A patient blood specimenbull Bags from units of blood transfused in the last 6 h
bull A copy of transfus ion record forms
bull Indicate the last unit transfused if possible
bull Results of the patient rsquos human leukocyte antigen type if available
bull For mild TRALI cases supplemental oxygen and supportive
care may be sufficient
bull For the most severe cases IV fluids mechanical or non-
invasive ventilation and invasive cardiovascular monitoring
may be required A low tidal volume strategy with low plateau
pressures should be employed when ventilating TRALI
patients just like other causes of ALIARDS
bull Extracorporeal membrane oxygenation has been used
successfully in a severe case of TRALI
bull Other less well-documented and unproven therapies (eg
diuretics corticosteroids prostaglandin E1) have also been
used
PREVENTION
bull Avoiding blood from multiparous women these women are at the
risk of producing anti-leucocyte antibodies during previous
pregnancies
bull Donors whose blood has resulted in TRALI like reaction
previously
bull Blood which has been stored for long duration long storage
results in production of anti-leucocyte antibodies
bull Not using whole blood
bull Leukoreduction can be done by ɤ - irradiation of the blood
componentor by using micro filters in the transfusion setsor by
using centrifuged blood component which has reduced leucocytes
Transfusion Associated Circulatory
Overload(TACO)
bull There is no universally agreed-upon definition for what
constitutes TACO
bull During or within several hours of transfusion If patients
develop respiratory distress orthopnea cyanosis
tachycardia and hypertension
bull Rales on auscultation
bull Some patients may have raised JVP an S3 on cardiac
auscultation or lower limb edema A chest radiograph can
reveal cardiomegaly and interstitial infiltrates
All patients with TACO may not have all these
abnormalities
Highest risk for TACO include those younger than 3 and
those older than 60 years of age particularly those with
underlying cardiac dysfunction
The pathogenesis of TACO is similar to other
causes of acute congestive heart failure an increase in
central venous pressure and pulmonary blood volume
causes an increase in hydrostatic pressure leading to fluid
extravasation into the alveolar space
Treatment of TACO starts with discontinuing any
ongoing transfusion
Respiratory distress is treated with
the degree of respiratory support needed to maintain the
patientrsquos oxygenation
Diuretics are administered to
remove excess fluid
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
The National Heart Lung and Blood Institute (NHLBI) Working
Group recognized that ALI in patients with other recognized risk
factor (such as trauma sepsis) would be difficult to classify as
TRALI and such cases would be designated as indeterminate
bull The Consensus Panel designates these indeterminate cases
as possible TRALI a category used by the Consensus Panel
for cases in which ALI is temporally related to a transfusion in
the presence of one other risk factor for ALI
bull The guidelines recommend classifying each suspected case in
one of the following 3 categories (1) TRALI(2) Possible
TRALI or (3) Not TRALI
bull Laboratory tests which strongly support but are not required for
the clinical diagnosis of TRALI include the
bull Demonstration of human leukocyte antigen (HLA) class I or class
II or
bull Neutrophil-specific antibodies in donor plasma
PATHOGENESIS
bull The exact pathogenesis of TRALI is not known thus several
theories have been proposed Two basic mechanisms have
been proposed for the pathogenesis of TRALI for
immune competent hosts
(1) single event hypothesis
(2) Two-event model
bull Other possible mechanisms - Several other explanations for
TRALI have been suggested but these are not supported by
clinical and experimental evidence
bull These include direct injury to pulmonary endothelium
bull Immune complex formation with complement activation and
bull Cytokine network activation
RISK FACTORS
Multiparous donors
Blood components platelet Concentratesgtfresh frozen
plasmagtpacked red cellsgtgranulocytesgtcryoprecipitategt
intravenous immunoglobulin
Massive transfusion
bull Stored blood products Inflammatory mediators like cytokines
and lipid soluble substances accumulate during storage of blood
products
bull Underlying clinical condition Factors such as trauma major
surgery sepsis may serve as initial priming event in the
development of TRALI (Two event hypothesis)
MANAGEMENT
Immediate Actions When Considering the
Diagnosis of Transfusion -Related Acute Lung Injury
1 Stop the transfusion immediately
2 Support the patient
3 If the patient is intubated obtain undiluted edema fluid as soon as possible
(preferably within 15 min) and simultaneous plasma for determination of total protein
concentrations
4 Obtain a complete blood count with differential and chest radiograph
5 Notify the blood bank of possible transfusion-related acute lung injury request a
different unit and quarantine other units from the same donor
6 Follow institutional policies for a trans fusion reaction workup and send blood
bank
bull A patient blood specimenbull Bags from units of blood transfused in the last 6 h
bull A copy of transfus ion record forms
bull Indicate the last unit transfused if possible
bull Results of the patient rsquos human leukocyte antigen type if available
bull For mild TRALI cases supplemental oxygen and supportive
care may be sufficient
bull For the most severe cases IV fluids mechanical or non-
invasive ventilation and invasive cardiovascular monitoring
may be required A low tidal volume strategy with low plateau
pressures should be employed when ventilating TRALI
patients just like other causes of ALIARDS
bull Extracorporeal membrane oxygenation has been used
successfully in a severe case of TRALI
bull Other less well-documented and unproven therapies (eg
diuretics corticosteroids prostaglandin E1) have also been
used
PREVENTION
bull Avoiding blood from multiparous women these women are at the
risk of producing anti-leucocyte antibodies during previous
pregnancies
bull Donors whose blood has resulted in TRALI like reaction
previously
bull Blood which has been stored for long duration long storage
results in production of anti-leucocyte antibodies
bull Not using whole blood
bull Leukoreduction can be done by ɤ - irradiation of the blood
componentor by using micro filters in the transfusion setsor by
using centrifuged blood component which has reduced leucocytes
Transfusion Associated Circulatory
Overload(TACO)
bull There is no universally agreed-upon definition for what
constitutes TACO
bull During or within several hours of transfusion If patients
develop respiratory distress orthopnea cyanosis
tachycardia and hypertension
bull Rales on auscultation
bull Some patients may have raised JVP an S3 on cardiac
auscultation or lower limb edema A chest radiograph can
reveal cardiomegaly and interstitial infiltrates
All patients with TACO may not have all these
abnormalities
Highest risk for TACO include those younger than 3 and
those older than 60 years of age particularly those with
underlying cardiac dysfunction
The pathogenesis of TACO is similar to other
causes of acute congestive heart failure an increase in
central venous pressure and pulmonary blood volume
causes an increase in hydrostatic pressure leading to fluid
extravasation into the alveolar space
Treatment of TACO starts with discontinuing any
ongoing transfusion
Respiratory distress is treated with
the degree of respiratory support needed to maintain the
patientrsquos oxygenation
Diuretics are administered to
remove excess fluid
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
bull Laboratory tests which strongly support but are not required for
the clinical diagnosis of TRALI include the
bull Demonstration of human leukocyte antigen (HLA) class I or class
II or
bull Neutrophil-specific antibodies in donor plasma
PATHOGENESIS
bull The exact pathogenesis of TRALI is not known thus several
theories have been proposed Two basic mechanisms have
been proposed for the pathogenesis of TRALI for
immune competent hosts
(1) single event hypothesis
(2) Two-event model
bull Other possible mechanisms - Several other explanations for
TRALI have been suggested but these are not supported by
clinical and experimental evidence
bull These include direct injury to pulmonary endothelium
bull Immune complex formation with complement activation and
bull Cytokine network activation
RISK FACTORS
Multiparous donors
Blood components platelet Concentratesgtfresh frozen
plasmagtpacked red cellsgtgranulocytesgtcryoprecipitategt
intravenous immunoglobulin
Massive transfusion
bull Stored blood products Inflammatory mediators like cytokines
and lipid soluble substances accumulate during storage of blood
products
bull Underlying clinical condition Factors such as trauma major
surgery sepsis may serve as initial priming event in the
development of TRALI (Two event hypothesis)
MANAGEMENT
Immediate Actions When Considering the
Diagnosis of Transfusion -Related Acute Lung Injury
1 Stop the transfusion immediately
2 Support the patient
3 If the patient is intubated obtain undiluted edema fluid as soon as possible
(preferably within 15 min) and simultaneous plasma for determination of total protein
concentrations
4 Obtain a complete blood count with differential and chest radiograph
5 Notify the blood bank of possible transfusion-related acute lung injury request a
different unit and quarantine other units from the same donor
6 Follow institutional policies for a trans fusion reaction workup and send blood
bank
bull A patient blood specimenbull Bags from units of blood transfused in the last 6 h
bull A copy of transfus ion record forms
bull Indicate the last unit transfused if possible
bull Results of the patient rsquos human leukocyte antigen type if available
bull For mild TRALI cases supplemental oxygen and supportive
care may be sufficient
bull For the most severe cases IV fluids mechanical or non-
invasive ventilation and invasive cardiovascular monitoring
may be required A low tidal volume strategy with low plateau
pressures should be employed when ventilating TRALI
patients just like other causes of ALIARDS
bull Extracorporeal membrane oxygenation has been used
successfully in a severe case of TRALI
bull Other less well-documented and unproven therapies (eg
diuretics corticosteroids prostaglandin E1) have also been
used
PREVENTION
bull Avoiding blood from multiparous women these women are at the
risk of producing anti-leucocyte antibodies during previous
pregnancies
bull Donors whose blood has resulted in TRALI like reaction
previously
bull Blood which has been stored for long duration long storage
results in production of anti-leucocyte antibodies
bull Not using whole blood
bull Leukoreduction can be done by ɤ - irradiation of the blood
componentor by using micro filters in the transfusion setsor by
using centrifuged blood component which has reduced leucocytes
Transfusion Associated Circulatory
Overload(TACO)
bull There is no universally agreed-upon definition for what
constitutes TACO
bull During or within several hours of transfusion If patients
develop respiratory distress orthopnea cyanosis
tachycardia and hypertension
bull Rales on auscultation
bull Some patients may have raised JVP an S3 on cardiac
auscultation or lower limb edema A chest radiograph can
reveal cardiomegaly and interstitial infiltrates
All patients with TACO may not have all these
abnormalities
Highest risk for TACO include those younger than 3 and
those older than 60 years of age particularly those with
underlying cardiac dysfunction
The pathogenesis of TACO is similar to other
causes of acute congestive heart failure an increase in
central venous pressure and pulmonary blood volume
causes an increase in hydrostatic pressure leading to fluid
extravasation into the alveolar space
Treatment of TACO starts with discontinuing any
ongoing transfusion
Respiratory distress is treated with
the degree of respiratory support needed to maintain the
patientrsquos oxygenation
Diuretics are administered to
remove excess fluid
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
PATHOGENESIS
bull The exact pathogenesis of TRALI is not known thus several
theories have been proposed Two basic mechanisms have
been proposed for the pathogenesis of TRALI for
immune competent hosts
(1) single event hypothesis
(2) Two-event model
bull Other possible mechanisms - Several other explanations for
TRALI have been suggested but these are not supported by
clinical and experimental evidence
bull These include direct injury to pulmonary endothelium
bull Immune complex formation with complement activation and
bull Cytokine network activation
RISK FACTORS
Multiparous donors
Blood components platelet Concentratesgtfresh frozen
plasmagtpacked red cellsgtgranulocytesgtcryoprecipitategt
intravenous immunoglobulin
Massive transfusion
bull Stored blood products Inflammatory mediators like cytokines
and lipid soluble substances accumulate during storage of blood
products
bull Underlying clinical condition Factors such as trauma major
surgery sepsis may serve as initial priming event in the
development of TRALI (Two event hypothesis)
MANAGEMENT
Immediate Actions When Considering the
Diagnosis of Transfusion -Related Acute Lung Injury
1 Stop the transfusion immediately
2 Support the patient
3 If the patient is intubated obtain undiluted edema fluid as soon as possible
(preferably within 15 min) and simultaneous plasma for determination of total protein
concentrations
4 Obtain a complete blood count with differential and chest radiograph
5 Notify the blood bank of possible transfusion-related acute lung injury request a
different unit and quarantine other units from the same donor
6 Follow institutional policies for a trans fusion reaction workup and send blood
bank
bull A patient blood specimenbull Bags from units of blood transfused in the last 6 h
bull A copy of transfus ion record forms
bull Indicate the last unit transfused if possible
bull Results of the patient rsquos human leukocyte antigen type if available
bull For mild TRALI cases supplemental oxygen and supportive
care may be sufficient
bull For the most severe cases IV fluids mechanical or non-
invasive ventilation and invasive cardiovascular monitoring
may be required A low tidal volume strategy with low plateau
pressures should be employed when ventilating TRALI
patients just like other causes of ALIARDS
bull Extracorporeal membrane oxygenation has been used
successfully in a severe case of TRALI
bull Other less well-documented and unproven therapies (eg
diuretics corticosteroids prostaglandin E1) have also been
used
PREVENTION
bull Avoiding blood from multiparous women these women are at the
risk of producing anti-leucocyte antibodies during previous
pregnancies
bull Donors whose blood has resulted in TRALI like reaction
previously
bull Blood which has been stored for long duration long storage
results in production of anti-leucocyte antibodies
bull Not using whole blood
bull Leukoreduction can be done by ɤ - irradiation of the blood
componentor by using micro filters in the transfusion setsor by
using centrifuged blood component which has reduced leucocytes
Transfusion Associated Circulatory
Overload(TACO)
bull There is no universally agreed-upon definition for what
constitutes TACO
bull During or within several hours of transfusion If patients
develop respiratory distress orthopnea cyanosis
tachycardia and hypertension
bull Rales on auscultation
bull Some patients may have raised JVP an S3 on cardiac
auscultation or lower limb edema A chest radiograph can
reveal cardiomegaly and interstitial infiltrates
All patients with TACO may not have all these
abnormalities
Highest risk for TACO include those younger than 3 and
those older than 60 years of age particularly those with
underlying cardiac dysfunction
The pathogenesis of TACO is similar to other
causes of acute congestive heart failure an increase in
central venous pressure and pulmonary blood volume
causes an increase in hydrostatic pressure leading to fluid
extravasation into the alveolar space
Treatment of TACO starts with discontinuing any
ongoing transfusion
Respiratory distress is treated with
the degree of respiratory support needed to maintain the
patientrsquos oxygenation
Diuretics are administered to
remove excess fluid
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
bull The exact pathogenesis of TRALI is not known thus several
theories have been proposed Two basic mechanisms have
been proposed for the pathogenesis of TRALI for
immune competent hosts
(1) single event hypothesis
(2) Two-event model
bull Other possible mechanisms - Several other explanations for
TRALI have been suggested but these are not supported by
clinical and experimental evidence
bull These include direct injury to pulmonary endothelium
bull Immune complex formation with complement activation and
bull Cytokine network activation
RISK FACTORS
Multiparous donors
Blood components platelet Concentratesgtfresh frozen
plasmagtpacked red cellsgtgranulocytesgtcryoprecipitategt
intravenous immunoglobulin
Massive transfusion
bull Stored blood products Inflammatory mediators like cytokines
and lipid soluble substances accumulate during storage of blood
products
bull Underlying clinical condition Factors such as trauma major
surgery sepsis may serve as initial priming event in the
development of TRALI (Two event hypothesis)
MANAGEMENT
Immediate Actions When Considering the
Diagnosis of Transfusion -Related Acute Lung Injury
1 Stop the transfusion immediately
2 Support the patient
3 If the patient is intubated obtain undiluted edema fluid as soon as possible
(preferably within 15 min) and simultaneous plasma for determination of total protein
concentrations
4 Obtain a complete blood count with differential and chest radiograph
5 Notify the blood bank of possible transfusion-related acute lung injury request a
different unit and quarantine other units from the same donor
6 Follow institutional policies for a trans fusion reaction workup and send blood
bank
bull A patient blood specimenbull Bags from units of blood transfused in the last 6 h
bull A copy of transfus ion record forms
bull Indicate the last unit transfused if possible
bull Results of the patient rsquos human leukocyte antigen type if available
bull For mild TRALI cases supplemental oxygen and supportive
care may be sufficient
bull For the most severe cases IV fluids mechanical or non-
invasive ventilation and invasive cardiovascular monitoring
may be required A low tidal volume strategy with low plateau
pressures should be employed when ventilating TRALI
patients just like other causes of ALIARDS
bull Extracorporeal membrane oxygenation has been used
successfully in a severe case of TRALI
bull Other less well-documented and unproven therapies (eg
diuretics corticosteroids prostaglandin E1) have also been
used
PREVENTION
bull Avoiding blood from multiparous women these women are at the
risk of producing anti-leucocyte antibodies during previous
pregnancies
bull Donors whose blood has resulted in TRALI like reaction
previously
bull Blood which has been stored for long duration long storage
results in production of anti-leucocyte antibodies
bull Not using whole blood
bull Leukoreduction can be done by ɤ - irradiation of the blood
componentor by using micro filters in the transfusion setsor by
using centrifuged blood component which has reduced leucocytes
Transfusion Associated Circulatory
Overload(TACO)
bull There is no universally agreed-upon definition for what
constitutes TACO
bull During or within several hours of transfusion If patients
develop respiratory distress orthopnea cyanosis
tachycardia and hypertension
bull Rales on auscultation
bull Some patients may have raised JVP an S3 on cardiac
auscultation or lower limb edema A chest radiograph can
reveal cardiomegaly and interstitial infiltrates
All patients with TACO may not have all these
abnormalities
Highest risk for TACO include those younger than 3 and
those older than 60 years of age particularly those with
underlying cardiac dysfunction
The pathogenesis of TACO is similar to other
causes of acute congestive heart failure an increase in
central venous pressure and pulmonary blood volume
causes an increase in hydrostatic pressure leading to fluid
extravasation into the alveolar space
Treatment of TACO starts with discontinuing any
ongoing transfusion
Respiratory distress is treated with
the degree of respiratory support needed to maintain the
patientrsquos oxygenation
Diuretics are administered to
remove excess fluid
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
bull Other possible mechanisms - Several other explanations for
TRALI have been suggested but these are not supported by
clinical and experimental evidence
bull These include direct injury to pulmonary endothelium
bull Immune complex formation with complement activation and
bull Cytokine network activation
RISK FACTORS
Multiparous donors
Blood components platelet Concentratesgtfresh frozen
plasmagtpacked red cellsgtgranulocytesgtcryoprecipitategt
intravenous immunoglobulin
Massive transfusion
bull Stored blood products Inflammatory mediators like cytokines
and lipid soluble substances accumulate during storage of blood
products
bull Underlying clinical condition Factors such as trauma major
surgery sepsis may serve as initial priming event in the
development of TRALI (Two event hypothesis)
MANAGEMENT
Immediate Actions When Considering the
Diagnosis of Transfusion -Related Acute Lung Injury
1 Stop the transfusion immediately
2 Support the patient
3 If the patient is intubated obtain undiluted edema fluid as soon as possible
(preferably within 15 min) and simultaneous plasma for determination of total protein
concentrations
4 Obtain a complete blood count with differential and chest radiograph
5 Notify the blood bank of possible transfusion-related acute lung injury request a
different unit and quarantine other units from the same donor
6 Follow institutional policies for a trans fusion reaction workup and send blood
bank
bull A patient blood specimenbull Bags from units of blood transfused in the last 6 h
bull A copy of transfus ion record forms
bull Indicate the last unit transfused if possible
bull Results of the patient rsquos human leukocyte antigen type if available
bull For mild TRALI cases supplemental oxygen and supportive
care may be sufficient
bull For the most severe cases IV fluids mechanical or non-
invasive ventilation and invasive cardiovascular monitoring
may be required A low tidal volume strategy with low plateau
pressures should be employed when ventilating TRALI
patients just like other causes of ALIARDS
bull Extracorporeal membrane oxygenation has been used
successfully in a severe case of TRALI
bull Other less well-documented and unproven therapies (eg
diuretics corticosteroids prostaglandin E1) have also been
used
PREVENTION
bull Avoiding blood from multiparous women these women are at the
risk of producing anti-leucocyte antibodies during previous
pregnancies
bull Donors whose blood has resulted in TRALI like reaction
previously
bull Blood which has been stored for long duration long storage
results in production of anti-leucocyte antibodies
bull Not using whole blood
bull Leukoreduction can be done by ɤ - irradiation of the blood
componentor by using micro filters in the transfusion setsor by
using centrifuged blood component which has reduced leucocytes
Transfusion Associated Circulatory
Overload(TACO)
bull There is no universally agreed-upon definition for what
constitutes TACO
bull During or within several hours of transfusion If patients
develop respiratory distress orthopnea cyanosis
tachycardia and hypertension
bull Rales on auscultation
bull Some patients may have raised JVP an S3 on cardiac
auscultation or lower limb edema A chest radiograph can
reveal cardiomegaly and interstitial infiltrates
All patients with TACO may not have all these
abnormalities
Highest risk for TACO include those younger than 3 and
those older than 60 years of age particularly those with
underlying cardiac dysfunction
The pathogenesis of TACO is similar to other
causes of acute congestive heart failure an increase in
central venous pressure and pulmonary blood volume
causes an increase in hydrostatic pressure leading to fluid
extravasation into the alveolar space
Treatment of TACO starts with discontinuing any
ongoing transfusion
Respiratory distress is treated with
the degree of respiratory support needed to maintain the
patientrsquos oxygenation
Diuretics are administered to
remove excess fluid
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
RISK FACTORS
Multiparous donors
Blood components platelet Concentratesgtfresh frozen
plasmagtpacked red cellsgtgranulocytesgtcryoprecipitategt
intravenous immunoglobulin
Massive transfusion
bull Stored blood products Inflammatory mediators like cytokines
and lipid soluble substances accumulate during storage of blood
products
bull Underlying clinical condition Factors such as trauma major
surgery sepsis may serve as initial priming event in the
development of TRALI (Two event hypothesis)
MANAGEMENT
Immediate Actions When Considering the
Diagnosis of Transfusion -Related Acute Lung Injury
1 Stop the transfusion immediately
2 Support the patient
3 If the patient is intubated obtain undiluted edema fluid as soon as possible
(preferably within 15 min) and simultaneous plasma for determination of total protein
concentrations
4 Obtain a complete blood count with differential and chest radiograph
5 Notify the blood bank of possible transfusion-related acute lung injury request a
different unit and quarantine other units from the same donor
6 Follow institutional policies for a trans fusion reaction workup and send blood
bank
bull A patient blood specimenbull Bags from units of blood transfused in the last 6 h
bull A copy of transfus ion record forms
bull Indicate the last unit transfused if possible
bull Results of the patient rsquos human leukocyte antigen type if available
bull For mild TRALI cases supplemental oxygen and supportive
care may be sufficient
bull For the most severe cases IV fluids mechanical or non-
invasive ventilation and invasive cardiovascular monitoring
may be required A low tidal volume strategy with low plateau
pressures should be employed when ventilating TRALI
patients just like other causes of ALIARDS
bull Extracorporeal membrane oxygenation has been used
successfully in a severe case of TRALI
bull Other less well-documented and unproven therapies (eg
diuretics corticosteroids prostaglandin E1) have also been
used
PREVENTION
bull Avoiding blood from multiparous women these women are at the
risk of producing anti-leucocyte antibodies during previous
pregnancies
bull Donors whose blood has resulted in TRALI like reaction
previously
bull Blood which has been stored for long duration long storage
results in production of anti-leucocyte antibodies
bull Not using whole blood
bull Leukoreduction can be done by ɤ - irradiation of the blood
componentor by using micro filters in the transfusion setsor by
using centrifuged blood component which has reduced leucocytes
Transfusion Associated Circulatory
Overload(TACO)
bull There is no universally agreed-upon definition for what
constitutes TACO
bull During or within several hours of transfusion If patients
develop respiratory distress orthopnea cyanosis
tachycardia and hypertension
bull Rales on auscultation
bull Some patients may have raised JVP an S3 on cardiac
auscultation or lower limb edema A chest radiograph can
reveal cardiomegaly and interstitial infiltrates
All patients with TACO may not have all these
abnormalities
Highest risk for TACO include those younger than 3 and
those older than 60 years of age particularly those with
underlying cardiac dysfunction
The pathogenesis of TACO is similar to other
causes of acute congestive heart failure an increase in
central venous pressure and pulmonary blood volume
causes an increase in hydrostatic pressure leading to fluid
extravasation into the alveolar space
Treatment of TACO starts with discontinuing any
ongoing transfusion
Respiratory distress is treated with
the degree of respiratory support needed to maintain the
patientrsquos oxygenation
Diuretics are administered to
remove excess fluid
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
Multiparous donors
Blood components platelet Concentratesgtfresh frozen
plasmagtpacked red cellsgtgranulocytesgtcryoprecipitategt
intravenous immunoglobulin
Massive transfusion
bull Stored blood products Inflammatory mediators like cytokines
and lipid soluble substances accumulate during storage of blood
products
bull Underlying clinical condition Factors such as trauma major
surgery sepsis may serve as initial priming event in the
development of TRALI (Two event hypothesis)
MANAGEMENT
Immediate Actions When Considering the
Diagnosis of Transfusion -Related Acute Lung Injury
1 Stop the transfusion immediately
2 Support the patient
3 If the patient is intubated obtain undiluted edema fluid as soon as possible
(preferably within 15 min) and simultaneous plasma for determination of total protein
concentrations
4 Obtain a complete blood count with differential and chest radiograph
5 Notify the blood bank of possible transfusion-related acute lung injury request a
different unit and quarantine other units from the same donor
6 Follow institutional policies for a trans fusion reaction workup and send blood
bank
bull A patient blood specimenbull Bags from units of blood transfused in the last 6 h
bull A copy of transfus ion record forms
bull Indicate the last unit transfused if possible
bull Results of the patient rsquos human leukocyte antigen type if available
bull For mild TRALI cases supplemental oxygen and supportive
care may be sufficient
bull For the most severe cases IV fluids mechanical or non-
invasive ventilation and invasive cardiovascular monitoring
may be required A low tidal volume strategy with low plateau
pressures should be employed when ventilating TRALI
patients just like other causes of ALIARDS
bull Extracorporeal membrane oxygenation has been used
successfully in a severe case of TRALI
bull Other less well-documented and unproven therapies (eg
diuretics corticosteroids prostaglandin E1) have also been
used
PREVENTION
bull Avoiding blood from multiparous women these women are at the
risk of producing anti-leucocyte antibodies during previous
pregnancies
bull Donors whose blood has resulted in TRALI like reaction
previously
bull Blood which has been stored for long duration long storage
results in production of anti-leucocyte antibodies
bull Not using whole blood
bull Leukoreduction can be done by ɤ - irradiation of the blood
componentor by using micro filters in the transfusion setsor by
using centrifuged blood component which has reduced leucocytes
Transfusion Associated Circulatory
Overload(TACO)
bull There is no universally agreed-upon definition for what
constitutes TACO
bull During or within several hours of transfusion If patients
develop respiratory distress orthopnea cyanosis
tachycardia and hypertension
bull Rales on auscultation
bull Some patients may have raised JVP an S3 on cardiac
auscultation or lower limb edema A chest radiograph can
reveal cardiomegaly and interstitial infiltrates
All patients with TACO may not have all these
abnormalities
Highest risk for TACO include those younger than 3 and
those older than 60 years of age particularly those with
underlying cardiac dysfunction
The pathogenesis of TACO is similar to other
causes of acute congestive heart failure an increase in
central venous pressure and pulmonary blood volume
causes an increase in hydrostatic pressure leading to fluid
extravasation into the alveolar space
Treatment of TACO starts with discontinuing any
ongoing transfusion
Respiratory distress is treated with
the degree of respiratory support needed to maintain the
patientrsquos oxygenation
Diuretics are administered to
remove excess fluid
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
MANAGEMENT
Immediate Actions When Considering the
Diagnosis of Transfusion -Related Acute Lung Injury
1 Stop the transfusion immediately
2 Support the patient
3 If the patient is intubated obtain undiluted edema fluid as soon as possible
(preferably within 15 min) and simultaneous plasma for determination of total protein
concentrations
4 Obtain a complete blood count with differential and chest radiograph
5 Notify the blood bank of possible transfusion-related acute lung injury request a
different unit and quarantine other units from the same donor
6 Follow institutional policies for a trans fusion reaction workup and send blood
bank
bull A patient blood specimenbull Bags from units of blood transfused in the last 6 h
bull A copy of transfus ion record forms
bull Indicate the last unit transfused if possible
bull Results of the patient rsquos human leukocyte antigen type if available
bull For mild TRALI cases supplemental oxygen and supportive
care may be sufficient
bull For the most severe cases IV fluids mechanical or non-
invasive ventilation and invasive cardiovascular monitoring
may be required A low tidal volume strategy with low plateau
pressures should be employed when ventilating TRALI
patients just like other causes of ALIARDS
bull Extracorporeal membrane oxygenation has been used
successfully in a severe case of TRALI
bull Other less well-documented and unproven therapies (eg
diuretics corticosteroids prostaglandin E1) have also been
used
PREVENTION
bull Avoiding blood from multiparous women these women are at the
risk of producing anti-leucocyte antibodies during previous
pregnancies
bull Donors whose blood has resulted in TRALI like reaction
previously
bull Blood which has been stored for long duration long storage
results in production of anti-leucocyte antibodies
bull Not using whole blood
bull Leukoreduction can be done by ɤ - irradiation of the blood
componentor by using micro filters in the transfusion setsor by
using centrifuged blood component which has reduced leucocytes
Transfusion Associated Circulatory
Overload(TACO)
bull There is no universally agreed-upon definition for what
constitutes TACO
bull During or within several hours of transfusion If patients
develop respiratory distress orthopnea cyanosis
tachycardia and hypertension
bull Rales on auscultation
bull Some patients may have raised JVP an S3 on cardiac
auscultation or lower limb edema A chest radiograph can
reveal cardiomegaly and interstitial infiltrates
All patients with TACO may not have all these
abnormalities
Highest risk for TACO include those younger than 3 and
those older than 60 years of age particularly those with
underlying cardiac dysfunction
The pathogenesis of TACO is similar to other
causes of acute congestive heart failure an increase in
central venous pressure and pulmonary blood volume
causes an increase in hydrostatic pressure leading to fluid
extravasation into the alveolar space
Treatment of TACO starts with discontinuing any
ongoing transfusion
Respiratory distress is treated with
the degree of respiratory support needed to maintain the
patientrsquos oxygenation
Diuretics are administered to
remove excess fluid
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
Immediate Actions When Considering the
Diagnosis of Transfusion -Related Acute Lung Injury
1 Stop the transfusion immediately
2 Support the patient
3 If the patient is intubated obtain undiluted edema fluid as soon as possible
(preferably within 15 min) and simultaneous plasma for determination of total protein
concentrations
4 Obtain a complete blood count with differential and chest radiograph
5 Notify the blood bank of possible transfusion-related acute lung injury request a
different unit and quarantine other units from the same donor
6 Follow institutional policies for a trans fusion reaction workup and send blood
bank
bull A patient blood specimenbull Bags from units of blood transfused in the last 6 h
bull A copy of transfus ion record forms
bull Indicate the last unit transfused if possible
bull Results of the patient rsquos human leukocyte antigen type if available
bull For mild TRALI cases supplemental oxygen and supportive
care may be sufficient
bull For the most severe cases IV fluids mechanical or non-
invasive ventilation and invasive cardiovascular monitoring
may be required A low tidal volume strategy with low plateau
pressures should be employed when ventilating TRALI
patients just like other causes of ALIARDS
bull Extracorporeal membrane oxygenation has been used
successfully in a severe case of TRALI
bull Other less well-documented and unproven therapies (eg
diuretics corticosteroids prostaglandin E1) have also been
used
PREVENTION
bull Avoiding blood from multiparous women these women are at the
risk of producing anti-leucocyte antibodies during previous
pregnancies
bull Donors whose blood has resulted in TRALI like reaction
previously
bull Blood which has been stored for long duration long storage
results in production of anti-leucocyte antibodies
bull Not using whole blood
bull Leukoreduction can be done by ɤ - irradiation of the blood
componentor by using micro filters in the transfusion setsor by
using centrifuged blood component which has reduced leucocytes
Transfusion Associated Circulatory
Overload(TACO)
bull There is no universally agreed-upon definition for what
constitutes TACO
bull During or within several hours of transfusion If patients
develop respiratory distress orthopnea cyanosis
tachycardia and hypertension
bull Rales on auscultation
bull Some patients may have raised JVP an S3 on cardiac
auscultation or lower limb edema A chest radiograph can
reveal cardiomegaly and interstitial infiltrates
All patients with TACO may not have all these
abnormalities
Highest risk for TACO include those younger than 3 and
those older than 60 years of age particularly those with
underlying cardiac dysfunction
The pathogenesis of TACO is similar to other
causes of acute congestive heart failure an increase in
central venous pressure and pulmonary blood volume
causes an increase in hydrostatic pressure leading to fluid
extravasation into the alveolar space
Treatment of TACO starts with discontinuing any
ongoing transfusion
Respiratory distress is treated with
the degree of respiratory support needed to maintain the
patientrsquos oxygenation
Diuretics are administered to
remove excess fluid
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
bull For mild TRALI cases supplemental oxygen and supportive
care may be sufficient
bull For the most severe cases IV fluids mechanical or non-
invasive ventilation and invasive cardiovascular monitoring
may be required A low tidal volume strategy with low plateau
pressures should be employed when ventilating TRALI
patients just like other causes of ALIARDS
bull Extracorporeal membrane oxygenation has been used
successfully in a severe case of TRALI
bull Other less well-documented and unproven therapies (eg
diuretics corticosteroids prostaglandin E1) have also been
used
PREVENTION
bull Avoiding blood from multiparous women these women are at the
risk of producing anti-leucocyte antibodies during previous
pregnancies
bull Donors whose blood has resulted in TRALI like reaction
previously
bull Blood which has been stored for long duration long storage
results in production of anti-leucocyte antibodies
bull Not using whole blood
bull Leukoreduction can be done by ɤ - irradiation of the blood
componentor by using micro filters in the transfusion setsor by
using centrifuged blood component which has reduced leucocytes
Transfusion Associated Circulatory
Overload(TACO)
bull There is no universally agreed-upon definition for what
constitutes TACO
bull During or within several hours of transfusion If patients
develop respiratory distress orthopnea cyanosis
tachycardia and hypertension
bull Rales on auscultation
bull Some patients may have raised JVP an S3 on cardiac
auscultation or lower limb edema A chest radiograph can
reveal cardiomegaly and interstitial infiltrates
All patients with TACO may not have all these
abnormalities
Highest risk for TACO include those younger than 3 and
those older than 60 years of age particularly those with
underlying cardiac dysfunction
The pathogenesis of TACO is similar to other
causes of acute congestive heart failure an increase in
central venous pressure and pulmonary blood volume
causes an increase in hydrostatic pressure leading to fluid
extravasation into the alveolar space
Treatment of TACO starts with discontinuing any
ongoing transfusion
Respiratory distress is treated with
the degree of respiratory support needed to maintain the
patientrsquos oxygenation
Diuretics are administered to
remove excess fluid
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
PREVENTION
bull Avoiding blood from multiparous women these women are at the
risk of producing anti-leucocyte antibodies during previous
pregnancies
bull Donors whose blood has resulted in TRALI like reaction
previously
bull Blood which has been stored for long duration long storage
results in production of anti-leucocyte antibodies
bull Not using whole blood
bull Leukoreduction can be done by ɤ - irradiation of the blood
componentor by using micro filters in the transfusion setsor by
using centrifuged blood component which has reduced leucocytes
Transfusion Associated Circulatory
Overload(TACO)
bull There is no universally agreed-upon definition for what
constitutes TACO
bull During or within several hours of transfusion If patients
develop respiratory distress orthopnea cyanosis
tachycardia and hypertension
bull Rales on auscultation
bull Some patients may have raised JVP an S3 on cardiac
auscultation or lower limb edema A chest radiograph can
reveal cardiomegaly and interstitial infiltrates
All patients with TACO may not have all these
abnormalities
Highest risk for TACO include those younger than 3 and
those older than 60 years of age particularly those with
underlying cardiac dysfunction
The pathogenesis of TACO is similar to other
causes of acute congestive heart failure an increase in
central venous pressure and pulmonary blood volume
causes an increase in hydrostatic pressure leading to fluid
extravasation into the alveolar space
Treatment of TACO starts with discontinuing any
ongoing transfusion
Respiratory distress is treated with
the degree of respiratory support needed to maintain the
patientrsquos oxygenation
Diuretics are administered to
remove excess fluid
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
bull Avoiding blood from multiparous women these women are at the
risk of producing anti-leucocyte antibodies during previous
pregnancies
bull Donors whose blood has resulted in TRALI like reaction
previously
bull Blood which has been stored for long duration long storage
results in production of anti-leucocyte antibodies
bull Not using whole blood
bull Leukoreduction can be done by ɤ - irradiation of the blood
componentor by using micro filters in the transfusion setsor by
using centrifuged blood component which has reduced leucocytes
Transfusion Associated Circulatory
Overload(TACO)
bull There is no universally agreed-upon definition for what
constitutes TACO
bull During or within several hours of transfusion If patients
develop respiratory distress orthopnea cyanosis
tachycardia and hypertension
bull Rales on auscultation
bull Some patients may have raised JVP an S3 on cardiac
auscultation or lower limb edema A chest radiograph can
reveal cardiomegaly and interstitial infiltrates
All patients with TACO may not have all these
abnormalities
Highest risk for TACO include those younger than 3 and
those older than 60 years of age particularly those with
underlying cardiac dysfunction
The pathogenesis of TACO is similar to other
causes of acute congestive heart failure an increase in
central venous pressure and pulmonary blood volume
causes an increase in hydrostatic pressure leading to fluid
extravasation into the alveolar space
Treatment of TACO starts with discontinuing any
ongoing transfusion
Respiratory distress is treated with
the degree of respiratory support needed to maintain the
patientrsquos oxygenation
Diuretics are administered to
remove excess fluid
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
Transfusion Associated Circulatory
Overload(TACO)
bull There is no universally agreed-upon definition for what
constitutes TACO
bull During or within several hours of transfusion If patients
develop respiratory distress orthopnea cyanosis
tachycardia and hypertension
bull Rales on auscultation
bull Some patients may have raised JVP an S3 on cardiac
auscultation or lower limb edema A chest radiograph can
reveal cardiomegaly and interstitial infiltrates
All patients with TACO may not have all these
abnormalities
Highest risk for TACO include those younger than 3 and
those older than 60 years of age particularly those with
underlying cardiac dysfunction
The pathogenesis of TACO is similar to other
causes of acute congestive heart failure an increase in
central venous pressure and pulmonary blood volume
causes an increase in hydrostatic pressure leading to fluid
extravasation into the alveolar space
Treatment of TACO starts with discontinuing any
ongoing transfusion
Respiratory distress is treated with
the degree of respiratory support needed to maintain the
patientrsquos oxygenation
Diuretics are administered to
remove excess fluid
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
bull There is no universally agreed-upon definition for what
constitutes TACO
bull During or within several hours of transfusion If patients
develop respiratory distress orthopnea cyanosis
tachycardia and hypertension
bull Rales on auscultation
bull Some patients may have raised JVP an S3 on cardiac
auscultation or lower limb edema A chest radiograph can
reveal cardiomegaly and interstitial infiltrates
All patients with TACO may not have all these
abnormalities
Highest risk for TACO include those younger than 3 and
those older than 60 years of age particularly those with
underlying cardiac dysfunction
The pathogenesis of TACO is similar to other
causes of acute congestive heart failure an increase in
central venous pressure and pulmonary blood volume
causes an increase in hydrostatic pressure leading to fluid
extravasation into the alveolar space
Treatment of TACO starts with discontinuing any
ongoing transfusion
Respiratory distress is treated with
the degree of respiratory support needed to maintain the
patientrsquos oxygenation
Diuretics are administered to
remove excess fluid
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
Highest risk for TACO include those younger than 3 and
those older than 60 years of age particularly those with
underlying cardiac dysfunction
The pathogenesis of TACO is similar to other
causes of acute congestive heart failure an increase in
central venous pressure and pulmonary blood volume
causes an increase in hydrostatic pressure leading to fluid
extravasation into the alveolar space
Treatment of TACO starts with discontinuing any
ongoing transfusion
Respiratory distress is treated with
the degree of respiratory support needed to maintain the
patientrsquos oxygenation
Diuretics are administered to
remove excess fluid
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
Treatment of TACO starts with discontinuing any
ongoing transfusion
Respiratory distress is treated with
the degree of respiratory support needed to maintain the
patientrsquos oxygenation
Diuretics are administered to
remove excess fluid
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
TRALI versus TACO
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
With above discussion it is still difficult to
distinguishe between the TRALI and TACO
Clinical presentation
Both TRALI and TACO are clinical diagnoses and
clinical features can sometimes distinguish between them
With both patients present with respiratory distress due to
acute onset pulmonary edema
With TRALI patients often have hypotension and fever and can
have transient leukopenia
With TACO one would typically expect hypertension and a lack
of fever and leukopenia
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
Features sometimes seen with TACO that would not be expected
in TRALI include raised JVP an S3 heard on cardiac
auscultation and peripheral edema
Fluid balance
A careful investigation of the patientrsquos fluid balance can
sometimes provide a clue to the underlying diagnosis in patient
with excess fluid intake pre transfusion or
significant diuresis post reaction TACO should be
considered A normal fluid balance does not however rule
out TACO or rule in TRALI
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
Cardiac function
Evidence of a new myocardial infarct can suggest that
pulmonary edema may not be transfusion related
Patients with known preceding congenital heart disease
are at risk for TACO
Systolic dysfunction identified
on echocardiography is also suggestive of TACO
but does not rule out TRALI
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
Biochemical markers
Elevated levels of brain natriuretic peptide (BNP) and
n-terminal pro-brain natriuretic peptide (NT-proBNP)
are established markers for congestive heart failure
These BNP levels can be used to distinguish between
cardiogenic and non cardiogenic pulmonary edema in patients
presenting with acute respiratory failure
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
Comparison of the features of transfusion related acute lung
injury and transfusion associated circulatory overload
bull Feature TRALI TACO
bull Temperature Fever is present no fever
bull Blood pressure Hypotension Hypertension
bull Respiratory
symptoms Acute dyspnea Acute dyspnea
bull JVP Unchanged Can be raised
bull Auscultation Rales Rales + S3
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
Chest radiograph
Diffuse bilateral infiltrates Diffuse bilateral
bull infiltrates
bull
Ejection fraction Normal decreased Decreased
PA occlusion
pressure lt 18mmhg gt18mmhg
Pulmonary
edema fluid Exudate Transudate
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
bull Response
to diuretic Minimal Significat
improvement
bull WBC Transient leukopenia Unchanged
BNP lt200 pgml gt1200 pgml
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
THANK YOU
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42
Reference
bull Goldman M Webert KE Arnold DM Freedman J Hannon J Blajchman MA
Proceedings of a consensus conference towards an understanding of TRALI Transfus
Med Rev 2005192ndash31
bull Pradeep et al TRAL-A less commonly known complication of transfusion Indian
journal of anaesthesia 2008 52(2) 126-131
bull Christopher C Silliman Daniel R Ambruso and Lynn K Boshkov Transfusion-
related acute lung injury Blood 20051052266-2273
bull Bhatia P Tulsiani KL TRALI - A Less Commonly Known Complication of Transfusion
Indian J Anaesth 200852126-31
bull Popovsky M A and Moore S B (1985) Diagnostic and pathogenetic considerations
in transfusion-related acute lung injury Transfusion 25 573ndash577 doi 101046j1537-
2995198525686071434x
bull Kleinman S Caulfield T Chan P et al Toward an understanding of transfusion-relate
acute lung injury Statement of a consensus panel Transfusion 2004 441774ndash1789
bull Silliman CC Bjornsen AJ Wyman TH et al Plasma and lipids from stored platelets
cause acute lung injury in an animal model Transfusion 200343633-40
bull Sachs UJ Recent insights into the mechanism of transfusion-related acute lung injury
Curr Opin Hematol 2011 Nov18(6)436-42