Transfusion-related acute lung injury: Difference between revisions
 
(10 intermediate revisions by 4 users not shown)
Line 1: Line 1:
==Background==
==Background==
[[File:Lung and diaphragm.jpg|thumb|Lobes of the lung with related anatomy.]]
===Epidemiology===
===Epidemiology===
*Leading cause of transfusion related mortality in the US – 5-8% <ref>Fatalities Reported to FDA Following Blood Collection and Transfusion: Annual Summary for Fiscal Year 2011. Available at www.fda/gov/biologicsbloodvaccines/safetyavailability/reportaproblem/transfusiondonationfatalities/ucm302847.htm</ref><ref name="sixteen">Looney MR, et al. Transfusion-related acute lung injury: a review. Chest. 2004;126:249</ref>
*Leading cause of transfusion related mortality in the US – 5-8% <ref>Fatalities Reported to FDA Following Blood Collection and Transfusion: Annual Summary for Fiscal Year 2011. Available at www.fda/gov/biologicsbloodvaccines/safetyavailability/reportaproblem/transfusiondonationfatalities/ucm302847.htm</ref><ref name="sixteen">Looney MR, et al. Transfusion-related acute lung injury: a review. Chest. 2004;126:249</ref>
Line 16: Line 17:
*Liver disease
*Liver disease
*Hematologic malignancy
*Hematologic malignancy
*Alcohol abuse
*[[Ethanol toxicity|Alcohol abuse]]
*High peak airway pressures on mechanical ventilation
*High peak airway pressures on mechanical ventilation
*Current smoking
*Current smoking
*Positive fluid balance
*Positive fluid balance
*Massive transfusion
*[[Massive transfusion]]
*Critical illness
*Critical illness
*Sepsis
*[[Sepsis]]
*Shock
*[[Shock]]


====Blood component factors<ref name="fifteen"></ref>====
====Blood component factors<ref name="fifteen"></ref>====
Line 39: Line 40:
**Some present 1-2 hours post-transfusion and up to 6 hours after <ref name="one">Kleinman S, et al. Toward an understanding of transfusion-related acute lung injury: statement of a consensus panel. Transfusion. 2004;44:1774</ref><ref>Sillman CC, et al. Transfusion-related acute lung injury. Blood. 2005;105:2266</ref>
**Some present 1-2 hours post-transfusion and up to 6 hours after <ref name="one">Kleinman S, et al. Toward an understanding of transfusion-related acute lung injury: statement of a consensus panel. Transfusion. 2004;44:1774</ref><ref>Sillman CC, et al. Transfusion-related acute lung injury. Blood. 2005;105:2266</ref>
*Most common signs/symptoms<ref>van Stein D, et al. Transfusion-related acute lung injury reports in the Netherlands: an observational study. Transfusion. 2010;50:213</ref>
*Most common signs/symptoms<ref>van Stein D, et al. Transfusion-related acute lung injury reports in the Netherlands: an observational study. Transfusion. 2010;50:213</ref>
**Hypoxemia
**[[Hypoxemia]]
**New pulmonary infiltrates
**New pulmonary infiltrates
**Pink frothy secretions via ETT
**Pink frothy secretions via ETT
**Fever
**[[Fever]] (as opposed to [[TACO]], where fever is uncommon)
**Hypotension
**[[Hypotension]]
**Cyanosis
**Cyanosis
*Other Symptoms
*Other Symptoms
**Tachypnea
**[[Tachypnea]]
**Tachycardia
**[[Tachycardia]]
**Elevated peak/plateau pressures on ventilator
**Elevated peak/plateau pressures on ventilator
**Transient drip in peripheral neutrophil count (from neutrophil sequestration in lung)
**Transient drip in peripheral neutrophil count (from neutrophil sequestration in lung)
Line 57: Line 58:


==Evaluation==
==Evaluation==
*'''Clinical diagnosis''' - consider in any patient during/post-transfusion who develops hypoxemic respiratory insufficiency
[[File:Transfusion-related acute lung injury chest X-ray.gif|thumb|Chest X-ray of transfusion-related acute lung injury (TRALI syndrome) compared to chest X-ray of the same subject afterwards.]]
 
===Workup===
*Diagnostic criteria (NHLBI working group and Canadian Consensus Conference on TRALI): <ref name="one"></ref><ref>Toy P, et al. Transfusion-related acute lung injury: definition and review. Crit Care Med. 2005;33:721</ref>
*ABG
*[[CXR]]
*Rule out other possible etiologies (i.e. CHF, TACO, anaphylaxis, sepsis, etc.)


===[[TRALI]] and [[Possible TRALI]]===
===Diagnosis===
*'''Clinical diagnosis'''
**Consider in any patient during/post-transfusion who develops hypoxemic respiratory insufficiency
**Diagnostic criteria (NHLBI working group and Canadian Consensus Conference on TRALI): <ref name="one"></ref><ref>Toy P, et al. Transfusion-related acute lung injury: definition and review. Crit Care Med. 2005;33:721</ref>


*ALI/ARDS risk factor*- aspiration, toxic inhalation, pneumonia, pulmonary contusion, near drowning, shock, severe sepsis, multiple trauma, burn injury, acute pancreatitis, cardiopulmonary bypass, drug overdose
===[[TRALI]] and Possible TRALI===
*ALI/[[ARDS]] risk factor*- aspiration, toxic inhalation, pneumonia, pulmonary contusion, near drowning, shock, severe sepsis, multiple trauma, burn injury, acute pancreatitis, cardiopulmonary bypass, drug overdose
**Diagnosis of "possible TRALI" (aka "transfused ARDS") made when temporal relationship to an alternative cause for ARDS exists
**Diagnosis of "possible TRALI" (aka "transfused ARDS") made when temporal relationship to an alternative cause for ARDS exists
===Workup===
*ABG
*[[CXR]]
*R/O other possible etiologies (i.e. CHF, TACO, anaphylaxis, sepsis, etc.)


{{TRALI vs TACO}}
{{TRALI vs TACO}}
Line 77: Line 79:
**Typically includes CBC, bilirubin, haptaglobin, direct Coombs test, BNP, HLA antigen typing
**Typically includes CBC, bilirubin, haptaglobin, direct Coombs test, BNP, HLA antigen typing
*Supportive care (i.e. treat like ARDS)
*Supportive care (i.e. treat like ARDS)
**O2 supplementation
**[[O2]] supplementation
**NIV pressure support or mechanical ventilation
**[[NIPPV|NIV]] pressure support or [[mechanical ventilation]]
***If mechanical ventilation required, ARDSnet guidelines for ventilator menagement
***If mechanical ventilation required, ARDSnet guidelines for ventilator management
**BP support
**BP support
**Consider diuresis ''only'' after demonstrated hemodynamic stability  
**Consider [[diuretics|diuresis]] ''only'' after demonstrated hemodynamic stability  
***'''no early empiric administration''' - associated with hypotension <ref name="sixteen"></ref><ref>Levy GJ, et al. Transfusion-associated non-cardiogenic pulmonary edema. Report of a case and warning regarding treatment. Transfusion. 1986;26:278</ref>
***'''no early empiric administration''' - associated with hypotension <ref name="sixteen"></ref><ref>Levy GJ, et al. Transfusion-associated non-cardiogenic pulmonary edema. Report of a case and warning regarding treatment. Transfusion. 1986;26:278</ref>
**ECMO <ref>Worsley MH, et al. Non-cardiogenic pulmonary edema after transfusion with granulocyte antibody containing blood: treatment with extracorporeal membrane oxygenation. Br J Anaesth. 1991;67:116</ref>
**[[ECMO]] <ref>Worsley MH, et al. Non-cardiogenic pulmonary edema after transfusion with granulocyte antibody containing blood: treatment with extracorporeal membrane oxygenation. Br J Anaesth. 1991;67:116</ref>
*Additional transfusions
*Additional transfusions
**For those who recover, '''no increased risk for recurrent episode from other donors'''
**For those who recover, '''no increased risk for recurrent episode from other donors'''

Latest revision as of 18:43, 24 April 2024

Background

Lobes of the lung with related anatomy.

Epidemiology

  • Leading cause of transfusion related mortality in the US – 5-8% [1][2]
  • Occurs at a rate of 0.04-0.1%, or 1/5000, transfused blood components [3][4][5][6]
    • Higher in critically ill

Pathophysiology

  • Two-hit mechanism [3][7][8]
    • Neutrophil sequestration and priming in lung microvasculature
    • Recipient neutrophil activation by factor in the blood product (i.e. antibodies in blood component directed at recipient antigens, bioactive lipids, etc.)
      • Neutrophils release cytokines, reactive oxygen species, etc. that damage pulmonary capillary endothelium
        • Leads to inflammatory pulmonary edema

Risk factors

Recipient factors[9][10][11][12]

Blood component factors[11]

  • Plasma or whole blood from female donor
  • Volume of HLA class II antibody reactive to recipient HLA antigen
  • Volume of transfused anti-human neutrophil antigen antibody
  • Highest risk components (though can occur with any, including pRBC)
    • Plasma
    • Apheresis platelet concentrates
    • Whole blood

Clinical Features

  • Acute onset hypoxemic respiratory failure due to non-cardiogenic pulmonary edema occurring during or shortly after transfusion
    • Majority of cases present within minutes of initiating transfusion [3]
    • Some present 1-2 hours post-transfusion and up to 6 hours after [13][14]
  • Most common signs/symptoms[15]
  • Other Symptoms
    • Tachypnea
    • Tachycardia
    • Elevated peak/plateau pressures on ventilator
    • Transient drip in peripheral neutrophil count (from neutrophil sequestration in lung)

Differential Diagnosis

Transfusion Reaction Types

Acute allergic reaction

Evaluation

Chest X-ray of transfusion-related acute lung injury (TRALI syndrome) compared to chest X-ray of the same subject afterwards.

Workup

  • ABG
  • CXR
  • Rule out other possible etiologies (i.e. CHF, TACO, anaphylaxis, sepsis, etc.)

Diagnosis

  • Clinical diagnosis
    • Consider in any patient during/post-transfusion who develops hypoxemic respiratory insufficiency
    • Diagnostic criteria (NHLBI working group and Canadian Consensus Conference on TRALI): [13][16]

TRALI and Possible TRALI

  • ALI/ARDS risk factor*- aspiration, toxic inhalation, pneumonia, pulmonary contusion, near drowning, shock, severe sepsis, multiple trauma, burn injury, acute pancreatitis, cardiopulmonary bypass, drug overdose
    • Diagnosis of "possible TRALI" (aka "transfused ARDS") made when temporal relationship to an alternative cause for ARDS exists

TRALI vs TACO

TRALI TACO
Onset Acute, within 6hrs Often more gradual
BP Low High
Temp Febrile Normal
JVD/pedal edema Unlikely Likely
CVP/PAWP Normal Elevated
BNP Normal Elevated
Resp Dyspneic Dyspneic
CXR B/l infiltrates B/l infiltrates

Management

  • STOP the transfusion and report to the blood bank for transfusion reaction work-up
    • Typically includes CBC, bilirubin, haptaglobin, direct Coombs test, BNP, HLA antigen typing
  • Supportive care (i.e. treat like ARDS)
    • O2 supplementation
    • NIV pressure support or mechanical ventilation
      • If mechanical ventilation required, ARDSnet guidelines for ventilator management
    • BP support
    • Consider diuresis only after demonstrated hemodynamic stability
      • no early empiric administration - associated with hypotension [2][17]
    • ECMO [18]
  • Additional transfusions
    • For those who recover, no increased risk for recurrent episode from other donors
      • Transfusion of needed blood products from other donors should not be withheld

Disposition

  • Majority require ICU admission and mechanical ventilation [9]
    • Mean duration of mechanical ventilation 40 hours, upwards of 10 days [3][9]

Prognosis

See Also

External Links

References

  1. ↑ Fatalities Reported to FDA Following Blood Collection and Transfusion: Annual Summary for Fiscal Year 2011. Available at www.fda/gov/biologicsbloodvaccines/safetyavailability/reportaproblem/transfusiondonationfatalities/ucm302847.htm
  2. ↑ 2.0 2.1 Looney MR, et al. Transfusion-related acute lung injury: a review. Chest. 2004;126:249
  3. ↑ 3.0 3.1 3.2 3.3 Silliman CC, et al. Transfusion-related acute lung injury: epidemiology and a prospective analysis of etiologic factors. Blood. 2003;101:454
  4. ↑ Popovsky MA, et al. Diagnostic and pathogenietic considerations in transfusion-related acute lung injury. Transfusion. 1985;25:573
  5. ↑ Wallis JP. Transfusion-related acute lung injury (TRALI) - under-diagnosed and under-reported. Br J Anaesth. 2003;90:573
  6. ↑ 6.0 6.1 Rana R, et al. Transfusion-related acute lung injury and pulmonary edema in critically ill patients: a retrospective study. Transfusion. 2006;46:1478
  7. ↑ Sillman CC. The two-event model of transfusion-related acute lung injury. Crit Care Med. 2006;34:S124
  8. ↑ Bux J, et al. The pathogenesis of transfusion-related acute lung injury (TRALI). Br J Haematol. 2007;136:788
  9. ↑ 9.0 9.1 9.2 9.3 Vlaar AP, et al. Risk factors and outcome of transfusion-related acute lung injury in the critically ill: a nested case-control study. Crit Care Med. 2007;176:886
  10. ↑ 10.0 10.1 Gajic O, et al. Transfusion-related acute lung injury in the critically ill: prospective nested case-control study. Am J Respir Crit Care Med. 2007;176:886
  11. ↑ 11.0 11.1 Toy P, et al. Transfusion-related acute lung injury: incidence and risk factors. Blood. 2012;119:1757
  12. ↑ Benson AB, et al. Transfusion-related acute lung injury in ICU patients admitted with gastrointestinal bleeding. Intensive Care Med. 2010;36:1710
  13. ↑ 13.0 13.1 Kleinman S, et al. Toward an understanding of transfusion-related acute lung injury: statement of a consensus panel. Transfusion. 2004;44:1774
  14. ↑ Sillman CC, et al. Transfusion-related acute lung injury. Blood. 2005;105:2266
  15. ↑ van Stein D, et al. Transfusion-related acute lung injury reports in the Netherlands: an observational study. Transfusion. 2010;50:213
  16. ↑ Toy P, et al. Transfusion-related acute lung injury: definition and review. Crit Care Med. 2005;33:721
  17. ↑ Levy GJ, et al. Transfusion-associated non-cardiogenic pulmonary edema. Report of a case and warning regarding treatment. Transfusion. 1986;26:278
  18. ↑ Worsley MH, et al. Non-cardiogenic pulmonary edema after transfusion with granulocyte antibody containing blood: treatment with extracorporeal membrane oxygenation. Br J Anaesth. 1991;67:116
  19. ↑ Looney MR, et al. Prospective study on the clinical course and outcomes in transfusion-related acute lung injury. Crit Care Med. 2014;42:1676
  20. ↑ Popovsky MA, et al. Transfusion-related acute lung injury: a neglected serious complication of hemotherapy. Transfusion. 1992;32:589
  21. ↑ Sillman CC, et al. Transfusion-related acute lung injury (TRALI): current concepts and misconceptions. Blood Rev. 2009;23:245
  22. ↑ Wallis JP, et al. Single hospital experience of TRALI. Transfusion. 2003;43:1053
Retrieved from "https://www.wikem.org/w/index.php?title=Transfusion-related_acute_lung_injury&oldid=373322"