Transfusion-related acute lung injury: Difference between revisions
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==Background== | ==Background== | ||
* | ===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> | ||
*Occurs at a rate of 0.04-0.1%, or 1/5000, transfused blood components <ref name="four">Silliman CC, et al. Transfusion-related acute lung injury: epidemiology and a prospective analysis of etiologic factors. Blood. 2003;101:454</ref><ref>Popovsky MA, et al. Diagnostic and pathogenietic considerations in transfusion-related acute lung injury. Transfusion. 1985;25:573</ref><ref>Wallis JP. Transfusion-related acute lung injury (TRALI) - under-diagnosed and under-reported. Br J Anaesth. 2003;90:573</ref><ref name="seven">Rana R, et al. Transfusion-related acute lung injury and pulmonary edema in critically ill patients: a retrospective study. Transfusion. 2006;46:1478</ref> | |||
**Higher in critically ill | |||
===Pathophysiology=== | |||
*Two-hit mechanism <ref name="four"></ref><ref>Sillman CC. The two-event model of transfusion-related acute lung injury. Crit Care Med. 2006;34:S124</ref><ref>Bux J, et al. The pathogenesis of transfusion-related acute lung injury (TRALI). Br J Haematol. 2007;136:788</ref> | |||
**'''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<ref name ="twelve">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</ref><ref name="thirteen">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</ref><ref name="fifteen">Toy P, et al. Transfusion-related acute lung injury: incidence and risk factors. Blood. 2012;119:1757</ref><ref>Benson AB, et al. Transfusion-related acute lung injury in ICU patients admitted with gastrointestinal bleeding. Intensive Care Med. 2010;36:1710</ref>==== | |||
*Liver disease | |||
*Hematologic malignancy | |||
*[[Ethanol toxicity|Alcohol abuse]] | |||
*High peak airway pressures on mechanical ventilation | |||
*Current smoking | |||
*Positive fluid balance | |||
*[[Massive transfusion]] | |||
*Critical illness | |||
*[[Sepsis]] | |||
*[[Shock]] | |||
====Blood component factors<ref name="fifteen"></ref>==== | |||
*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== | ==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 <ref name="four"></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> | |||
**[[Hypoxemia]] | |||
**New pulmonary infiltrates | |||
**Pink frothy secretions via ETT | |||
**[[Fever]] (as opposed to [[TACO]], where fever is uncommon) | |||
**[[Hypotension]] | |||
**Cyanosis | |||
*Other Symptoms | |||
**[[Tachypnea]] | |||
**[[Tachycardia]] | |||
**Elevated peak/plateau pressures on ventilator | |||
**Transient drip in peripheral neutrophil count (from neutrophil sequestration in lung) | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Transfusion reaction types}} | {{Transfusion reaction types}} | ||
== | {{Acute Allergic DDX}} | ||
* | |||
==Evaluation== | |||
*'''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> | |||
===[[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 | |||
===Workup=== | |||
*ABG | |||
*[[CXR]] | |||
*Rule out other possible etiologies (i.e. CHF, TACO, anaphylaxis, sepsis, etc.) | |||
{{TRALI vs TACO}} | |||
==Management== | ==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 | |||
**[[NIPPV|NIV]] pressure support or [[mechanical ventilation]] | |||
***If mechanical ventilation required, ARDSnet guidelines for ventilator management | |||
**BP support | |||
**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> | |||
**[[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 | |||
**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== | ==Disposition== | ||
* | *Majority require ICU admission and mechanical ventilation <ref name="twelve"></ref> | ||
**Mean duration of mechanical ventilation 40 hours, upwards of 10 days <ref name="four"></ref><ref name="twelve"></ref> | |||
==Prognosis== | |||
*Mortality | |||
**Non-critically ill with TRALI - 5-7% <ref>Looney MR, et al. Prospective study on the clinical course and outcomes in transfusion-related acute lung injury. Crit Care Med. 2014;42:1676</ref><ref>Popovsky MA, et al. Transfusion-related acute lung injury: a neglected serious complication of hemotherapy. Transfusion. 1992;32:589</ref><ref>Sillman CC, et al. Transfusion-related acute lung injury (TRALI): current concepts and misconceptions. Blood Rev. 2009;23:245</ref> | |||
**Critically ill with TRALI - 41-67% <ref name="seven"></ref><ref name="twelve"></ref><ref name="thirteen"></ref><ref>Wallis JP, et al. Single hospital experience of TRALI. Transfusion. 2003;43:1053</ref> | |||
==See Also== | ==See Also== | ||
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==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:Pulmonary]] |
Latest revision as of 17:38, 25 October 2023
Background
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
- Neutrophils release cytokines, reactive oxygen species, etc. that damage pulmonary capillary endothelium
Risk factors
Recipient factors[9][10][11][12]
- Liver disease
- Hematologic malignancy
- Alcohol abuse
- High peak airway pressures on mechanical ventilation
- Current smoking
- Positive fluid balance
- Massive transfusion
- Critical illness
- Sepsis
- Shock
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
- Most common signs/symptoms[15]
- Hypoxemia
- New pulmonary infiltrates
- Pink frothy secretions via ETT
- Fever (as opposed to TACO, where fever is uncommon)
- Hypotension
- Cyanosis
- 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
- Delayed
Acute allergic reaction
- Allergic reaction/urticaria
- Anaphylaxis
- Angioedema
- Anxiety attack
- Asthma exacerbation
- Carcinoid syndrome
- Cold urticaria
- Contrast induced allergic reaction
- Scombroid
- Shock
- Transfusion reaction
Evaluation
- Clinical diagnosis - consider in any patient during/post-transfusion who develops hypoxemic respiratory insufficiency
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
Workup
- ABG
- CXR
- Rule out other possible etiologies (i.e. CHF, TACO, anaphylaxis, sepsis, etc.)
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)
- 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
- For those who recover, no increased risk for recurrent episode from other donors
Disposition
- Majority require ICU admission and mechanical ventilation [9]
Prognosis
- Mortality
See Also
External Links
References
- ↑ 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
- ↑ 2.0 2.1 Looney MR, et al. Transfusion-related acute lung injury: a review. Chest. 2004;126:249
- ↑ 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
- ↑ Popovsky MA, et al. Diagnostic and pathogenietic considerations in transfusion-related acute lung injury. Transfusion. 1985;25:573
- ↑ Wallis JP. Transfusion-related acute lung injury (TRALI) - under-diagnosed and under-reported. Br J Anaesth. 2003;90:573
- ↑ 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
- ↑ Sillman CC. The two-event model of transfusion-related acute lung injury. Crit Care Med. 2006;34:S124
- ↑ Bux J, et al. The pathogenesis of transfusion-related acute lung injury (TRALI). Br J Haematol. 2007;136:788
- ↑ 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
- ↑ 10.0 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
- ↑ 11.0 11.1 Toy P, et al. Transfusion-related acute lung injury: incidence and risk factors. Blood. 2012;119:1757
- ↑ Benson AB, et al. Transfusion-related acute lung injury in ICU patients admitted with gastrointestinal bleeding. Intensive Care Med. 2010;36:1710
- ↑ 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
- ↑ Sillman CC, et al. Transfusion-related acute lung injury. Blood. 2005;105:2266
- ↑ van Stein D, et al. Transfusion-related acute lung injury reports in the Netherlands: an observational study. Transfusion. 2010;50:213
- ↑ Toy P, et al. Transfusion-related acute lung injury: definition and review. Crit Care Med. 2005;33:721
- ↑ Levy GJ, et al. Transfusion-associated non-cardiogenic pulmonary edema. Report of a case and warning regarding treatment. Transfusion. 1986;26:278
- ↑ 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
- ↑ Looney MR, et al. Prospective study on the clinical course and outcomes in transfusion-related acute lung injury. Crit Care Med. 2014;42:1676
- ↑ Popovsky MA, et al. Transfusion-related acute lung injury: a neglected serious complication of hemotherapy. Transfusion. 1992;32:589
- ↑ Sillman CC, et al. Transfusion-related acute lung injury (TRALI): current concepts and misconceptions. Blood Rev. 2009;23:245
- ↑ Wallis JP, et al. Single hospital experience of TRALI. Transfusion. 2003;43:1053