Difference between revisions of "Transfusion-related acute lung injury"

(updated with references)
 
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==Background==
 
==Background==
−
*Abbreviation: TRALI
 
−
 
 
===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><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>
−
*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>Rana R, et al. Transfusion-related acute lung injury and pulmonary edema in critically ill patients: a retrospective study. Transfusion. 2006;46:1478</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
 
**Higher in critically ill
  
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*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>
 
*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'''
 
**'''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.)
+
**'''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
 
***Neutrophils release cytokines, reactive oxygen species, etc. that damage pulmonary capillary endothelium
 
****Leads to '''inflammatory pulmonary edema'''
 
****Leads to '''inflammatory pulmonary edema'''
  
 
===Risk factors===
 
===Risk factors===
−
*'''Recipient factors''' <ref>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>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>
+
====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
+
*Liver disease
−
**Hematologic malignancy
+
*Hematologic malignancy
−
**Alcohol abuse
+
*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>
+
 
−
**Plasma or whole blood from female donor
+
====Blood component factors<ref name="fifteen"></ref>====
−
**Volume of HLA class II antibody reactive to recipient HLA antigen
+
*Plasma or whole blood from female donor
−
**Volume of transfused anti-human neutrophil antigen antibody
+
*Volume of HLA class II antibody reactive to recipient HLA antigen
−
**Highest risk components (though '''can occur with any, including PRBC''')
+
*Volume of transfused anti-human neutrophil antigen antibody
−
***Plasma
+
*Highest risk components (though can occur with any, including pRBC)
−
***Apheresis platelet concentrates
+
**Plasma
−
***Whole blood
+
**Apheresis platelet concentrates
 +
**Whole blood
  
−
==Clinical Presentation==
+
==Clinical Features==
−
*'''Acute onset hypoxemic respiratory failure''' due to non-cardiogenic pulmonary edema occurring '''during or shortly after transfusion'''
+
*'''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>
 
**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>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]]
−
**Hypotension
+
**[[Hypotension]]
 
**Cyanosis
 
**Cyanosis
−
*Other
+
*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)
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==Evaluation==
 
==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}}
 
{{TRALI vs TACO}}
  
 
==Management==
 
==Management==
−
*Strop transfusion
+
*'''STOP the transfusion''' and report to the blood bank for transfusion reaction work-up
−
*Treat like [[ARDS]]
+
**Typically includes CBC, bilirubin, haptaglobin, direct Coombs test, BNP, HLA antigen typing
−
*Avoid diuresis
+
*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==
−
*Bilateral pulmonary infiltrates due to noncardiogenic pulmonary edema within 6h of transfusion
+
*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==

Latest revision as of 19:56, 13 October 2019

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

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
    • 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

  • 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

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)
    • 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
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