Transfusion-related acute lung injury: Difference between revisions
(updated with references) |
(updating references) |
||
Line 38: | Line 38: | ||
*'''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 |
Revision as of 17:51, 26 July 2016
Background
- Abbreviation: TRALI
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 Presentation
- 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
- Hypotension
- Cyanosis
- Other
- 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
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
- Strop transfusion
- Treat like ARDS
- Avoid diuresis
Disposition
- Bilateral pulmonary infiltrates due to noncardiogenic pulmonary edema within 6h of transfusion
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
- ↑ <Looney MR, et al. Transfusion-related acute lung injury: a review. Chest. 2004;126:249
- ↑ 3.0 3.1 3.2 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
- ↑ 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
- ↑ 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
- ↑ 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
- ↑ 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