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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]
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
- 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]
- Hypoxemia
- New pulmonary infiltrates
- Pink frothy secretions via ETT
- Fever
- 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
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]
- 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
- R/O other possible etiologies (i.e. CHF, TACO, anaphylaxis, sepsis, etc.)
|
|
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 menagement
- 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
- ↑ 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
