Critical Care Medicine
Download
Report
Transcript Critical Care Medicine
Transfusion-Related
Acute Lung Injury
Melanie F. Clemens, CRNA, MSN
Brooklyn VA Medical Center
Objectives
Discuss the incidence of TRALI
Review the proposed pathophysiology of TRALI
Discuss the proposed risk factors associated with TRALI
Review the clinical presentation & diagnosis of TRALI
Review the treatment of TRALI
Discuss the clinical impact of TRALI
Disclosures
Clinical Relevance
TRALI
1 in 5,000 units*
1 in 625 patients*
Bacterial Contamination
Related Sepsis
1 in 25,000 platelets
1 in 250,000 PRBCs
Hepatitis C
Hepatitis B
1 in 1,935,000 transfusions
1 in 205,000 transfusions
HIV
1 in 2,135,000 transfusions
Clinical Relevance
http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/ReportaProblem/TransfusionDonationFatalities
Presentation
Within 6 hours of transfusion
Symptoms
Dyspnea
Cyanosis
Hypoxemia
Pulmonary edema
Hypotension
Decreased lung
compliance
Fever
Chills
Cough
Tachycardia
Frothy sputum
Absence of other clinical
indicators of fluid overload
Pathophysiology
Antibody Hypothesis
Human leukocyte antigen
(HLA)
Human neutrophil antigen
(HNA)
Biologic Response Modifiers
Class I & class II
Not antibody mediated
Two-Hit Hypothesis
2 events
Opportunistic
Sachs 2011
Pathophysiology
Antibody mediated lung injury
70% of TRALI cases
HLA & HNA antibody formation
85%-90% component based
5%-10% recipient based
Pregnancy
Transplantation
Transfusion
Antibodies target WBCs
Pulmonary microvascular
infiltration & damage
Dennison 2008
Pathophysiology
Biologic Response Modifiers
Accumulate in stored blood
Activate & prime neutrophils
Independent of antibodies
Lower morbidity & mortality
http://online.wsj.com/article/SB10001424052748703939404574567771148801570.html
Pathophysiology
Two-Hit Theory
First event
System activation
Pulmonary endothelium
Primed neutrophils
Second event
Transfusion
Opportunistic
Threshold
Sachs 2011
Risk Factors
Product related risk factors
Triulzi 2009
Risk Factors
Recipient related risk factors
Sachs 2011
Diagnosis
Unrecognized
TRALI vs. TACO
http://www.arabanesthesia.com/2011/03/association-between-intraoperative.html
Diagnosis
Transfusion-Related Cardiac Overload (TACO)
Similar presentation to TRALI
Jugular venous distension
Hypertension
Elevated pulmonary artery occlusion or central venous pressures*
Prompt improvement of symptoms with diuresis
Pulmonary edema/plasma protein concentration ratio <0.65
≥50% increase in post transfusion BNP levels
Presentation
Within 6 hours of transfusion
Symptoms
Dyspnea
Cyanosis
Hypoxemia
Pulmonary edema
Hypotension
Decreased lung
compliance
Fever
Chills
Cough
Tachycardia
Frothy sputum
Absence of other clinical
indicators of fluid overload
Diagnosis
Gilliss et al. 2011
http://jama.ama-assn.org/content/287/15/1968.full
Diagnosis
Gajic et al. 2006
Diagnosis
Skeate et al. 2007
Treatment
Differential diagnosis
Stop the suspected product
Supportive
Intubation & mechanical ventilation
Fluids
Vasopressors
5%-20% mortality rate
Retain the transfused products
http://web.squ.edu.om
Clinical Impact
Prevention
Limit unnecessary transfusions
Donor limitations
Leukocyte reduction
Washing cellular components
Pooled products
Product testing
Using freshest available products
www.ag.ndsu.edu
Clinical Impact
Alternatives to transfusion
Crystalloids
Colloids
Conservative transfusion thresholds
Risk stratification
Concentrated fibrinogen/Factor VII
Vitamin K
Questions
References
Curtis, Brian. McFarland, Janice. (2006). Mechanisms of
Transfusion-Related Acute Lung Injury. Critical Care
Medicine, 34, S118-S123.
Dennison, Carol. (2008). Transfusion-Related Acute Lung Injury-A
Clinical Challenge. Dimensions of Critical Care Nursing, 27,
1-7.
Gajic, Ognjen. Gropper, Michael. Hubmayr, Rolf. (2006).
Pulmonary Edema After Transfusion: How to Differential
Transfusion-Associated Circulatory Overload from
Transfusion-Related Acute Lung Injury. Critical Care
Medicine, 34, S109-S113.
References
Gillis, Brian. Looney, Mark. Gropper, Michael. (2011). Reducing
Noninfectious Risks of Blood Transfusion. Anesthesiology,
115, 635-649.
Kopko, Patricia. (2010). Transfusion-Related Acute Lung Injury.
Journal of Infusion Nursing, 33, 32-37.
Looney, Mark. Gillis, Brian. Matthay, Michael. (2010).
Pathophysiology of Transfusion-Related Acute Lung Injury.
Current Opinion in Hematology, 17, 418-423.
Mair, D. Hirschler, Nora. Eastlund, Ted. (2006). Blood Donor and
Component Management Strategies to Prevent TransfusionRelated Acute Lung Injury. Critical Care Medicine, 34, S137S143.
References
Moore, S. (2006). Transfusion-Related Acute Lung Injury: Clinical
Presentation, Treatment, and Prognosis. Critical Care
Medicine, 34, S114-S117.
Sachs, Ulrich. (2011). Recent Insights into the Mechanic of
Transfusion-Related Acute Lung Injury. Current Opinion in
Hematology, 18, 436-442.
Skeate, Robert. Eastlund, Ted. (2007). Distinguishing Between
Transfusion-Related Acute Lung Injury and TransfusionAssociated Circulatory Overload. Current Opinion in
Hematology, 14, 682-687.
References
Triulzi, Darrell. (2009). Transfusion-Related Acute Lung Injury:
Current Concepts for the Clinician. Anesthesia and
Analgesia, 108, 770-776.
Vlaar, Alexander. Binnekade, Jan. Prins, David. Van Stein,
Danielle. Hofstra, Jorrit. Schultz, Marcus. Juffermans,
Nicole. (2010). Risk Factors and Outcome of TransfusionRelated Acute Lung Injury in the Critically Ill: A Nested CaseControl Study. Critical Care Medicine, 38, 771-778.
Federal Drug Administration (2010). Fatalities Reported to FDA
Following Blood Collection and Transfusion. Annual
Summary for Fiscal Year 2010. www.fda.org