Critical Care Medicine

January 29, 2018 | Author: Anonymous | Category: Science, Health Science, Immunology
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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
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