TRALI You May Lose, If You Transfuse.

Haney A. Mallemat, MDDepartment of Critical CareDartmouth-Hitchcock Medical Center

Clinical Case• 77 M• AAA repair• POD #3

• Extubated• Stable vitals• Hb 8.1

Evening Vascular Rounds…

• 2U PRBC• No indication documented

3 hours later…• Respiratory distress

• 85% sat• 85/50 • P: 125

• STAT Airway• Levophed

OUTLINE• Definition• Epidemiology• Pathogenesis• Diagnosis• Treatment• Prognosis

Definition• Epidemiology• Pathogenesis• Diagnosis• Treatment• Prognosis

1951• Pulmonary Hypersensitivity Reaction

• Allergic Pulmonary Edema

• Non-Cardiogenic Pulmonary Edema

• Pulmonary Leucoagglutinin Reaction

1983: Dr. Popovosky

Transfusion-Associated Popovoskitis

•TRansfusion

•Associated

•Lung

•Injury

Definition

• No formal definition

TRALI Consensus Conference

• ALI from blood products• P/F ratio <300• B/L infiltrates• No circulatory overload• No previous ALI• No causes ALI

TRALI“Classic” TRALI

< 6 h ▪~30-120 min

“Delayed” TRALI6 – 72 h

• DefinitionEpidemiology• Pathogenesis• Diagnosis• Treatment• Prognosis

Epidemiology• #1 transfusion-related mortality• >Infection• >ABO mismatch

• Under recognized / reported

• Mortality 5-10%

Epidemiology• PRBC 1 in 5000• Plasma 1 in 2000• Platelets 1 in 2000

• IVIG• Cryoprecipitate• Stem cells

Risk FactorsHOST

• M = F• Recent surgery• Active infections• Recent transfusion• Cytokine treatment• Thrombocytopenia• Increased age• Ethanol use• Tobacco• Severe illness

DONOR

• Multi-parous female donors• Prolonged blood storage

• Definition• EpidemiologyPathogenesis• Diagnosis• Treatment• Prognosis

3 Theories…1. Anti-granulocyte antibody

2. Endothelial-cell priming

3. “Two-hit” hypothesis

• Definition• Epidemiology• PathogenesisDiagnosis• Treatment• Prognosis

Clinical Presentation• Mild symptoms• • •

• • Death

Non-Specific Si/Sx• Fever• Dyspnea• Tachypnea• Tachycardia• Hypotension• Hypertension• No lung findings• Crackles• Retractions

• No S3• Frothy sputum• Cough• No JVD• No cardiomegaly• Non-cardiac edema• Leukopenia• Thrombocytpoenia• Hyponatremia

Question 1: Recent Transfusion?

Question 2: Acute Lung Injury

• <6 hours

• Hypoxemia• P/F <300• O2sat <90%

• B/l infiltrates

• No evidence of HF

Bilateral pulmonary infiltrates

Question 3: R/o other causes of ALI

• Aspiration• Pneumonia• Toxic inhalation• Lung contusion• Near drowning• Severe sepsis

• Shock• Trauma• Burns• Pancreatitis• Bypass surgery• Drug overdose

Question 4: R/o volume overload

• CHF• Nephrotic syndrome• Fluid overload• Post-sepsis• ESRD• AKI

Diagnosis: Physical Exam

• Frothy sputum•Hypoxia• Tachycardia•Hypotension• Fever

Diagnosis: Radiology

• CXR

Diagnosis: Lab Tests

Diagnosis: Nursing

• Rare and subtle diagnosis

• Subtlety is your specialty• Notice changes first

• Key to diagnosis• Stick to your guns

• Definition• Pathogenesis• Epidemiology• DiagnosisTreatment• Prognosis

Treatment• Stop transfusion!• Report reaction

• Supportive Care

Treatment• Hemodynamic support• Fluids +/- pressors• No diuresis!• “Wet” CXR confusing

• Ventilatory support• NIPPV vs. Intubate • Lung protective strategy

Treatment• Need transfusion?• Single donor units• Leukodepleted blood• Newer blood

• Definition• Pathogenesis• Epidemiology• Diagnosis• TreatmentPrognosis

Prognosis

Live

Prognosis

Die

Live?• Recovery 24 – 96

• No long-term sequelae

• CXR lingers

Practice Guidelines

Bottom LineTransfusion + Clinical decline =

TRALI

Summary Questions• What is the #1 cause of #1 transfusion related

mortality?• What transfusion reaction is very under

reported and under-recognized?• What can any blood product cause?• What should you think about if there is any

clinical change within 6 hours of transfusion? • Who is the most important person to

recognize TRALI?

• Supportive Good prognosis

• Question all transfusions!

Thank you DHMC!