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Transfusion-Related Acute Lung Injury

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

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Transfusion-Related Acute Lung Injury

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  1. Transfusion-Related Acute Lung Injury Melanie F. Clemens, CRNA, MSN Brooklyn VA Medical Center

  2. 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

  3. Disclosures

  4. 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 • 1 in 1,935,000 transfusions • Hepatitis B • 1 in 205,000 transfusions • HIV • 1 in 2,135,000 transfusions

  5. Clinical Relevance http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/ReportaProblem/TransfusionDonationFatalities

  6. 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

  7. Pathophysiology • Antibody Hypothesis • Human leukocyte antigen (HLA) • Class I & class II • Human neutrophil antigen (HNA) • Biologic Response Modifiers • Not antibody mediated • Two-Hit Hypothesis • 2 events • Opportunistic Sachs 2011

  8. Pathophysiology • Antibody mediated lung injury • 70% of TRALI cases • 85%-90% component based • 5%-10% recipient based • HLA & HNA antibody formation • Pregnancy • Transplantation • Transfusion • Antibodies target WBCs • Pulmonary microvascular infiltration & damage Dennison 2008

  9. Pathophysiology • Biologic Response Modifiers • Accumulate in stored blood • Activate & prime neutrophils • Independent of antibodies • Lower morbidity & mortality http://online.wsj.com/article/SB10001424052748703939404574567771148801570.html

  10. Pathophysiology • Two-Hit Theory • First event • System activation • Pulmonary endothelium • Primed neutrophils • Second event • Transfusion • Opportunistic • Threshold Sachs 2011

  11. Risk Factors • Product related risk factors Triulzi 2009

  12. Risk Factors • Recipient related risk factors Sachs 2011

  13. Diagnosis • Unrecognized • TRALI vs. TACO http://www.arabanesthesia.com/2011/03/association-between-intraoperative.html

  14. 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

  15. 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

  16. Diagnosis http://jama.ama-assn.org/content/287/15/1968.full Gilliss et al. 2011

  17. Diagnosis Gajic et al. 2006

  18. Diagnosis Skeate et al. 2007

  19. 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

  20. 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

  21. Clinical Impact • Alternatives to transfusion • Crystalloids • Colloids • Conservative transfusion thresholds • Risk stratification • Concentrated fibrinogen/Factor VII • Vitamin K

  22. Questions

  23. 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.

  24. 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 Transfusion- Related Acute Lung Injury. Critical Care Medicine, 34, S137- S143.

  25. 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 Transfusion- Associated Circulatory Overload. Current Opinion in Hematology, 14, 682-687.

  26. 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 Transfusion- Related Acute Lung Injury in the Critically Ill: A Nested Case- Control 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

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