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TRALI You May Lose, If You Transfuse.

Haney A. Mallemat, MD Department of Critical Care Dartmouth-Hitchcock Medical Center. TRALI You May Lose, If You Transfuse. 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….

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TRALI You May Lose, If You Transfuse.

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  1. Haney A. Mallemat, MDDepartment of Critical Care Dartmouth-Hitchcock Medical Center TRALI You May Lose, If You Transfuse.

  2. Clinical Case • 77 M • AAA repair • POD #3 • Extubated • Stable vitals • Hb 8.1

  3. Evening Vascular Rounds… • 2U PRBC • No indication documented

  4. 3 hours later… • Respiratory distress • 85% sat • 85/50 • P: 125 • STAT Airway • Levophed

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

  6. Definition • Epidemiology • Pathogenesis • Diagnosis • Treatment • Prognosis

  7. 1951 • Pulmonary Hypersensitivity Reaction • Allergic Pulmonary Edema • Non-CardiogenicPulmonary Edema • Pulmonary Leucoagglutinin Reaction

  8. 1983: Dr. Popovosky Transfusion-Associated Popovoskitis

  9. TRansfusion • Associated • Lung • Injury

  10. Definition • No formal definition

  11. TRALI Consensus Conference • ALI from blood products • P/F ratio <300 • B/L infiltrates • No circulatory overload • No previous ALI • No causes ALI

  12. TRALI • “Classic” TRALI • < 6 h • ~30-120 min • “Delayed” TRALI • 6 – 72 h

  13. Definition Epidemiology • Pathogenesis • Diagnosis • Treatment • Prognosis

  14. Epidemiology • #1 transfusion-related mortality • >Infection • >ABO mismatch • Under recognized / reported • Mortality 5-10%

  15. Epidemiology • PRBC  1 in 5000 • Plasma  1 in 2000 • Platelets  1 in 2000 • IVIG • Cryoprecipitate • Stem cells

  16. Risk Factors Host Donor Multi-parous female donors Prolonged blood storage • M = F • Recent surgery • Active infections • Recent transfusion • Cytokine treatment • Thrombocytopenia • Increased age • Ethanol use • Tobacco • Severe illness

  17. Definition • Epidemiology Pathogenesis • Diagnosis • Treatment • Prognosis

  18. 3 Theories… • Anti-granulocyte antibody • Endothelial-cell priming • “Two-hit” hypothesis

  19. Definition • Epidemiology • Pathogenesis Diagnosis • Treatment • Prognosis

  20. Clinical Presentation • Mild symptoms • Death

  21. 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

  22. Question 1: Recent Transfusion?

  23. Question 2: Acute Lung Injury • <6 hours • Hypoxemia • P/F <300 • O2sat <90% • B/linfiltrates • No evidence of HF

  24. Bilateral pulmonary infiltrates

  25. 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

  26. Question 4: R/o volume overload • CHF • Nephrotic syndrome • Fluid overload • Post-sepsis • ESRD • AKI

  27. Diagnosis: Physical Exam • Frothy sputum • Hypoxia • Tachycardia • Hypotension • Fever

  28. Diagnosis: Radiology • CXR

  29. Diagnosis: Lab Tests

  30. Diagnosis: Nursing • Rare and subtle diagnosis • Subtlety is your specialty • Notice changes first • Key to diagnosis • Stick to your guns

  31. Definition • Pathogenesis • Epidemiology • Diagnosis Treatment • Prognosis

  32. Treatment • Stop transfusion! • Report reaction • Supportive Care

  33. Treatment • Hemodynamic support • Fluids +/- pressors • No diuresis! • “Wet” CXR  confusing • Ventilatory support • NIPPV vs. Intubate • Lung protective strategy

  34. Treatment • Need transfusion? • Single donor units • Leukodepletedblood • Newer blood

  35. Definition • Pathogenesis • Epidemiology • Diagnosis • Treatment Prognosis

  36. Prognosis Live

  37. Prognosis Die

  38. Live? • Recovery  24 – 96 • No long-term sequelae • CXR lingers

  39. Practice Guidelines

  40. Bottom Line Transfusion + Clinical decline = TRALI

  41. 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?

  42. Supportive  Good prognosis • Question all transfusions!

  43. Thank you DHMC!

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