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