Learner Version
Module 30
Created by Michael Reyes MD, and Sara Koenig MD
4/14
Objectives:
See Facilitator Version
References:
See Facilitator Version
Case
A 68 year old male with a history of chronic lymphocytic leukemia, hypertension, and cirrhosis
secondary to alcohol abuse presents to the ED following a brief episode of melena. His medications
include fludarabine, lisinopril, metoprolol, and diazepam for occasional anxiety.
On physical examination, his temperature is 37.3 degrees Celsius, blood pressure is 150/90 mm Hg,
pulse is 90/minute, respiratory rate is 16/min, and O2sat is 97% on room air. There is no scleral icterus
or jaundice, however trace bilateral lower extremity edema is present. There is no evidence of ascites.
The patient’s spleen is mildly enlarged and non-tender. The patient weighs 100 kg.
Labs: Wbc 16, Hgb 11, Hct 33, Plt 80, LFTs: AST: 320, ALT:90, TP 5.3 g/dL, TB 3.1, DB 0.8, Chem7 normal,
INR 1.5, PT 15s, PTT 38s
The patient is admitted to Blue Medicine and a GI consult is obtained to identify the source of the
melena. GI says that they will not “scope” the patient unless the INR is less than 1.5. They recommend
FFP to lower the INR prior to endoscopy.
What are the common indications for FFP?
What are some of the potential complications of transfusing FFP?
Is FFP likely to be helpful in this patient whose melena has resolved?
What is a therapeutic dose of FFP?
Does this patient’s FFP need to be irradiated?
Despite pleading with GI regarding the lack of an indication for the 2 units of FFP in this patient who is
not currently bleeding with a mildly elevated INR, you give in to their request as they will not perform
endoscopy without pre-procedure FFP.
The patient receives 2 units of FFP. About half way through the second unit of FFP the patient’s nurse
notices that he has developed a fever of 38.7 degrees Celsius. All other vital signs are normal, and the
patient reports no clinical symptoms. The patient’s nurse calls the Blue Medicine Resident, reports the
fever, and asks how to proceed.
What is the very first thing you will tell the nurse?
What further steps should be taken in this suspected transfusion reaction?
What is your differential diagnosis at this point?
While waiting for the suspected transfusion reaction testing to come back, the patient’s nurse calls you
back and says that the patient has developed severe shortness of breath and is requiring supplemental
oxygen to keep his O2 sats around 90.
Based on the current symptoms, what is your differential diagnosis now?
Which studies/lab tests will you order/what other information should be assessed?
The results of the suspected transfusion reaction work-up and of the other studies are now available,
and are as follows:
The following studies were negative/no discrepancy: Bedside clerical check, BB clerical check, DAT,
serum hemoglobin, ABO and Rh type.
The patient’s vitals are as follows:
Pre-transfusion: Pulse 84, Temp. 37.3, RR 12, BP 150/92, O2sat. 97% on RA
At time of reaction: Pulse 110, Temp. 38.7, RR 28, BP 135/82, O2sat. 80% on RA
The chest x-ray shows a bilateral “whiteout” consistent with pulmonary edema. The patient’s pre- and
post-transfusion BNPs are similar and within the normal range and a stat ECG shows normal rhythm with
sinus tachycardia.
Following review of the patient’s symptoms, the suspected transfusion reaction results, vitals, and
additional testing, a preliminary diagnosis of TRALI is made.
Reaction
TACO
Signs and Symptoms
Dyspnea,
hypertension,
pulmonary edema,
JVD, peripheral
edema, increased
pulmonary capillary
Studies/Labs
BNP (pre- and posttransfusion), chest Xray
Usual Cause
Rapid/excessive
infusion of blood
products in at risk
patients (CHF, MI,
renal failure, etc.)
Treatment
Stop transfusion,
diuresis, supportive
care
Prevention
Avoid rapid or
excessive infusion of
blood products—
especially in at risk
patients, use low
volume products if
TRALI
wedge pressure
Dyspnea,
hypoxemia, fever,
hypotension,
pulmonary edema,
normal pulmonary
capillary wedge
pressure
Chest X-ray, BNP (to
r/o TACO), labs to
assess for hemolysis
(r/o hemolytic
transfusion reaction)
Donor HLA or antineutrophil
antibodies
Supportive care,
intubation if severe
symptoms
necessary
Deferral of high risk
donors, reporting
and deferral of TRALI
associated donors
** All signs and symptoms may not be present for any given reaction
A diagnosis of Transfusion related acute lung injury (TRALI) is made. The patient continues to
deteriorate and requires emergent transfer to the MICU and intubation. The patient’s MICU course is
uneventful and following resolution of his pulmonary edema he is eventually extubated. No further
episodes of melena are reported during his inpatient stay and he is eventually discharged with an
appointment to see GI as an outpatient.
Describe the pathophysiology of TRALI
Is this patient at increased risk of TRALI with future transfusions?
Which blood products are most associated with TRALI?
How is TRALI managed?
How have blood banks sought to minimize the risk of TRALI?
Associated Transfusion MKSAP questions for this module:
Hematology
Question 3
Question 7
Question 14
Question 50
Post Module Evaluation
Please place completed evaluation in an interdepartmental mail envelope and address to Dr.
Wendy Gerstein, Department of Medicine, VAMC (111), or give to Dr. Patrick Rendon, UNM
Hospital Division of Hospital Medicine 4 ACC.
1) Topic of module:__________________________
2) On a scale of 1-5, how effective was this module for learning this topic? _________
(1= not effective at all, 5 = extremely effective)
3) Were there any obvious errors, confusing data, or omissions? Please list/comment below:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________
4) Was the attending involved in the teaching of this module? Yes/no (please circle)
5) Please provide any further comments/feedback about this module, or the inpatient curriculum
in general:
6) Please circle one:
Attending
Resident (R2/R3)
Intern
Medical student