ASA Annual Meeting 2014, New Orleans
Is TRALI not a severe form of acute lung injury? Evaluation of the clinical features of transfusion-related acute lung injury (TRALI) in an intensive care unit Satoshi Kazuma, Yoshiki Masuda, Hitoshi Imaizumi, Hiroomi Tatsumi, Kyoko Goto, Kanako Takahashi and Michiaki Yamakage Department of Anesthesiology, Sapporo Medical University School of Medicine, Sapporo, JAPAN
Table 1. Characteristics of patients
Introduction ・Transfusion-related acute lung injury (TRALI), which is defined as the onset of acute respiratory failure after blood transfusion, has long been regarded as a rare complication. ・Recently, an international definition of TRALI has been established and has enabled TRALI to be diagnosed more easily. ・Despite a higher incidence of TRALI than previously acknowledged1), the incidence of TRALI has still been low as recently reported (0.01～0.04 % per blood bag in Japan). Therefore, the pathophysiology of and appropriate treatments for TRALI remain unclear. ・We evaluated 11 patients with TRALI treated in our hospital’s ICU as well as the clinical features and the treatment used.
Case Age
1) Goldman M, et al. Transfus Med Rev 2005; 19: 2–31.
Methods ・Data for patients who were admitted to our hospital’s ICU during the period from March 2003 to October 2012 and who met the TRALI criteria were used for analysis in this study. ・We collected data on each patient’s background, clinical symptoms, kind of transfusion, onset time at the start of transfusion, PaO2/FIO2 ratio (P/F ratio) and PEEP level of mechanical ventilation, and lung CT findings within 24 hours after onset. ・We also obtained data for duration of mechanical ventilation, drug therapy, prone ventilation, use of extracorporeal membrane oxygenation (ECMO), mortality in 28 days and duration of ICU stay. ・The data are presented as means ± SD.
Sex
Underlying disease
Therapy
Total Age Gender（male：female） Underlying disease Cardiovascular surgery Gastrointestinal surgery Liver failure Leukemia Myasthenia Gravis Survive / Dead
11 61.5 ± 12.1 8：3
Table 3. Characteristics of TRALI at onset Total Use of blood products
（RCC：FFP：RCC+FFP： RCC+FFP+PC）
3:2:4:2
Time until onset (min)
about less than 240 min
P/F ratio at onset
118.2 ± 50 9.0 ± 1.2 9 / 11 9.1 ± 5.6 8.2 ± 5.8
6 2 2 1
PEEP at admission to ICU（cmH2O）
1
Ventilation day (day)
11 / 0
Hypotension ICU stay (day)
Ventilation day (day)
CT
catechol prone steroid ECMO -amine position
69
M
Sigmoid colon cancer
Sigmoidectomy
No
TRALI
FFP
240
76
8
6
6
CON+ATL
Yes
Yes
No
No
2
61
M
Liver abscess
Hepatic draignage
No
TRALI
RCC, FFP
unknown
106
6
11
10
CON+ATL
Yes
Yes
Yes
No
3
66
M
Angina Pectoris, AS
CABG, AVR
Yes
Possible TRALI
RCC
unknown
92
10
14
13
CON+ATL
Yes
No
Yes
No
4
71
M
TAAA
Endovascular stentgraft
No
TRALI
RCC, FFP, PC
180-240
105
13
10
9
CON+ATL
No
Yes
Yes
No
5
57
M
AS, MS
AVR, MVP
Yes
60
202
9
8
6
CON+ATL
Yes
No
No
No
6
36
F
MR
MVR
Yes
240
112
6
5
4
CON+ATL
Yes
Yes
Yes
No
7
47
F
PBC, Hepatic failure
PE
No
TRALI
FFP
180
181
3
4
3
CON+ATL
Yes
No
No
No
Red blood cell tlansfusion
No
TRALI
RCC
60
194
3
4
3
CON+ATL
No
No
No
No
PE
TRALI
FFP
120
86
3
23
23
CON+ATL +GGO
No
Yes
No
No
8
63
M
Luekemia, post CBSCT
9
75
M
MG
No
Possible RCC, FFP, PC TRALI Possible RCC, FFP TRALI
Possible RCC, FFP 100 86 8 6 5 No No No CON+ATL Yes TRALI Possible 11 56 M MR MVP RCC, FFP 20 60 7 9 8 Yes No Yes CON+ATL Yes Yes TRALI AS, Aortic valve stenosis; CABG, Coronary artery bypass graft; AVR, Aortic valve replacement; TAAA, Thoracoabdominal aortic aneurysm; MS, Mitral valve stenosis; MVP, Mitral valve plasty; MR, Mitral valve regurgitation; PBC, Primary biliary cirrhosis; PE, Plasma Exchange; CBSCT, cord blood stem cell transplantation; MG, Myasthenia GravisFFP, Fresh frozen plasma; RCC, Red cell concentrates; PC, Platelet concentrates; VFD, Ventilator free days; CON, Consolidation; ATL, Atelectasis; GGO, ground glass opacity; IFD, ICU free days; ECMO, Extracorporeal membranous oxygenation
10
76
F
MR
MVP
Yes
Figure 1. Chest radiography (A) and CT (B) of Case 7. (A) (B) (A)
Table 4. Treatment of patients
11
ICU stay (day)
1
Results Table 2. Background of patients
Risk factor Diagnosis of ALI
Duration of Onset time from Use of Blood P/F ratio mechanical transfusion products at onset ventilation (min) (day)
Total
11
Catecholamine
8 / 11
Steroids
6 / 11
Sivelestat
5 / 11
Prone position
4 / 11
ECMO
1 / 11
Figure 2. Definition of transfusion-related acute lung injury (TRALI) Suspected TRALI ・ Acute onset within 6 h of blood transfusion ・ PaO2/FIO2 < 300 mmHg, or worsening of P/F ratio ・ Bilateral infiltrative changes on chest radiograph ・ No sign of hydrostatic pulmonary edema (pulmonary arterial occlusion pressure ≦18 mmHg or central venous pressure ≦ 15 mmHg) ・ No other risk factor for acute lung injury Possible TRALI Same as for suspected TRALI, but another risk factor present for acute lung injury
Conclusions All the cases survival though the severe respiratory failure was late for several days, necessary in all cases the mechanical ventilation. If TRALI can get over the early period, the physical status often improve afterwards. Therefore the positive treatment is thought to be should not hesitate.
