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

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Presentation on theme: "Transfusion-Related Acute Lung Injury Melanie F. Clemens, CRNA, MSN Brooklyn VA Medical Center."— Presentation transcript:

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

2  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 Objectives

3 Disclosures

4  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 Clinical Relevance

5

6  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 Presentation

7  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 Pathophysiology Sachs 2011

8  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 Pathophysiology Dennison 2008

9  Biologic Response Modifiers  Accumulate in stored blood  Activate & prime neutrophils  Independent of antibodies  Lower morbidity & mortality Pathophysiology

10  Two-Hit Theory  First event  System activation  Pulmonary endothelium  Primed neutrophils  Second event  Transfusion  Opportunistic  Threshold Pathophysiology Sachs 2011

11  Product related risk factors Risk Factors Triulzi 2009

12  Recipient related risk factors Risk Factors Sachs 2011

13  Unrecognized  TRALI vs. TACO Diagnosis

14  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 Diagnosis

15  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 Presentation

16 Diagnosis Gilliss et al

17 Diagnosis Gajic et al. 2006

18 Diagnosis Skeate et al. 2007

19  Differential diagnosis  Stop the suspected product  Supportive  Intubation & mechanical ventilation  Fluids  Vasopressors  5%-20% mortality rate  Retain the transfused products Treatment

20  Prevention  Limit unnecessary transfusions  Donor limitations  Leukocyte reduction  Washing cellular components  Pooled products  Product testing  Using freshest available products Clinical Impact

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

22 Questions

23  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

24  Gillis, Brian. Looney, Mark. Gropper, Michael. (2011). Reducing Noninfectious Risks of Blood Transfusion. Anesthesiology, 115,  Kopko, Patricia. (2010). Transfusion-Related Acute Lung Injury. Journal of Infusion Nursing, 33,  Looney, Mark. Gillis, Brian. Matthay, Michael. (2010). Pathophysiology of Transfusion-Related Acute Lung Injury. Current Opinion in Hematology, 17,  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. References

25  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,  Skeate, Robert. Eastlund, Ted. (2007). Distinguishing Between Transfusion-Related Acute Lung Injury and Transfusion- Associated Circulatory Overload. Current Opinion in Hematology, 14, References

26  Triulzi, Darrell. (2009). Transfusion-Related Acute Lung Injury: Current Concepts for the Clinician. Anesthesia and Analgesia, 108,  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,  Federal Drug Administration (2010). Fatalities Reported to FDA Following Blood Collection and Transfusion. Annual Summary for Fiscal Year References


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