Haney A. Mallemat, MD Department of Critical Care Dartmouth-Hitchcock Medical Center

77 M AAA repair POD #3 Extubated Stable vitals Hb 8.1

2U PRBC No indication documented

Respiratory distress 85% sat 85/50 P: 125 STAT Airway Levophed

Definition Epidemiology Pathogenesis Diagnosis Treatment Prognosis

Definition Epidemiology Pathogenesis Diagnosis Treatment Prognosis

Pulmonary Hypersensitivity Reaction Allergic Pulmonary Edema Non-Cardiogenic Pulmonary Edema Pulmonary Leucoagglutinin Reaction

Transfusion-Associated Popovoskitis

TR ansfusion A ssociated L ung I njury

No formal definition

ALI from blood products P/F ratio <300 B/L infiltrates No circulatory overload No previous ALI No causes ALI

 “Classic” TRALI  < 6 h ▪ ~ min  “Delayed” TRALI  6 – 72 h

Definition Epidemiology Pathogenesis Diagnosis Treatment Prognosis

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

PRBC  1 in 5000 Plasma  1 in 2000 Platelets  1 in 2000 IVIG Cryoprecipitate Stem cells

HOST M = F Recent surgery Active infections Recent transfusion Cytokine treatment Thrombocytopenia Increased age Ethanol use Tobacco Severe illness DONOR Multi-parous female donors Prolonged blood storage

Definition Epidemiology Pathogenesis Diagnosis Treatment Prognosis

1. Anti-granulocyte antibody 2. Endothelial-cell priming 3. “Two-hit” hypothesis

Definition Epidemiology Pathogenesis Diagnosis Treatment Prognosis

Mild symptoms Death

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

<6 hours Hypoxemia P/F <300 O2sat <90% B/l infiltrates No evidence of HF

Aspiration Pneumonia Toxic inhalation Lung contusion Near drowning Severe sepsis Shock Trauma Burns Pancreatitis Bypass surgery Drug overdose

CHF Nephrotic syndrome Fluid overload Post-sepsis ESRD AKI

Frothy sputum Hypoxia Tachycardia Hypotension Fever

CXR

Rare and subtle diagnosis Subtlety is your specialty Notice changes first Key to diagnosis Stick to your guns

Definition Pathogenesis Epidemiology Diagnosis Treatment Prognosis

Stop transfusion! Report reaction Supportive Care

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

Need transfusion? Single donor units Leukodepleted blood Newer blood

Definition Pathogenesis Epidemiology Diagnosis Treatment Prognosis

Live

Die

Recovery  24 – 96 No long-term sequelae CXR lingers

Transfusion + Clinical decline = TRALI

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?

Supportive  Good prognosis Question all transfusions!