1. Becky Piper, MN RN Pierce College Nursing Program Transfusion Related Acute Lung Injury: A Simulation Case Experience For Nurse Educators

2. Objectives Provide a brief overview of transfusion reactions Provide a brief overview of transfusion reactions Provide a definition of TRALI Provide a definition of TRALI Describe the steps used to build the TRALI SCE Describe the steps used to build the TRALI SCE

3. TRALI TRALI defined TRALI defined Pathophysiology Pathophysiology 4 primary causes 4 primary causes 1. HNA/HLA antibodies 2. Multiparous donors (>3pregnancies) 3. Lipid priming agents from older PRBC products 4. First hit-second hit model

4. TRALI Fatalities

5. Recent Trends TRALI Deaths

6. TRALI vs. TACO Comparison Comparison TRALI TRALI TACO TACO Blood Pressure HypotensionHypertension Onset Up to six hrs post transfusion Usually occurs during or immediately after a transfusion Chest X-Ray Bilateral pulmonary infiltrates, normal heart Bilateral pulmonary infiltrates, enlarged heart Lab tests Lab testsBNPTNI<250pg/ml Normal Normal >250 pg/ml Elevated Elevated

7. TRALI vs. Normal Lung

8. Treatment Symptoms may be mild to severe Symptoms may be mild to severe If severe may need intubation to support respiratory system - treatment in ICU If severe may need intubation to support respiratory system - treatment in ICU Use of steroids Use of steroids Lasix (Furosimide) is NOT appropriate Lasix (Furosimide) is NOT appropriate Symptoms may subside within 96 hrs. Symptoms may subside within 96 hrs.

9. Knowledge Gaps Lack of information on TRALI for nurses and transfusionists in peer review journals Lack of information on TRALI for nurses and transfusionists in peer review journals Few nursing text books mention it! Few nursing text books mention it!

10. Building the TRALI Simulation Research – TRALI and Simulation in Nursing Research – TRALI and Simulation in Nursing Writing the simulation using UWSON template Writing the simulation using UWSON template First review by Simulation experts at UWSON First review by Simulation experts at UWSON Review by two Medical Directors Review by two Medical Directors Dr. Tom Baker, Cascade Regional Blood Services – Tacoma Dr. Bob Ranlett, Inland Blood Centers - Spokane  Trial runs for debugging

11. TRALI Case Study Case Description: Case Description: Your patient is Lucy Leardal, a 72 yr old female who tripped over her cat and was subsequently admitted in the evening through the Emergency Room with a left hip fracture. Lucy has a history of A-Fib and takes 5 mg of Coumadin daily.

12. TRALI Case study You have just come out of shift report. Your patient is scheduled for hip surgery tomorrow You have just come out of shift report. Your patient is scheduled for hip surgery tomorrow (ORIF). She is receiving the first of three units of FFP ordered to reverse the effects of Coumadin prior to the surgery. She has received approximately 50 ml of the first unit of FFP. (ORIF). She is receiving the first of three units of FFP ordered to reverse the effects of Coumadin prior to the surgery. She has received approximately 50 ml of the first unit of FFP.

13. References Fatalities reported to FDA, Annual summary for fiscal years 2005 and 2006 Fatalities reported to FDA, Annual summary for fiscal years 2005 and 2006http://www.fda.gov/cber/blood/fatal0506.htm Bradley, P. (2006). The history of simulation in medical education and possible future directions. Medical Education, (40), 254-262. Bradley, P. (2006). The history of simulation in medical education and possible future directions. Medical Education, (40), 254-262. Issenberg, S.B., McGaghie, W., Petrusa, E., Gordon, D. & Scalese, R., (2005). Features and uses of high fidelity medical simulation that lead to effective learning: a BEME systematic review. Medical Teacher,(27) 1, 10 - 28. Issenberg, S.B., McGaghie, W., Petrusa, E., Gordon, D. & Scalese, R., (2005). Features and uses of high fidelity medical simulation that lead to effective learning: a BEME systematic review. Medical Teacher,(27) 1, 10 - 28. Jeffries, P.R., (Ed.), (2007). Simulation in Nursing Education, New York: National League for Nursing. Jeffries, P.R., (Ed.), (2007). Simulation in Nursing Education, New York: National League for Nursing.  Perkins, G. (2007). Simulation in resuscitation training. Resuscitation, (73), 202- 211.