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

2. 77 M AAA repair POD #3 Extubated Stable vitals Hb 8.1

3. 2U PRBC No indication documented

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

7. Definition Epidemiology Pathogenesis Diagnosis Treatment Prognosis

8. Definition Epidemiology Pathogenesis Diagnosis Treatment Prognosis

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

10. Transfusion-Associated Popovoskitis

11. TR ansfusion A ssociated L ung I njury

12. No formal definition

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

14.  “Classic” TRALI  < 6 h ▪ ~30-120 min  “Delayed” TRALI  6 – 72 h

15. Definition Epidemiology Pathogenesis Diagnosis Treatment Prognosis

16. #1 transfusion-related mortality >Infection >ABO mismatch Under recognized / reported Mortality 5-10%

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

18. 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

19. Definition Epidemiology Pathogenesis Diagnosis Treatment Prognosis

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

23. Definition Epidemiology Pathogenesis Diagnosis Treatment Prognosis

24. Mild symptoms Death

25. 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

28. <6 hours Hypoxemia P/F <300 O2sat <90% B/l infiltrates No evidence of HF

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

31. CHF Nephrotic syndrome Fluid overload Post-sepsis ESRD AKI

32. Frothy sputum Hypoxia Tachycardia Hypotension Fever

33. CXR

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

37. Definition Pathogenesis Epidemiology Diagnosis Treatment Prognosis

38. Stop transfusion! Report reaction Supportive Care

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

40. Need transfusion? Single donor units Leukodepleted blood Newer blood

41. Definition Pathogenesis Epidemiology Diagnosis Treatment Prognosis

42. Live

43. Die

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

47. Transfusion + Clinical decline = TRALI

48. 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?

49. Supportive  Good prognosis Question all transfusions!