TRALI

Calvin D. Sun, MD, PGY-3
Follow-Up Rounds 5/12/2017

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THE CASE

Triage Vitals: T 97.4F,  BP 137/49, HR 66, RR 18, O2 100% on RA

CC: Lower Back Pain, B/L LE numbness

HPI:

• 56M
• No known PMH
• Lower back pain radiating to BL feet x 1 week
• Numbness of BL feet since x 1 day
• Denies fever, LOC, headache, trauma, history of abdominal surgeries, abdominal pain
• Jehovah’s Witness
• Nightly AM Advil at home for back pain/sleeping aid also relieves pain.
• Pt also c/o blood on top of brown stool x months
• Normal colonoscopy and EGD 3 years ago

PHYSICAL EXAM

• Gen: AAO x 3, well appearing, NAD
• HEENT: atraumatic, no cyanosis, no pallor, MMM
• CV: RRR, no murmurs appreciated
• Pulm: CTA B/L, no wheezing
• Abd: S, NT, ND, + BS in all 4 quadrants
• Extr: pulses palpable bilaterally, no edema
• Neuro: moving all 4 extremities, no facial droop, no focal deficits, CN II-XII grossly intact

STUDIES

CBC
WBC (/nL)	10.2 (3.5 – 11.0)
Hgb (g/dL)	4.4 (12.0 – 16.0)

 

Coags
aPTT (sec)	23.3 (20.1 – 31.2) sec
PT	13.4 (9.5 – 12.2) sec
INR	1.0 (0.9 – 1.2)

 

CMP
Na	139 (135 – 145) mEq/L
K	7.1 (3.5 – 5.0) mEq/L
Cl	112 (98 – 108) mEq/L
CO2	17 (24 – 30) mEq/L
BUN	18 (5 – 26) mg/dL
Creat	2.27 (0.1 – 1.5) mg/dL
Gluc	111 (70 – 105) mg/dL

INTERVENTIONS

• Patient begins 1u pRBC transfusion
• 5 minutes later and after receiving 100 mL of blood, patient begins to feel SOB

INTERVENTIONS – 5 MINUTES LATER

• Nurse notices acute respiratory distress
• Patient becomes altered, obtunded, not answering questions, diaphoretic w/ retractions, unable to speak
• PO2 on NRB mask 79%
• Patient intubated
• …and pRBC transfusion stopped

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TRALI

• Transfusion-related acute lung injury
• Incidence among patients receiving transfusion
  • 04-0.10% (1 in 5000) in all cases
  • 5-8% in critically ill patients
• During or within 6 hours after blood product administration
• Can occur with any blood product
• Being critically ill is the highest risk factor
• Pathogenesis (2-hit):
  • Neutrophils primed to respond
  • Neutrophil activation by a factor in the blood product → damage capillary endothileum in lung → pulmonary edema

CLINICAL PRESENTATION OF TRALI

• Hypoxemia (100%)
• Bilateral pulmonary infiltrates (100%)
• Pink frothy airway secretions (56%)
• Fever (33%)

DIFFERENTIALS RELATED TO TRALI

• TACO: Transfusion-associated circulatory overload
  • More associated with volume overload
• Hemolytic transfusion reaction
  • More associated with fever and chills
• Anaphylaxis
  • More associated with stridor, cough, wheezing
• Sepsis
  • More associated with fever and hypotension with evidence of an active infectious process

MANAGEMENT OF TRALI

• O2, Airway management, CXR
• Stop transfusion immediately
  • Return blood product to the blood bank for a transfusion reaction workshop (CBC, bilirubin, haptoglobin, Coombs)
• Supportive care
  • Intubation often required (70-80%)
• Mixed results with steroids; not recommended
• Patients appear not to be at increased risk for repeat episodes with future transfusions if from other donors

REFERENCES

Fung YL, Silliman CC. The role of neutrophils in the pathogenesis of transfusion-related acute lung injury. Transfus Med Rev 2009; 23:266.

Silliman CC. The two-event model of transfusion-related acute lung injury. Crit Care Med 2006; 34:S124.

Bux J, Sachs UJ. The pathogenesis of transfusion-related acute lung injury (TRALI). Br J Haematol 2007; 136:788.

van Stein D, Beckers EA, Sintnicolaas K, et al. Transfusion-related acute lung injury reports in the Netherlands: an observational study. Transfusion 2010; 50:213.