Article

Transfusion-related acute lung injury and pulmonary edema in critically ill patients: A retrospective study

Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA.
Transfusion (Impact Factor: 3.57). 10/2006; 46(9):1478-83. DOI: 10.1111/j.1537-2995.2006.00930.x
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ABSTRACT Using the recent Consensus Panel recommendations, we sought to describe the incidence of transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO) in critically ill patients.
Consecutive patients at four intensive care units (ICUs) who did not require respiratory support at the time of transfusion were identified with custom electronic surveillance system that prospectively tracks the time of transfusion and onset of respiratory support. Respiratory failure was defined as the onset of noninvasive or invasive ventilator support within 6 hours of transfusion. Experts blinded to specific transfusion factors categorized the cases of pulmonary edema as permeability edema (suspected or possible TRALI) or hydrostatic edema (TACO) according to predefined algorithm. In a nested case-control design, transfusion variables and lung injury risk factors were compared between the TRALI cases and controls matched by age, sex, and admission diagnosis.
There were 8902 units transfused in 1351 patients of whom 94 required new respiratory support within 6 hours of transfusion. Among 49 patients with confirmed acute pulmonary edema, experts identified 7 cases with suspected TRALI, 17 patients with possible TRALI, and 25 cases with TACO. The incidence of suspected TRALI was 1 in 1271 units transfused; possible TRALI, 1 in 534 per unit transfused; and TACO, 1 in 356 per unit transfused. When adjusted for sepsis and fluid balance in a stepwise conditional logistic regression analysis, patients who developed acute lung injury (suspected or possible TRALI) received larger amount of plasma (odds ratio 3.4, 95% confidence interval 1.2-10.2, for each liter infused; p = 0.023).
In the ICU, pulmonary edema frequently occurs after blood transfusion. The association between infusion of plasma and the development of suspected or possible TRALI may have important implications with regards to etiology and prevention of this syndrome.

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    • "When activation status is too low, it is possible that priming factors in the transfusion are not strong enough to overcome the threshold. The threshold model may explain why the estimated incidence of TRALI is higher in cardiac surgery and critically ill patients [9] [10] [11] [12]. These patients often suffer from an inflammatory condition, which may contribute to "
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    ABSTRACT: Purpose. Onset of transfusion-related acute lung injury (TRALI) is suggested to be a threshold-event. Data is lacking on the relation between titer of antibodies infused and onset of TRALI. We determined whether onset of TRALI is dependent on the titer of MHC-I antibodies infused in a combined model of ventilator-induced lung injury and antibody-induced TRALl. Methods. BALB/c mice were ventilated for five hours with low (7.5 ml/kg) or high (15 ml/kg) tidal volume. After three hours of MV, TRALI was induced by infusion of 0.5 mg/kg, 2.0 mg/kg or 4.5 mg/kg MHC-I antibodies. Control animals received vehicle. After five hours of MV, animals were sacrificed. Results. MV with high tidal volumes resulted in increased levels of all markers of lung injury compared to animals ventilated with low tidal MV. In ventilator-induced lung injury, infusion of 4.5 mg/kg of antibodies further increased pulmonary wet-to-dry ratio, pulmonary neutrophil influx and pulmonary KC levels, whereas infusion of lower dose of antibodies did not augment lung injury. In contrast, mice ventilated with low tidal volumes did not develop lung injury, irrespective of the dose of antibody used. Conclusions. In the presence of injurious MV, onset of TRALI depends on the titer of antibodies infused.
    Critical care research and practice 06/2012; 2012:720950. DOI:10.1155/2012/720950
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    • "More recently, FFP administration has emerged as an independent risk factor for TRALI in both trauma, medical and surgical ICU populations (Gajic et al, 2004, 2007a,b; Khan et al, 2007; Sadis et al, 2007; Chaiwat et al, 2009). In most of these studies, plasma containing blood products (FFP), not PRBCs, were associated with TRALI (Gajic et al, 2004, 2007a; Rana et al, 2006; Khan et al, 2007; Sadis et al, 2007). Only recently have studies began to sort out the risk of ALI and TRALI (ALI within 6 h) with the transfusion of plasma-containing blood products as opposed to red blood cells in critically ill patients. "
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    ABSTRACT: Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion-related morbidity and mortality world-wide. Although first described in 1983, it took two decades to develop consensus definitions, which remain controversial. The pathogenesis of TRALI is related to the infusion of donor antibodies that recognize leucocyte antigens in the transfused host or the infusion of lipids and other biological response modifiers that accumulate during the storage or processing of blood components. TRALI appears to be the result of at least two sequential events and treatment is supportive. This review demonstrates that critically ill patients are more susceptible to TRALI and require special attention by critical care specialists, haematologists and transfusion medicine experts. Further research is required into TRALI and its pathogenesis so that transfusions are safer and administered appropriately. Avoidance including male-only transfusion practises, the use of leucoreduced components, fresher blood/blood components and solvent detergent plasma are also discussed.
    British Journal of Haematology 09/2009; 147(4):431-43. DOI:10.1111/j.1365-2141.2009.07840.x · 4.96 Impact Factor
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    • "They found a strong association with the amount of plasma transfused but not with any aspect of red cell transfusion . They went on to show that the association with ALI was much more marked for female donor plasma than for male donor plasma, in keeping with a donor antibody-mediated effect (Rana et al., 2006). The findings strongly suggest that TRALI can be a significant contributor to ALI in critically ill patients. "
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