Pulmonary edema after transfusion: How to differentiate transfusion-associated circulatory overload from transfusion-related acute lung injury

Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.
Critical Care Medicine (Impact Factor: 6.31). 06/2006; 34(5 Suppl):S109-13. DOI: 10.1097/01.CCM.0000214311.56231.23
Source: PubMed


Pulmonary edema is an under-recognized and potentially serious complication of blood transfusion. Distinct mechanisms include adverse immune reactions and circulatory overload. The former is associated with increased pulmonary vascular permeability and is commonly referred to as transfusion-related acute lung injury (TRALI). The latter causes hydrostatic pulmonary edema and is commonly referred to as transfusion-associated circulatory overload (TACO). In this review article we searched the National Library of Medicine PubMed database as well as references of retrieved articles and summarized the methods for differentiating between hydrostatic and permeability pulmonary edema.
The clinical and radiologic manifestations of TACO and TRALI are similar. Although echocardiography and B-type natriuretic peptide measurements may aid in the differential diagnosis between hydrostatic and permeability pulmonary edema, invasive techniques such as right heart catheterization and the sampling of alveolar fluid protein are sometimes necessary. The diagnostic differentiation is especially difficult in critically ill patients will multiple comorbidities so that the cause of edema may only be determined post hoc based on the clinical course and response to therapy. Guided by available evidence, we present an algorithm for establishing the pretest probability of TRALI as opposed to TACO. The decision to test donor and recipient blood for immunocompatibility may be made on this basis.
The distinction between hydrostatic (TACO) and permeability (TRALI) pulmonary edema after transfusion is difficult, in part because the two conditions may coexist. Knowledge of strengths and limitations of different diagnostic techniques is necessary before initiation of complex TRALI workup.

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Available from: Michael Gropper, Oct 12, 2015
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    • "Immune-mediated NISHOT include hemolytic and allergic reactions, transfusion-related immunomodulation (TRIM), transfusion-related acute lung injury (TRALI), nosocomial infections, transfusion-associated graft versus host disease, and alloimmunization to RBC and HLA antigens [57,62,63]. "
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    ABSTRACT: Anemia and red blood cell (RBC) transfusion occur frequently in hospitalized patients with cardiac disease. In this narrative review, we report the epidemiology of anemia and RBC transfusion in hospitalized adults and children (excluding premature neonates) with cardiac disease, and on the outcome of anemic and transfused cardiac patients. Both anemia and RBC transfusion are common in cardiac patients, and both are associated with mortality. RBC transfusion is the only way to rapidly treat severe anemia, but is not completely safe. In addition to hemoglobin (Hb) concentration, the determinant(s) that should drive a practitioner to prescribe a RBC transfusion to cardiac patients are currently unclear. In stable acyanotic cardiac patients, Hb level above 70 g/L in children and above 70 to 80 g/L in adults appears safe. In cyanotic children, Hb level above 90 g/L appears safe. The appropriate threshold Hb level for unstable cardiac patients and for children younger than 28 days is unknown. The optimal transfusion strategy in cardiac patients is not well characterized. The threshold at which the risk of anemia outweighs the risk of transfusion is not known. More studies are needed to determine when RBC transfusion is indicated in hospitalized patients with cardiac disease.
    Annals of Intensive Care 06/2014; 4(1):16. DOI:10.1186/2110-5820-4-16 · 3.31 Impact Factor
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    • "In the absence of pulmonary artery wedge catheter measurements, cardiac failure was diagnosed if two of the following were present: central venous pressure >15 mmHg, a history of heart failure or valve dysfunction, ejection fraction <45% as estimated by echocardiogram, or a positive fluid balance. The probability of cardiogenic pulmonary edema was scored by two physicians independently on a scale of 1–4 (APJV and NPJ) [31]. Chest radiographs were scored for the presence of new onset bilateral interstitial abnormalities by two independent physicians who were blinded to the predictor variables. "
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    ABSTRACT: Background Acute lung injury (ALI) is characterized by a pro-coagulant state. Heparin is an anticoagulant with anti-inflammatory properties. Unfractionated heparin has been found to be protective in experimental models of ALI. We hypothesized that an intravenous therapeutic dose of unfractionated heparin would favorably influence outcome of critically ill patients diagnosed with ALI. Methods Patients admitted to the Intensive Care Unit (ICU) of a tertiary referral center in the Netherlands between November 2004 and October 2007 were screened. Patients who developed ALI (consensus definition) were included. In this cohort, the impact of heparin use on mortality was assessed by logistic regression analysis in a propensity matched case–control design. Results Of 5,561 admitted patients, 2,138 patients had a length of stay > 48 hours, of whom 723 were diagnosed with ALI (34%), of whom 164 received intravenous heparin. In a propensity score adjusted logistic regression analysis, heparin use did not influence 28-day mortality (odds ratio 1.23 [confidence interval 95% 0.80–1.89], nor did it affect ICU length of stay. Conclusions Administration of therapeutic doses of intravenous unfractionated heparin was not associated with reduced mortality in critically ill patients diagnosed with ALI. Heparin treatment did not increase transfusion requirements. These results may help in the design of prospective trials evaluating the use of heparin as adjunctive treatment for ALI.
    BMC Pulmonary Medicine 08/2012; 12(1):43. DOI:10.1186/1471-2466-12-43 · 2.40 Impact Factor
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    • "It is generally known that TRALI occurs usually when FFP is administered, but it can be caused by all the other blood components [4]. The accurate pathogenesis of TRALI is not known, but it has been reported that TRALI is related with anti-HLA I, II, anti-neutrophil antibody, and biologically active lipids of the donor plasma [2,6]. Although it is known that TRALI pathogenesis is triggered by a trace amount of plasma, the relationship between the administered dose and the severity is not certain. "
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    ABSTRACT: Transfusion-related acute lung injury (TRALI) is one of the leading causes of transfusion-related morbidity and mortality. However, it is frequently not diagnosed and under-reported, which could result in inappropriate treatment. Diagnostic definition for TRALI consists of hypoxia and bilateral pulmonary edema occurring during or within 6 hours of a transfusion in the absence of cardiac failure or intravascular volume overload. Here, we report a fatal case, which resulted from under-recognition and misdiagnosis of TRALI occurring during transfusion with packed red blood cells during a bilateral total knee replacement.
    Korean journal of anesthesiology 01/2012; 62(1):73-8. DOI:10.4097/kjae.2012.62.1.73
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