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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: 6.15). 06/2006; 34(5 Suppl):S109-13. DOI: 10.1097/01.CCM.0000214311.56231.23
Source: PubMed

ABSTRACT 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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    ABSTRACT: Transfusion af saltvand, adenin, glukose og mannitol (SAGM) benyttes ofte i behandlingen af kritisk syge patienter, der er indlagt på en intensivafdeling [1]. I internationale studier er det vist, at 40-50% af alle intensivpatienter får SAGM-transfusioner, og mere end 90% af blodtransfusionerne administreres til ikkeblødende patienter med et gennemsnit på fem portioner SAGM pr. patient [2-4]. Forbruget af SAGM på danske intensivafdelinger er på samme niveau og er beskrevet i et nyere kohor-testudie. Niogtres ud af 132 (52%) patienter med septisk shock på seks intensivafdelinger i Østdanmark fik SAGM-transfusion inden for det første indlaeggel-sesdøgn [5]. Blodtransfusion har traditionelt vaeret opfattet som en virksom behandling til patienter med anaemi – isaer til patienter med kliniske tegn på nedsat vaevsoxy-genering. Ny viden om transfusion har sat fokus på im-munmodulerende egenskaber af blod og på lagringens virkninger på blodets iltbaerende egenskaber som mu-lig forklaring på de potentielt skadelige virkninger på kritisk syge recipienter. Derfor er diskus sionen om, hvorvidt den samlede virkning af blodtransfusion er gavnlig, hvilke haemoglobinniveauer der er optimale for ikkeblødende patienter, og praecis hvilke kritisk syge patienter der kan have gavn af SAGM, fortsat aktuel. Denne statusartikel beskriver virkninger og bivirkninger ved SAGM-transfusion til ikkeblødende kritisk syge patienter og diskuterer den aktuelle evi-dens og de aktuelle rekommandationer på området. PATOFYSIOLOGI Blod administreres for at øge haemoglobinkoncentra-tionen og dermed blodets iltbaerende kapacitet. Her-ved øges det globale ilttilbud (DO 2), men det er uvist, om det perifere ilttilbud øges som resultat heraf. Hos forskellige grupper af kritisk syge patienter, herunder patienter med septisk shock, er det vist, at DO 2 øges efter blodtransfusion, men at iltforbruget (VO 2) ikke nødvendigvis øges [6]. En mulig fortolkning af disse data er, at transfunderede erytrocytter ikke afgiver ilt så godt som genuine celler, og der er på denne bag-grund blevet stillet spørgsmålstegn ved den ønskede virkning af transfusion på vaevsiskaemi [7]. Storage lesion Hos den kritisk syge kan den i forvejen heterogene kapillaere perfusion som følge af perifer stase og shunt forvaerres efter blodtransfusion. Den mulige år-sag hertil er sammenfaldende med den potentielt manglende virkning af transfusion, nemlig kombina-tionen af aendret mikrocirkulation og kvalitative aen-dringer i blodet som følge af lagring. De biokemiske og morfologiske aendringer, der opstår i erytrocytten og dens medie, når den lagres ex vivo, kaldes samlet for storage lesion. Morfologisk sker der under lagrin-gen en korpuskular omdannelse af erytrocytten, hvil-ket samlet fører til, at lagrede erytrocytter har nedsat evne til at navigere i mikrocirkulationen og nedsat evne til at frigive oxygen til perifere vaev [8].
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    Dataset: TACO
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    Transfusion 12/2014; · 3.57 Impact Factor

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