Vlaar AP, Hofstra JJ, Determann RM, et al. The incidence, risk factors, and outcome of transfusion-related acute lung injury in a cohort of cardiac surgery patients: A prospective nested case-control study

Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands.
Blood (Impact Factor: 10.45). 02/2011; 117(16):4218-25. DOI: 10.1182/blood-2010-10-313973
Source: PubMed


Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion-related morbidity and mortality. Both antibodies and bioactive lipids that have accumulated during storage of blood have been implicated in TRALI pathogenesis. In a single-center, nested, case-control study, patients were prospectively observed for onset of TRALI according to the consensus definition. Of 668 patients, 16 patients (2.4%) developed TRALI. Patient-related risk factors for onset of TRALI were age and time on the cardiopulmonary bypass. Transfusion-related risk factors were total amount of blood products (odds ratio [OR] = 1.2; 95% confidence interval [CI], 1.03-1.44), number of red blood cells stored more than 14 days (OR = 1.6; 95% CI, 1.04-2.37), total amount of plasma (OR = 1.2; 95% CI, 1.03-1.44), presence of antibodies in donor plasma (OR = 8.8; 95% CI, 1.8-44), and total amount of transfused bioactive lipids (OR = 1.0; 95% CI, 1.00-1.07). When adjusted for patient risk factors, only the presence of antibodies in the associated blood products remained a risk factor for TRALI (OR = 14.2; 95% CI, 1.5-132). In-hospital mortality of TRALI was 13% compared with 0% and 3% in transfused and nontransfused patients, respectively (P < .05). In conclusion, the incidence of TRALI is high in cardiac surgery patients and associated with adverse outcome. Our results suggest that cardiac surgery patients may benefit from exclusion of blood products containing HLA/HNA antibodies.

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Available from: Maria M W Koopman, Sep 01, 2015
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    • "Our data on the duration of surgery and CPB as risk factors for possible TRALI are similar to the findings of Vlaar et al, who showed the risk of TRALI to be associated with a longer clamp-, pump-, and surgery time (29,31). A proportion of alterations in lung function may be attributed to surgical factors (eg, hemidiaphragm paresis with concomitant atelectasis, wound pain, etc). "
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    ABSTRACT: Aim To determine the incidence of possible transfusion-related acute lung injury (TRALI) and related risk factors in cardiac surgery patients. Methods A single-center prospective cohort study was conducted from January 2009 to March 2010 at the Zagreb University Hospital Center, Croatia. Patient-, transfusion-, and surgery-related data were collected. The study included 262 patients who were observed for respiratory worsening including measurements of arterial oxygen saturation (SaO2), fraction of inspired oxygen (FiO2), and partial pressure of arterial oxygen (PaO2). Possible TRALI was defined according to the Toronto Consensus Conference definition broadened for 24-hour post-transfusion. This cohort was divided in two groups. TRALI group included 32 participants with diagnosis of TRALI and the control group included 220 patients with or without respiratory worsening, but with no signs of ALI. Results Possible TRALI was observed in 32 (12.2%) patients. Compared with the control group, possible TRALI patients had higher American Association of Anesthesiology scores, higher rate of respiratory comorbidity (43.8% vs 15.5%), and required more red blood cells (median 4, range [2.5-6] vs 2 [1-3]), plasma (5 [0-6] vs 0 [0-2]), and platelet units (0 [0-8] vs 0 [0-0]) (P < 0.001 all). Risk factors for possible TRALI were total number of transfused blood units (odds ratio [OR] 1.23; 95% confidence interval [CI] 1.10-1.37) and duration of cardiopulmonary bypass (OR 1.08; 95% CI 1.05-1.11). Post-transfusion PaO2/FiO2 ratio was significantly decreased in possible TRALI patients and significantly increased in transfused controls without acute lung injury. Conclusion We observed a higher rate of possible TRALI cases than in other studies on cardiac surgery patients. Serial monitoring of PaO2/FiO2 ratio and detection of its post-transfusion worsening aids in identification of possible TRALI cases.
    Full-text · Article · Apr 2014 · Croatian Medical Journal
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    • "Vlaar i wsp. [8] [9] oszacowali ryzyko występowania TRALI na 0,02% na każdą przetoczoną jednostkę krwi i na 0,16% u transfuzjonowanych chorych. U chorych w stanie krytycznym zwiększa się ryzyko wystąpienia TRALI (do 0,9% na przetoczoną jednostkę i do 2,2% u chorych). "
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    ABSTRACT: Transfusion-related acute lung injury (TRALI) is the leading cause of mortality following transfusion of blood components. Characteristic for TRALI is acute hypoxemia during or up to 6 h after transfusion provided that cardiogenic respiratory failure and transfusion-associated circulatory overload (TACO) are excluded. In this article we present: 1) Etiology and pathomechanism of TRALI syndrome including the numerous issues that are still unresolved. Currently accepted is the multiple-event model which involves both the patient and the transfused blood components. The TRALI syndrome may be either immunological or nonimmunological dependant on the various factors that activate neutrophils – the main cells in TRALI pathogenesis. 2) TRALI diagnosis should be based mainly on the clinical presentation due to the variety of pathomechanism of the syndrome; however testing of anti-leukocyte antibodies in transfused blood components, according to ISBT guidelines, is recommended in order to prevent TRALI incidence. 3) Different strategies of TRALI prevention, although up to date no ultimate provisions have been accepted. Transfusion of plasma collected only from men seems to be a promising solution as in many countries that adapted this preventive measure the number of TRALI cases has substantially decreased. 4) Different methods of proceeding with donors who donated blood components that were the cause of TRALI in transfused patients. It still remains an open question whether to defer donors with anti-leukocyte antibodies or multi pregnant women.
    Preview · Article · Jul 2013 · Acta haematologica Polonica
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    • "The other important parameter that can be manipulated to enhance tissue DO 2 and maximize oxygen transfer through the membrane oxygenator is the blood hemoglobin concentration [14]. Guidelines from the Extracorporeal Life Support Organization (ELSO) and the CESAR trial recommend maintaining a normal hematocrit (40–45 %) and hemoglobin concentrations at 14 g/ dL, respectively, for patients on ECMO support [10, 22]. However, critically ill patients, and especially those already suffering from diffuse alveolar damage, may be at high risk of transfusion-related acute lung injury232425. "
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    ABSTRACT: Purpose This study was designed to optimize the latest generation venovenous (vv)-extracorporeal membrane oxygenation (ECMO)-circuit configuration and settings based on the evaluation of blood oxygenation and CO2 removal determinants in patients with severe acute respiratory distress syndrome (ARDS) on ultraprotective mechanical ventilation. Methods Blood gases and hemodynamic parameters were evaluated after changing one of three ECMO settings, namely, circuit blood flow, FiO2ECMO (fraction of inspired oxygen in circuit), or sweep gas flow ventilating the membrane, while leaving the other two parameters at their maximum setting. Results Ten mechanically ventilated ARDS patients (mean age 44 ± 16 years; 6 males; mean hemoglobin 8.0 ± 1.8 g/dL) on ECMO for a mean of 9.0 ± 3.8 days) receiving femoro–jugular vv-ECMO were evaluated. vv-ECMO blood flow and FiO2ECMO determined arterial oxygenation. Decreasing the ECMO flow from its baseline maximum value (5.8 ± 0.8 L/min) to 40 % less (2.4 ± 0.3 L/min) significantly decreased mean PaO2 (arterial oxygen tension; 88 ± 24 to 45 ± 9 mm Hg; p 90 %. Alternatively, the rate of sweep gas flow through the membrane lung determined blood decarboxylation, while PaCO2 (arterial carbon dioxide tension) was unaffected when the ECMO blood flow and FiO2ECMO were reduced to 60 % was constantly associated with adequate blood oxygenation and oxygen transport and delivery.
    Full-text · Article · Jan 2013 · Intensive Care Medicine
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