Transfusion-related acute lung injury

Transfusion-related acute lung injury

Transfusion-related acute lung injury (TRALI) is a life-threatening adverse event of transfusion, which has an increasing incidence in the United States and is the leading cause of transfusion-related death. TRALI and acute lung injury (ALI) share a common clinical definition except that TRALI is temporally- and mechanistically-related to transfusion of blood or blood components. A number of different models have been proposed to explain the pathogenesis. The first is an antibody-mediated event whereby transfusion of anti-HLA, class I or class II, or anti-granulocyte antibodies into patients whose leukocytes express the cognate antigens. The antibody:antigen interaction causes complement-mediated pulmonary sequestration and activation of neutrophils (PMNs) resulting in TRALI. The second is a two-event model: the first event is the clinical condition of the patient resulting in pulmonary endothelial activation and PMN sequestration, and the second event is the transfusion of a biologic response modifier (including anti-granulocyte antibodies, lipids, and CD40 ligand) that activates these adherent PMNs resulting in endothelial damage, capillary leak, and TRALI. These hypotheses are discussed with respect to animal models and human studies that provide the experimental and clinical relevance. The definition of TRALI, patient predisposition, treatment, prevention and reporting guidelines are also examined.

Massive Blood Loss and Transfusion in Obstetrics and Gynecology

Massive perioperative or periparturitional bleeding occasionally occurs in obstetric and gynecologic patients. Placenta previa, uterine atony, and ectopic pregnancy are just a few examples of many conditions that could predispose patients to significant blood loss. Therefore, it is important for physicians specializing in obstetrics and gynecology to be proficient in managing episodes of massive hemorrhage and the practice of the most commonly used blood components. We review and update the management of massive hemorrhage for obstetrics and gynecologic patients. In addition, we explore blood component therapy, its risks and benefits.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians Learning.

OBJECTIVES

After completion of this article, the reader should be able to explain the necessity of being proficient in managing episodes of massive hemorrhage, list the indications for use of various blood components, and summarize the risks and benefits of blood component therapy.

Transfusion-related acute lung injury

PURPOSE OF REVIEW

Transfusion-related acute lung injury is an uncommon complication of blood transfusion typically manifested by shortness of breath, fever, and hypotension. Transfusion-related acute lung injury is an important cause of transfusion-related morbidity and mortality.

RECENT FINDINGS

Much about the pathogenesis, treatment, and prevention of transfusion-related acute lung injury is poorly understood or is controversial. There is increasing recognition that transfusion-related acute lung injury is an important clinical syndrome, causing most transfusion-related deaths.

SUMMARY

In this report, what is known about transfusion-related acute lung injury is summarized with particular emphasis on recent studies. Some of the areas in which knowledge and/or consensus are currently lacking are identified.

Massive blood transfusion for trauma

PURPOSE OF REVIEW

Massive blood transfusion saves the lives of thousands of severely injured patients each year, but it does so in the context of the evolving epidemiology of injury, of trauma centers and trauma systems, and of blood safety and new technologies for hemorrhage control. This article reviews recent knowledge and advances that impact on the use and effectiveness of massive transfusion.

RECENT FINDINGS

Injury is rapidly becoming the second leading cause of death in the world. These deaths are highly preventable with social and engineering controls and good trauma care. Massive transfusion is readily available, safe, effective, and cheap in the context of modern trauma center care. However, aged blood products can cause transfusion-related acute lung injury, and better blood storage systems are under development. Recent work has improved understanding of the coagulopathy associated with acidosis and provided guidance for limiting dilutional coagulopathy. Nevertheless, massive transfusion always leads to coagulopathy and so is at best an adjunct to good surgical care. Better drugs and devices for hemorrhage control, such as recombinant activated factor VII and hemostatic bandages, are in development.

SUMMARY

Injury is a major public health and medical system problem. Progress in basic science, clinical care, and the development of better hemorrhage control devices are all improving outcome for massively transfused patients. Investment in trauma care and supporting blood supply systems is highly cost effective.

Early perioperative death associated with reexpansion pulmonary edema during liver transplantation

Hydrothorax is a frequent finding in patients with end-stage liver disease. During the hepatectomy phase of liver transplantation, it is often needed to evacuate large pleural effusions. The acute expansion of the collapsed lung can cause reexpansion pulmonary edema with variable clinical significance. However, this complication has rarely been reported after liver transplantation. In conclusion, we report on an overwhelming reexpansion pulmonary edema during a liver transplantation that rapidly led to the patient's demise and speculate if this condition has not been under recognized in the transplantation setting.

Structural organization of the neutrophil NADPH oxidase: phosphorylation and translocation during priming and activation

The reduced nicotinamide adenine dinucleotide phosphate (NADPH) oxidase is part of the microbicidal arsenal used by human polymorphonuclear neutrophils (PMNs) to eradicate invading pathogens. The production of a superoxide anion (O2-) into the phagolysosome is the precursor for the generation of more potent products, such as hydrogen peroxide and hypochlorite. However, this production of O2- is dependent on translocation of the oxidase subunits, including gp91phox, p22phox, p47phox, p67phox, p40phox, and Rac2 from the cytosol or specific granules to the plasma membrane. In response to an external stimuli, PMNs change from a resting, nonadhesive state to a primed, adherent phenotype, which allows for margination from the vasculature into the tissue and chemotaxis to the site of infection upon activation. Depending on the stimuli, primed PMNs display altered structural organization of the NADPH oxidase, in that there is phosphorylation of the oxidase subunits and/or translocation from the cytosol to the plasma or granular membrane, but there is not the complete assembly required for O2- generation. Activation of PMNs is the complete assembly of the membrane-linked and cytosolic NADPH oxidase components on a PMN membrane, the plasma or granular membrane. This review will discuss the individual components associated with the NADPH oxidase complex and the function of each of these units in each physiologic stage of the PMN: rested, primed, and activated.

Transfusion-Related Acute Lung Injury in an Infant During Craniofacial Surgery

Transfusion-related acute lung injury (TRALI) is a potentially life-threatening, systemic, immune-mediated reaction to transfused blood product. The symptoms may be masked under general anesthesia. In this case report, we describe an infant who developed TRALI under general anesthesia for craniofacial surgery. The difficulty with diagnosis, the pathophysiology, and the need for understanding and recognition to reduce morbidity and mortality are discussed.

IMPLICATIONS

Transfusion-related acute lung injury (TRALI) is a life-threatening problem that can occur during blood product transfusion in patients of any age. Understanding the pathophysiology may help make an earlier diagnosis to reduce more serious adverse outcomes.

[TRALI: from diagnosis to prevention]

Transfusion-Related Acute Lung Injury (TRALI) is a post-transfusion acute respiratory distress syndrome (ARDS). TRALI is a non-cardiogenic lung oedema occurring within 6 hours following the infusion of a blood component. Its frequency has been estimated from 1 in 5.000 to 1 in 500.000 injected blood products. Its aetiology is still controversial. Antibodies against HLA class I molecules or granulocyte surface molecules recognizing recipient leukocyte antigens were implicated at first. More recently anti HLA class II were involved in some cases. Finally granulocyte activating lipids released from cells during blood storage were claimed to account for cases in which no antibody were detected. Nevertheless, in most cases, none of these triggering factors alone seems sufficient to induce a TRALI. A predisposing condition, associated with leucostasis in pulmonary vessels, is required. Whatever the mechanism, the pulmonary lesion is eventually due to release of neutrophil granule content in contact with endothelial cells of lung micro-capillary vessels. The basement membrane damages leads to fluid and cell extravasations in interstitial and alveolar spaces. Among blood donors multiparous women are the most frequently involved. Up to now there are neither definite guidelines regarding detection of harmful antibodies nor regulation for deferral of potentially dangerous blood donors.

Transfusion-Related Acute Lung Injury and the ICU

Transfusion-related acute lung injury (TRALI) has been the leading cause of transfusion-related deaths reported to the United States Food and Drug Administration for three consecutive years. Although traditionally TRALI has been viewed as having a one event pathogenesis (passive donor anti-leukocyte antibody interacting with a cognate antigen on the recipients leukocytes), emerging evidence suggests that TRALI is a multifactorial syndrome, and a true two-event subtype of ALI. Both recipient predisposition and biological response modifiers, generated during storage of cellular blood products, appear to play major pathogenetic roles. This review highlights recent advances in our knowledge of the pathophysiology of TRALI and recent progress towards a consensus definition of TRALI. It also guides the reader as to the recognition, investigation, and clinical management of TRALI.