Transfusion-related acute lung injury

Blood Products

Perioperative hemorrhage, anemia, thrombocytopenia, and coagulopathy are common in the surgical intensive care unit. As a result, blood product transfusion occurs frequently. While red blood cell, plasma, and platelet transfusions have a lifesaving role in the resuscitation of patients with trauma and hemorrhagic shock, their application in other settings is under scrutiny. Current data would suggest a conservative approach be taken, thus avoiding unnecessary transfusion and associated potential adverse events. New and developmental products such as prothrombin complex concentrates offer appealing alternatives to traditional transfusion practice—potentially with fewer risks—however, further investigation into their safety and efficacy is required before practice change can take place.

Accumulation of CD62P during storage of apheresis platelet concentrates and the role of CD62P in transfusion-related acute lung injury

Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion-associated morbidity and mortality. Activated platelets have important roles in TRALI and CD62P was identified to be an important indicator of platelet activation. However, the precise roles of CD62P in TRALI have remained elusive. The present study assessed CD62P accumulation during storage of apheresis platelet concentrates (A‑Plts) and established a mouse model of TRALI to further investigate the roles of CD62P in TRALI. The results showed that the CD62P concentration in A‑Plts was increased with the storage time. Mice were treated with monoclonal major histocompatibility complex (MHC)‑1 antibody to induce TRALI. The murine model of TRALI was successfully established as evidenced by pulmonary oedema, accompanied by decreased clearance of bronchoalveolar lavage fluid (BALF), increased pulmonary and systemic inflammation, elevated lung myeloperoxidase (MPO) activity as well as increased pulmonary and systemic coagulation in the TRALI group compared with those in the control group. To further determine the role of CD62P in TRALI, mice were treated with anti‑CD62P antibody to knockdown CD62P in vivo. It was found that pulmonary oedema, BALF clearance, pulmonary and systemic inflammation, MPO activity as well as pulmonary and systemic coagulation were decreased in the TRALI + anti‑CD62P antibody group compared with those in the TRALI + isotype antibody group. The present study supported the notion that CD62P is involved in mediating TRALI and may provide an important molecular basis for enhancing the clinical safety and effectiveness of platelet transfusion.

Pediatric acute respiratory distress syndrome: definition, incidence, and epidemiology: proceedings from the Pediatric Acute Lung Injury Consensus Conference

OBJECTIVES

Although there are similarities in the pathophysiology of acute respiratory distress syndrome in adults and children, pediatric-specific practice patterns, comorbidities, and differences in outcome necessitate a pediatric-specific definition. We sought to create such a definition.

DESIGN

A subgroup of pediatric acute respiratory distress syndrome investigators who drafted a pediatric-specific definition of acute respiratory distress syndrome based on consensus opinion and supported by detailed literature review tested elements of the definition with patient data from previously published investigations.

SETTINGS

International PICUs.

SUBJECTS

Children enrolled in published investigations of pediatric acute respiratory distress syndrome.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Several aspects of the proposed pediatric acute respiratory distress syndrome definition align with the Berlin Definition of acute respiratory distress syndrome in adults: timing of acute respiratory distress syndrome after a known risk factor, the potential for acute respiratory distress syndrome to coexist with left ventricular dysfunction, and the importance of identifying a group of patients at risk to develop acute respiratory distress syndrome. There are insufficient data to support any specific age for "adult" acute respiratory distress syndrome compared with "pediatric" acute respiratory distress syndrome. However, children with perinatal-related respiratory failure should be excluded from the definition of pediatric acute respiratory distress syndrome. Larger departures from the Berlin Definition surround 1) simplification of chest imaging criteria to eliminate bilateral infiltrates; 2) use of pulse oximetry-based criteria when PaO2 is unavailable; 3) inclusion of oxygenation index and oxygen saturation index instead of PaO2/FIO2 ratio with a minimum positive end-expiratory pressure level for invasively ventilated patients; 4) and specific inclusion of children with preexisting chronic lung disease or cyanotic congenital heart disease.

CONCLUSIONS

This pediatric-specific definition for acute respiratory distress syndrome builds on the adult-based Berlin Definition, but has been modified to account for differences between adults and children with acute respiratory distress syndrome. We propose using this definition for future investigations and clinical care of children with pediatric acute respiratory distress syndrome and encourage external validation with the hope for continued iterative refinement of the definition.

Characterizing the epidemiology of postoperative transfusion-related acute lung injury

BACKGROUND

Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion-related death in the United States; however, it remains poorly characterized in surgical populations. To better inform perioperative transfusion practice, and to help mitigate perioperative TRALI, the authors aimed to better define its epidemiology before and after TRALI mitigation strategies were introduced.

METHODS

This retrospective cohort study examined outcomes of adult patients undergoing noncardiac surgery with general anesthesia who received intraoperative transfusions during 2004 (n = 1,817) and 2011 (n = 1,562). The demographics and clinical characteristics of transfusion recipients, blood transfusion descriptors, and combined TRALI/possible TRALI incidence rates were evaluated. Univariate analyses were used to compare associations between patient characteristics, transfusion details, and TRALI mitigation strategies with TRALI/possible TRALI incidence rates in a before-and-after study design.

RESULTS

The incidence of TRALI/possible TRALI was 1.3% (23 of 1,613) in 2004 versus 1.4% (22 of 1,562) in 2011 (P = 0.72), with comparable overall rates in males versus females (1.4% [23 of 1,613] vs. 1.2% [22 of 1,766]) (P = 0.65). Overall, thoracic (3.0% [4 of 133]), vascular (2.7% [10 of 375]), and transplant surgeries (2.2% [4 of 178]) carried the highest rates of TRALI/possible TRALI. Obstetric and gynecologic surgical patients had no TRALI episodes. TRALI/possible TRALI incidence increased with larger volumes of blood product transfused (P < 0.001).

CONCLUSIONS

Perioperative TRALI/possible TRALI is more common than previously reported and its risk increases with greater volumes of blood component therapies. No significant reduction in the combined incidence of TRALI/possible TRALI occurred between 2004 and 2011, despite the introduction of TRALI mitigation strategies. Future efforts to identify specific risk factors for TRALI/possible TRALI in surgical populations may reduce the burden of this life-threatening complication.

Perioperative retinoic acid syndrome in a patient with acute promyelocytic leukemia

All-trans retinoic acid (ATRA), a vitamin A derivative, is prescribed for induction of chemotherapy in patients with acute promyelocytic leukemia. Like other chemotherapy agents, ATRA has an adverse effect known as retinoic acid syndrome. The case of a 22 year old woman with acute promyelocytic leukemia, who received ATRA and subsequently developed retinoic acid syndrome, is presented. The patient's symptoms resolved after administration of dexamethasone, allowing the completion of chemotherapy without further complications.

[Naloxone-induced pulmonary edema. Case report with review of the literature and critical evaluation]

A case of pulmonary edema after the administration of naloxone for laparoscopic splenectomy is reported. Previous reports of naloxone-induced pulmonary edema are listed and reviewed. The clinical course is compared to other forms of non-cardiogenic pulmonary edema. Uncertainty remains about the underlying pathophysiological process and the true impact of naloxone on the development of pulmonary edema.

Female donors and transfusion-related acute lung injury: A case-referent study from the International TRALI Unisex Research Group

BACKGROUND

Although quantitative evidence is lacking, it is generally believed that the majority of cases of transfusion-related acute lung injury (TRALI) are caused by female blood donors. We aimed to examine the relation between female donors and the occurrence of TRALI.

STUDY DESIGN AND METHODS

We performed an international, multicenter case-referent study. TRALI patients who were diagnosed clinically, independent of serology or donor sex, and had received transfusions either only from male donors or only from female donors (unisex cases) were selected. The observed sex distribution among the donors of these TRALI patients was compared to the expected sex distribution, based on the relevant donor populations.

RESULTS

Eighty-three clinical TRALI cases were included; 67 cases received only red blood cells (RBCs), 13 only plasma-rich products, and three both. Among RBC recipients the relative risk (RR) of TRALI after a transfusion from a female donor was 1.2 (95% confidence interval [CI], 0.69-2.1) and among plasma-rich product recipients the RR was 19 (95% CI, 1.9-191). The p value for the difference between RBCs and plasma was 0.023.

CONCLUSION

Our data support the notion that plasma from female donors is associated with an increased risk of TRALI, while RBCs from female donors are not.

Pleuropulmonary Changes Induced by Drugs in Patients with Hematologic Diseases

Patients with hematologic diseases who are being treated with therapy drugs, or receive radiation therapy or blood transfusions may develop a host of potentially fatal infectious and noninfectious pulmonary complications [1]. The increased complexity of multimodality and high-dose treatment regimens with the intended benefit of augmented antineoplastic efficacy and prolonged disease-free survival, the use of a panel of novel drugs to treat malignant and nonmalignant hematologic conditions (e.g., azacytidine, bortezomib, cladribine, dasatinib, fludarabine, imatinib, lenalidomide, rituximab, and thalidomide), total body irradiation (TBI) and hematopietic stem cell transplantation (HSCT) have increased the incidence of severe sometimes life-threatening pulmonary complications.

Early identification of patients at risk of acute lung injury: evaluation of lung injury prediction score in a multicenter cohort study

RATIONALE

Accurate, early identification of patients at risk for developing acute lung injury (ALI) provides the opportunity to test and implement secondary prevention strategies.

OBJECTIVES

To determine the frequency and outcome of ALI development in patients at risk and validate a lung injury prediction score (LIPS).

METHODS

In this prospective multicenter observational cohort study, predisposing conditions and risk modifiers predictive of ALI development were identified from routine clinical data available during initial evaluation. The discrimination of the model was assessed with area under receiver operating curve (AUC). The risk of death from ALI was determined after adjustment for severity of illness and predisposing conditions.

MEASUREMENTS AND MAIN RESULTS

Twenty-two hospitals enrolled 5,584 patients at risk. ALI developed a median of 2 (interquartile range 1-4) days after initial evaluation in 377 (6.8%; 148 ALI-only, 229 adult respiratory distress syndrome) patients. The frequency of ALI varied according to predisposing conditions (from 3% in pancreatitis to 26% after smoke inhalation). LIPS discriminated patients who developed ALI from those who did not with an AUC of 0.80 (95% confidence interval, 0.78-0.82). When adjusted for severity of illness and predisposing conditions, development of ALI increased the risk of in-hospital death (odds ratio, 4.1; 95% confidence interval, 2.9-5.7).

CONCLUSIONS

ALI occurrence varies according to predisposing conditions and carries an independently poor prognosis. Using routinely available clinical data, LIPS identifies patients at high risk for ALI early in the course of their illness. This model will alert clinicians about the risk of ALI and facilitate testing and implementation of ALI prevention strategies. Clinical trial registered with www.clinicaltrials.gov (NCT00889772).

Transfusion-Related Acute Lung Injury — A Review

Transfusion-related acute lung injury (TRALI), a type of non-cardiogenic pulmonary oedema related to blood transfusion, is gaining prominence as a common adverse event related to blood transfusions in hospitals. Various mechanisms have been postulated to cause TRALI including both antibody-related and non-immune mechanisms. Although transfusion of all types of blood components have been implicated, by far the commonest product related to TRALI was, until recently, fresh frozen plasma, especially that obtained from female donors. However the use of male-only plasma donation in the UK has resulted in an increased observance of TRALI with platelet and red cell transfusions. The diagnosis of this condition is primarily one of exclusion of other causes of pulmonary oedema, with specialist laboratory tests performed to support the diagnosis. The management of TRALI is early diagnosis and good supportive care with, occasionally, ventilatory support. An increased awareness of this complication among intensive care physicians is desirable to prevent one of the commonest and most frequently under-recognised transfusion-related adverse events of the present day.

Transfusion-Related Acute Lung Injury

Transfusion-related acute lung injury (TRALI) refers to a clinical syndrome of acute lung injury that occurs in a temporal relationship with the transfusion of blood products. Because of the difficulty in making its diagnosis, TRALI is often underreported. Three not necessarily mutually exclusive hypotheses have been described to explain its etiogenesis: antibody mediated, non-antibody mediated, and two hit mechanisms. Treatment is primarily supportive and includes supplemental oxygen. Diuretics are generally not indicated, as hypovolemia should be avoided. Compared with many other forms of acute lung injury, including the acute respiratory distress syndrome, TRALI is generally transient, reverses spontaneously, and carries a better prognosis. A variety of prevention strategies have been proposed, ranging from restrictive transfusion strategies to using plasma derived only from males.

Toward the prevention of acute lung injury: Protocol-guided limitation of large tidal volume ventilation and inappropriate transfusion*

OBJECTIVE

We evaluated the effect of two quality improvement interventions (low tidal volume ventilation and restrictive transfusion) on the development of acute lung injury in mechanically ventilated patients.

DESIGN

Observational cohort study.

SETTING

Three intensive care units in a tertiary academic center.

PATIENTS

We included patients who were mechanically ventilated for > or =48 hrs excluding those who refused research authorization or had preexisting acute lung injury or pneumonectomy.

INTERVENTIONS

Multifaceted interdisciplinary intervention consisting of Web-based teaching, respiratory therapy protocol, and decision support within computerized order entry.

MEASUREMENTS AND MAIN RESULTS

Of 375 patients who met the inclusion and exclusion criteria, 212 were ventilated before and 163 after the interventions. Baseline characteristics were similar between the two groups except for a lower frequency of sepsis (27% vs. 17%, p = .030), trend toward lower median glucose level (140 mg/dL, interquartile range 118-168 vs. 132 mg/dL, interquartile range 113-156, p = .096), and lower frequency of pneumonia (27% vs. 20%, p = .130) during the second period. We observed a large decrease in tidal volume (10.6-7.7 mL/kg predicted body weight, p < .001), in peak airway pressure (31-25 cm H2O, p < .001), and in the percentage of transfused patients (63% to 38%, p < .001) after the intervention. The frequency of acute lung injury decreased from 28% to 10% (p < .001). The duration of mechanical ventilation decreased from a median of 5 (interquartile range 4-9) to 4 (interquartile range 4-8) days (p = .030). When adjusted for baseline characteristics in a multivariate logistic regression analysis, protocol intervention was associated with a reduction in the frequency of new acute lung injury (odds ratio 0.21, 95% confidence interval 0.10-0.40).

CONCLUSIONS

Interdisciplinary intervention effectively decreased large tidal volumes and unnecessary transfusion in mechanically ventilated patients and was associated with a decreased frequency of new acute lung injury.

Fresh-Frozen Plasma and Platelet Transfusions Are Associated With Development of Acute Lung Injury in Critically Ill Medical Patients

BACKGROUND

Transfusion has long been identified as a risk factor for acute lung injury (ALI)/ARDS. No study has formally evaluated the transfusion of specific blood products as a risk factor for ALI/ARDS in critically ill medical patients.

METHOD

In this single-center retrospective cohort study, 841 consecutive critically ill patients were studied for the development of ALI/ARDS. Patients who received blood product transfusions were compared with those who did not, in univariate and multivariate propensity analyses.

RESULTS

Two hundred ninety-eight patients (35%) received blood transfusions. Transfused patients were older (mean [+/- SD] age, 67 +/- 17 years vs 62 +/- 19 years; p < 0.001) and had higher acute physiologic and chronic health evaluation (APACHE) III scores (74 +/- 32 vs 58 +/- 23; p < 0.001) than those who had not received transfusions. ALI/ARDS developed more commonly (25% vs 18%; p = 0.025) in patients exposed to transfusion. Seventeen patients received massive RBC transfusions (ie, > 10 U of blood transfused within 24 h), of whom 13 also received fresh-frozen plasma (FFP) and 11 received platelet transfusions. When adjusted for the probability of transfusion and other ALI/ARDS risk factors, any transfusion was associated with the development of ALI/ARDS (odds ratio [OR], 2.14; 95% confidence interval [CI], 1.24 to 3.75). Among those patients receiving individual blood products, ALI/ARDS was more likely to develop in patients who received FFP transfusions (OR, 2.48; 95% CI, 1.29 to 4.74) and platelet transfusions (OR, 3.89; 95% CI, 1.36 to 11.52) than in those who received only RBC transfusions (OR, 1.39; 95% CI, 0.79 to 2.43).

CONCLUSION

Transfusion is associated with an increased risk of the development of ALI/ARDS in critically ill medical patients. The risk is higher with transfusions of plasma-rich blood products, FFP, and platelets, than with RBCs.

Lesão pulmonar aguda associada à transfusão

Lesão pulmonar aguda associada à transfusão (transfusion-related acute lung injury, TRALI) é uma complicação clínica grave relacionada à transfusão de hemocomponentes que contêm plasma. Recentemente, TRALI foi considerada a principal causa de morte associada à transfusão nos Estados Unidos e Reino Unido. É manifestada tipicamente por dispnéia, hipoxemia, hipotensão, febre e edema pulmonar não cardiogênico, que ocorre durante ou dentro de 6 h, após completada a transfusão. Embora o exato mecanismo não tenha sido totalmente elucidado, postula-se que TRALI esteja associada à infusão de anticorpos contra antígenos leucocitários (classes I ou II ou aloantígenos específicos de neutrófilos) e a mediadores biologicamente ativos presentes em componentes celulares estocados. A maioria dos doadores implicados em casos da TRALI são mulheres multíparas. TRALI, além de ser pouco diagnosticada, pode ainda ser confundida com outras situações de insuficiência respiratória aguda. Um melhor conhecimento sobre TRALI pode ser crucial na prevenção e tratamento desta severa complicação transfusional.

Transfusion therapy in the intensive care unit

PURPOSE OF REVIEW

Transfusion therapy in the intensive care unit is an ever-growing field, with new understanding of potential complications, new drug therapies to reduce the need for transfusion, and new additions in component therapy. In addition to the risks of sepsis, ABO blood group mismatch, and other complications associated with transfusion, the intensivist needs to be familiar with alternative therapies to minimize transfusion.

RECENT FINDINGS

Transfusion-related acute lung injury and immunosuppression are two newly recognized complications in transfusion. Transfusion-related acute lung injury can lead to respiratory failure in an acute respiratory distress syndrome-like picture, often necessitating intubation and critical care services. Immunosuppression following transfusion has been linked to cytokine and complement activation. Recombinant erythropoietin (rHuEPO, Epogen, Procrit), by maximizing red cell counts, and aprotinin (Trasylol), by inhibiting fibrinolysis, are two old drugs being used with increasing frequency in a new setting: the intensive care unit. A new component therapy, recombinant factor VIIa (rFVIIa, NovoSeven), assists in turning on the extrinsic pathway of the coagulation cascade.

SUMMARY

Recognizing early signs of transfusion-related acute lung injury may aid in the treatment and reporting of this entity. Realizing the mechanism and severity of immunosuppression associated with transfusion may alter transfusion triggers in the intensive care unit. rHuEPO and aprotinin are now being used with increasing frequency to increase red cell counts and minimize the need for transfusion. Recombinant factor FVIIa targets coagulation cascade activation which helps to reduce the number of units of blood products transfused in the actively bleeding patient.

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

BACKGROUND

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.

STUDY DESIGN AND METHODS

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.

RESULTS

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).

CONCLUSION

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.

Fresh frozen plasma and platelet transfusion for nonbleeding patients in the intensive care unit: benefit or harm?

OBJECTIVE

Whereas restrictive red cell transfusion has become a standard of care for the critically ill, evidenced-based indications for use of other blood components such as fresh frozen plasma (FFP) and platelet transfusions are limited. We searched the National Library of Medicine PubMed database as well as references of retrieved articles and summarized the current evidence for the use of FFP and platelet transfusions in critically ill patients.

RESULTS

Routine coagulation tests are poor determinants of bleeding risk in critically ill patients with coagulopathy. FFP transfusion has limited efficacy and is associated with significant morbidity in critically ill patients, in particular, pulmonary edema and acute lung injury. Routine minimally invasive critical care procedures can be safely performed by experienced clinicians in the setting of mildly abnormal coagulation test results, and there is no evidence that FFP transfusion alters the risk of bleeding. For platelet transfusion, the American Society of Clinical Oncology has developed practice guidelines designed for oncology patients. However, because the pathophysiology of thrombocytopenia in critically ill patients often differs from that of thrombocytopenia in oncology patients, published guidelines for oncology patients may not be applicable.

CONCLUSION

Because the risk-benefit ratio of a liberal FFP or platelet transfusion strategy for critically ill patients may not be favorable, randomized controlled trials are warranted for evaluating a restrictive vs. liberal FFP or platelet transfusion strategy for nonbleeding patients in the intensive care unit.

Transfusion-related acute lung injury (TRALI): clinical presentation, treatment, and prognosis

The term transfusion-related acute lung injury (TRALI) was coined in 1983 to describe a constellation of clinical and laboratory features seen within 6 hrs of the transfusion of plasma-containing blood products. These products contain antibodies directed to human leukocyte antigens (and subsequently described to nonhuman leukocyte antigens) found on white blood cells. In the intervening 2 decades, other cases not associated with antibodies have been reported as TRALI and an association with passive infusion of lipids accumulated in stored cellular blood products has been made in those cases. This has led to confusion as to what should be considered to constitute TRALI. Therefore, the true incidence of this pulmonary reaction to blood products is currently conjectural at best. Recent consensus development conferences have been held to develop and standardize definitions of TRALI so that epidemiologic and research aspects of this condition can be explored in a scientific manner. These conferences have set out criteria by which TRALI is distinguished from other causes of acute lung injury. This review outlines the widely accepted clinical (mainly pulmonary) features of TRALI, the treatment options, and the excellent long-term prognosis for patients who survive the initial pulmonary insult.

A review of red cell transfusion in the neurological intensive care unit

The treatment of anemia in critically ill patients has changed significantly in the past decade with a major shift toward restrictive blood-transfusion strategy. There is a paucity of studies regarding the approach toward anemia in the neurological critical care population. Anemia is a complex problem in this group of patients because of the extreme sensitivity of brain tissue to changes in the cerebral perfusion pressure and oxygen deficit. Most of the evidence regarding management of anemia and optimal hematocrit threshold is based on animal experiments and observational studies. Recent studies have shown a mixed response in the local oxygen saturations and patient outcomes after blood transfusion in neurological critically ill patients. Although there is little reason to suspect that restrictive transfusion protocols would be detrimental, further studies are needed to determine optimal transfusion threshold in this population.

Blood donor and component management strategies to prevent transfusion-related acute lung injury (TRALI)

OBJECTIVE

Discuss the pros and cons of using donor and blood product-management strategies to prevent transfusion-related acute lung injury (TRALI).

DATA SOURCE

A review of the literature was performed.

RESULTS

Despite therapeutic advances in pulmonary and critical care medicine, TRALI is now considered to be one of the leading causes of transfusion-associated mortality, and thus determining how to prevent TRALI is extremely important. Donor and product-management strategies to prevent this life-threatening condition have been suggested, but because of gaps in our understanding of TRALI, blood-bankers do not know how beneficial these interventions will be, nor the amount of potential harm-such as decreasing the availability of blood-that could arise if they were implemented. This article discusses the advantages and disadvantages of the various preventive measures that have been described in the literature.

CONCLUSIONS

Preventing TRALI poses a difficult challenge for blood-banking experts, because it is unknown which measures will be effective in decreasing the incidence of TRALI and which could have significant drawbacks. Only additional research into TRALI prevention will provide the answers on how to best protect patients from this potentially fatal reaction.

Adequacy of physician documentation of red blood cell transfusion and correlation with assessment of transfusion appropriateness

CONTEXT

A major function of the hospital transfusion service is to assess the appropriateness of blood transfusion. Inadequate documentation of transfusions may hamper this assessment process.

OBJECTIVE

To correlate the level of physician documentation of transfusion with the ability to justify transfusion.

DESIGN

Retrospective review of red blood cell transfusions in adult patients in 2 hospital facilities during 1-week audit periods of each month from April 2001 to March 2003. Assessment forms were used to classify the level of physician documentation of transfusions into 3 groups: adequately, intermediately, and inadequately documented. Transfusions were deemed justified or not via comparison with hospital transfusion guidelines.

RESULTS

There were 5062 audited red blood cells transfused to 2044 adult (> or = 18 years) patients. Medical records from 154 patients transfused with 257 units of red blood cells during 172 transfusion events were reviewed after initial screenings of hemoglobin/hematocrit values failed to justify the transfusions. Nine percent of adequately documented, 50% of intermediately documented, and 73% of inadequately documented transfusion events could not be justified. Transfusion events with suboptimal (intermediate and inadequate) documentation accounted for 49% of all medical record-reviewed transfusion events and 62% could not be justified. The correlation between inadequate documentation and failure to justify transfusion was significant (P < .001), as was the correlation between suboptimal documentation and failure to justify transfusion (P = .03).

CONCLUSIONS

There is a significant correlation between suboptimal documentation and failure to justify transfusions. Educating clinicians to improve documentation along with appropriate indications for transfusions may enhance efficiency of blood utilization assessment and lead to reduced rates of unjustifiable transfusions.

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.