Transfusion-related acute lung injury

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.

Universal Leukocyte Reduction

This article discusses the evidence for the generally accepted uses of leukocyte-reduced blood and the controversy over leukocyte reduction and transfusion-related immunomodulation. A perspective is provided on the continued need for leukocyte reduction on the part of all patients in the United States.

Investigating transfusion-related acute lung injury (TRALI)

AIM

Transfusion-related acute lung injury (TRALI) can be a life-threatening transfusion complication and should be considered whenever respiratory distress occurs during a transfusion. Management of donors implicated in TRALI is a n important haemovigilance responsibility for blood services. To enable this, it is imperative to develop an effective strategy for investigating TRALI. The present paper describes an effective approach.

METHODS

Cases of suspected TRALI we re referred to the Platelet and Granulocyte Immunobiology Laboratory at the Australian Red Cross Blood Service-Queensland; a reference neutrophil testing service. Recipient and donor samples were tested for the presence of leucocyte antibodies. Where possible, compatibility testing was performed between donor and recipient samples.

RESULTS

From March 1999 to June 2001 , leucocyte antibodies directed against neutrophil-specific or human leucocyte antigens (HIA) were detected in at least one donor in seven of the nine cases investigated. Incompatibility with patient antigens (HNA-2a, non-specific HLA and HLA B5, B16, B35) was confirmed by cross matching in three cases.

CONCLUSION

TRALI is a serious non-infectious hazard of transfusion that must be reported and investigated promptly. Prompt investigations allow appropriate management of implicated donations and donors so as to minimize the incidence of TRALI. Therefore, the role of clinicians in reporting such cases and the hospital blood banks in collecting appropriate samples is critical. We suggest that hospital blood banks retain transfused donation units for at least 24 h after transfusion to expedite TRALI investigations. Due to the specialized nature of investigation, it is necessary to direct such investigations to specialist reference neutrophil testing services. In cases where the recipient has the leucocyte antibody, the use of white cell filters in future transfusions should be beneficial, because there is little evidence to substantiate the use of phenotyped blood products.

Exposure to allogeneic plasma and risk of postoperative pneumonia and/or wound infection in coronary artery bypass graft surgery

BACKGROUND

A relationship may exist between the immunomodulatory effects of allogeneic blood transfusion and the volume of transfused allogeneic plasma and/or the number of transfused plasma-containing units.

STUDY DESIGN AND METHODS

The records of 416 consecutive patients undergoing coronary artery bypass graft operations at the Massachusetts General Hospital were reviewed. Exposure to allogeneic plasma in units of transfused RBCs, platelets, FFP, and cryoprecipitate was recorded, and diagnoses of postoperative pneumonia and wound infection were made by CDC criteria. The association between postoperative infection and exposure to allogeneic plasma was calculated by logistic regression analyses adjusting for the effects of confounding factors that related to severity of illness, difficulty of operation, and risk of postoperative pneumonia.

RESULTS

Two hundred seventy-four patients received (mean +/- SE) 636.2 +/- 64.3 mL of allogeneic plasma, contained in 8.5 +/- 0.7 units of blood components. Sixty-four patients (15.4%) developed pneumonia and/or wound infection, and 54 (13.0%) developed pneumonia. Patients who did (n = 64) or did not develop infection received 956.6 +/- 180.6 and 321.3 +/- 39.6 mL of plasma, respectively (p<0.0001). In multivariate analyses, the volume of transfused allogeneic plasma was not associated with postoperative pneumonia and/or wound infection (p = 0.24), pneumonia (p = 0.21), or wound infection (p = 0.74). Similarly, the number of transfused plasma-containing units was not associated with these outcomes (p = 0.08, p = 0.08, and p = 0.46, respectively).

CONCLUSION

A relationship between the exposure to allogeneic plasma and the risk of postoperative pneumonia and/or wound infection was not detected in this study population.