Hypotension and acute pulmonary insufficiency following transfusion of autologous red blood cells during surgery: a case report and review of the literature

Bronchospasm and Kidney Injury Associated With Salvaged Blood Reinfusion During Pediatric Neurosurgical Procedure: A Case Report

Adverse events associated with salvaged blood reinfusion are common, but bronchospasm has been rarely reported, especially in pediatrics. We report the case of a child undergoing epileptogenic focus resection, who experienced bronchospasm and kidney injury associated with reinfusion of salvaged blood, presumably related to excessive free hemoglobin.

Ten years of TRALI mitigation: measuring our progress

BACKGROUND

Transfusion-related acute lung injury (TRALI) is a leading cause of transfusion-associated mortality for which multiple mitigation strategies have been implemented over the past decade. However, product-specific TRALI rates have not been reported longitudinally and may help refine additional mitigation strategies.

STUDY DESIGN AND METHODS

This retrospective multicenter study included analysis of TRALI rates from 2007 through 2017. Numerators included definite or probable TRALI reports from five blood centers serving nine states in the United States. Denominators were components distributed from participating centers. Rates were calculated as per 100,000 components distributed (p < 0.05 significant).

RESULTS

One hundred four TRALI cases were reported from 10,012,707 components distributed (TRALI rate of 1.04 per 100,000 components). The TRALI rate was 2.25 for female versus 1.08 for male donated components (p < .001). The TRALI rate declined from 2.88 in 2007 to 0.60 in 2017. From 2007 to 2013, there was a significantly higher TRALI rate associated with female versus male plasma (33.85 vs. 1.59; p < 0.001) and RBCs (1.97 vs. 1.15; p = 0.03). From 2014 through 2017, after implementation of mitigation strategies, a significantly higher TRALI rate only from female-donated plateletpheresis continued to be observed (2.98 vs. 0.75; p = 0.04).

CONCLUSION

Although the TRALI rates have substantially decreased secondary to multiple strategies over the past decade, a residual risk remains, particularly with female-donated plateletpheresis products. Additional tools that may further mitigate TRALI incidence include the use of buffy coat pooled platelets suspended in male donor plasma or platelet additive solution due to the lower amounts of residual plasma.

Blood Products in the Management of Abnormal Placentation

A critical tool in the successful management of patients with abnormal placentation is an established massive transfusion protocol designed to rapidly deliver blood products in obstetrical and surgical hemorrhage. Spurred by trauma research and an understanding of consumptive coagulopathy, the past 2 decades have seen a shift in volume resuscitation from an empiric, crystalloid-based method to balanced, targeted transfusion therapy. The present article reviews patient blood management in abnormal placentation, beginning with optimizing the patient's status in the antenatal period to the laboratory assessment and transfusion strategy for blood products at the time of hemorrhage.

Concise Review: Amniotic Fluid Stem Cells: The Known, the Unknown, and Potential Regenerative Medicine Applications

The amniotic fluid has been identified as an untapped source of cells with broad potential, which possess immunomodulatory properties and do not have the ethical and legal limitations of embryonic stem cells. CD117(c-Kit)+ cells selected from amniotic fluid have been shown to differentiate into cell lineages representing all three embryonic germ layers without generating tumors, making them ideal candidates for regenerative medicine applications. Moreover, their ability to engraft in injured organs and modulate immune and repair responses of host tissues, suggest that transplantation of such cells may be useful for the treatment of various degenerative and inflammatory diseases. Although significant questions remain regarding the origin, heterogeneous phenotype, and expansion potential of amniotic fluid stem cells, evidence to date supports their potential role as a valuable stem cell source for the field of regenerative medicine. Stem Cells 2017;35:1663-1673.

Stem cells from amniotic fluid--Potential for regenerative medicine

Regenerative medicine has recently been established as an emerging field focussing on repair, replacement or regeneration of cells, tissues and whole organs. The significant recent advances in the field have intensified the search for novel sources of stem cells with potential for therapy. Recently, researchers have identified the amniotic fluid as an untapped source of stem cells that are multipotent, possess immunomodulatory properties and do not have the ethical and legal limitations of embryonic stem cells. Stem cells from the amniotic fluid have been shown to differentiate into cell lineages representing all three embryonic germ layers without generating tumours, which make them an ideal candidate for tissue engineering applications. In addition, their ability to engraft in injured organs and modulate immune and repair responses of host tissues suggest that transplantation of such cells may be useful for the treatment of various degenerative and inflammatory diseases affecting major tissues/organs. This review summarises the evidence on amniotic fluid cells over the past 15 years and explores the potential therapeutic applications of amniotic fluid stem cells and amniotic fluid mesenchymal stem cells.

Transfusion-related acute lung injury: advances in understanding the role of proinflammatory mediators in its genesis

Transfusion-related acute lung injury (TRALI) is the most common cause of serious morbidity and mortality due to hemotherapy. The pathogenesis is the result of two events: the first related to the recipient's clinical condition, predisposing to acute lung injury (ALI) through neutrophil or polymorphonuclear leukocyte sequestration, and the second being the infusion of antibodies or mediators that activate these adherent polymorphonuclear neutrophils, resulting in endothelial damage, capillary leak and ALI. TRALI is most prevalent in the critically ill, although many of these cases are termed ALI. Although mitigation strategies, such as the use of male-only plasma, have decreased the number of TRALI cases and deaths, TRALI still occurs. This review will detail the pathophysiology of TRALI, provide insight into newer areas of research and critically assess current practices to mitigate TRALI and improve transfusion safety.

RECENT DEVELOPMENTS IN THERAPIES WITH STEM CELLS FROM AMNIOTIC FLUID AND PLACENTA

Significant advances in the field of regenerative medicine have intensified the search for novel sources of stem cells with potential for therapy. Although embryonic and adult tissues can be used for the isolation of pluripotent stem cells, significant limitations including ethical concerns, complexity of isolation/culture and tumorigenicity have hindered translation of laboratory findings to clinical practice.

Therapeutic options for transfusion related acute lung injury; the potential of the G2A receptor

Priming of polymorphonuclear leukocytes (PMNs) enhances their adhesion to endothelium, the release of their granule content and their production of reactive oxygen species. These effects are etiological in transfusion related acute lung injury (TRALI) and many clinically important mediators of TRALI prime PMNs. A priming activity that develops over time in stored blood products has been shown to be due to the accumulation of lysophospatidylcholines (lyso-PCs) and has been found to be related clinically to TRALI. Lyso- PCs prime PMNs activating the G2A receptor and several inhibitors of this receptor, which could potentially be therapeutic in TRALI, have been identified. Recent work has described early steps in the signaling from the G2A receptor which has revealed potential targets for novel antagonists of lyso-PC mediated priming via G2A. Additionally, characterization of the process by which lyso-PCs are generated in stored blood products could allow development of inhibitors and additive solutions to block their formation in the first place.

Pathology consultation on transfusion-related acute lung injury (TRALI)

Transfusion-related acute lung injury (TRALI) is a serious condition characterized by respiratory distress, hypoxia, and bilateral pulmonary infiltrates, which occur within 6 hours of transfusion. Several theories have been proposed to explain the underlying pathologic mechanisms of TRALI. Immune-mediated TRALI accounts for over 80% of reported cases and is mediated by donor antibodies to HLAs and/or human neutrophil antigens (HNA). Immune-mediated TRALI is most commonly associated with donor plasma transfusion or other blood products from multiparous women, which has led many countries to reduce or exclude women from donating high-volume plasma products. This policy change has resulted in a decrease in the incidence of TRALI and highlighted the importance of nonimmune-mediated TRALI, which is thought to be caused by bioreactive lipids and other biologic response modifiers that accumulate during storage of blood products. When TRALI is suspected, clinical consultation with a transfusion medicine specialist helps differentiate it from other transfusion reactions with similar characteristics.

Fresh and stored red blood cell transfusion equivalently induce subclinical pulmonary gas exchange deficit in normal humans

BACKGROUND

Transfusion can cause severe acute lung injury, although most transfusions do not seem to induce complications. We tested the hypothesis that transfusion can cause mild pulmonary dysfunction that has not been noticed clinically and is not sufficiently severe to fit the definition of transfusion-related acute lung injury.

METHODS

We studied 35 healthy, normal volunteers who donated 1 U of blood 4 weeks and another 3 weeks before 2 study days separated by 1 week. On study days, 2 U of blood were withdrawn while maintaining isovolemia, followed by transfusion with either the volunteer's autologous fresh red blood cells (RBCs) removed 2 hours earlier or their autologous stored RBCs (random order). The following week, each volunteer was studied again, transfused with the RBCs of the other storage duration. The primary outcome variable was the change in alveolar to arterial difference in oxygen partial pressure (AaDo(2)) from before to 60 minutes after transfusion with fresh or older RBCs.

RESULTS

Fresh RBCs and RBCs stored for 24.5 days equally (P = 0.85) caused an increase of AaDo(2) (fresh: 2.8 mm Hg [95% confidence interval: 0.8-4.8; P = 0.007]; stored: 3.0 mm Hg [1.4-4.7; P = 0.0006]). Concentrations of all measured cytokines, except for interleukin-10 (P = 0.15), were less in stored leukoreduced (LR) than stored non-LR packed RBCs; however, vascular endothelial growth factor was the only measured in vivo cytokine that increased more after transfusion with LR than non-LR stored packed RBCs. Vascular endothelial growth factor was the only cytokine tested with in vivo concentrations that correlated with AaDo(2).

CONCLUSION

RBC transfusion causes subtle pulmonary dysfunction, as evidenced by impaired gas exchange for oxygen, supporting our hypothesis that lung impairment after transfusion includes a wide spectrum of physiologic derangements and may not require an existing state of altered physiology. These data do not support the hypothesis that transfusion of RBCs stored for >21 days is more injurious than that of fresh RBCs.

Translational prospects for human induced pluripotent stem cells

The pace of research on human induced pluripotent stem (iPS) cells is frantic worldwide, based on the enormous therapeutic potential of patient-specific pluripotent cells free of the ethical and political issues that plagued human embryonic stem cell research. iPS cells are now relatively easy to isolate from somatic cells and reprogramming can be accomplished using nonmutagenic technologies. Access to iPS cells is already paying dividends in the form of new disease-in-a-dish models for drug discovery and as scalable sources of cells for toxicology. For translation of cell therapies, the major advantage of iPS cells is that they are autologous, but for many reasons, perfect immunologic tolerance of iPS-based grafts should not be assumed. This article focuses on the functional identity of iPS cells, anticipated safety and technical issues in their application, as well as a survey of the progress likely to be realized in clinical applications in the next decade.

Transfusion therapy and acute lung injury

Transfusion-related acute lung injury (TRALI) remains the deadliest complication of transfusion. Consensus definitions of TRALI have been developed but remain controversial. Recent evidence supports a strong relationship between blood transfusion and the development of acute lung injury in the critically ill and trauma population. Plasma and platelet transfusions have been the most commonly implicated blood products. The 'two hit' model may best explain the immune and nonimmune pathogenesis of TRALI. Current treatment remains largely supportive; effective measures for decreasing the incidence of TRALI include the use of predominantly male plasma and apheresis platelets. Greater understanding of the blood component and patient risk factors for TRALI will hopefully lead to novel treatment and preventive strategies for reducing the risk of this life-threatening syndrome.

Transfusion-related acute lung injury

Transfusion-related acute lung injury is a clinical syndrome that occurs within 6 hours of transfusion. It is the leading cause of transfusion-related mortality. It presents with shortness of breath, acute pulmonary edema, fever, hypotension, or hypertension followed by hypotension. Treatment consists of respiratory support and fluid administration to support blood pressure. A majority of cases are associated with antibodies to white blood cells in the blood donor. Blood centers in the United States are currently taking measures to reduce the risk of transfusion-related acute lung injury from blood components.

TRALI is due to pulmonary venule damage from leucocytes with cholesterol crystal formation

BACKGROUND

There are two presumed mechanisms for the pulmonary oedema in transfusion-related acute lung injury (TRALI). One is antibodies to leucocytes while the other is biologically active lipids. We evaluated the vascular injury due to the former.

METHODS

The pulmonary vasculature was studied by light microscopy (LM) and scanning electron microscopy (SEM) in three fatal cases of TRALI and compared with that of two autopsied control patients. Lung tissue from two of the TRALI cases and both controls was studied by gas chromatography-mass spectroscopy (GC-MS) to identify crystals present in the former.

RESULTS

All three TRALI cases exhibited massive pulmonary oedema by weight and light microscopy and extensive defects by SEM in the endothelium of venules of the lungs. Such endothelial defects were absent in controls. Thrombi, composed of crystals, were present in venules and small veins diffusely throughout the lungs in Case 1. Similar crystals were identified in Case 2. The crystals in the lung vessels were identified morphologically as cholesterol and were proximate to the cytoplasmic defects of the endothelial surfaces. By GC-MS, there were markedly elevated levels of cholesterol and fatty acids in the two TRALI lungs tested compared with the lungs of the two controls.

CONCLUSIONS

Pulmonary damage in TRALI is related to formation of cholesterol crystals that appear to pierce endothelial membranes of venules. The endothelial defects lead to plasma extravasation into the alveoli causing TRALI.

Transfusion-related acute lung injury (TRALI): current concepts and misconceptions

Transfusion-related acute lung injury (TRALI) is the most common cause of serious morbidity and mortality due to hemotherapy. Although the pathogenesis has been related to the infusion of donor antibodies into the recipient, antibody negative TRALI has been reported. Changes in transfusion practices, especially the use of male-only plasma, have decreased the number of antibody-mediated cases and deaths; however, TRALI still occurs. The neutrophil appears to be the effector cell in TRALI and the pathophysiology is centered on neutrophil-mediated endothelial cell cytotoxicity resulting in capillary leak and ALI. This review will detail the pathophysiology of TRALI including recent pre-clinical data, provide insight into newer areas of research, and critically assess current practices to decrease it prevalence and to make transfusion safer.

Transfusion-related acute lung injury: clinical features and diagnostic dilemmas

Transfusion-related acute lung injury (TRALI) is recognized as the number-one cause of transfusion-associated death in the United States. Although TRALI was not designated as the number-one cause until 2004, respiratory-related symptoms associated with blood transfusion have been reported for decades. More recently, our understanding of the pathophysiology and clinical significance of TRALI has advanced significantly, and great efforts are being implemented for patient safety. This article reviews the background, history, definitions, clinical features, and pathophysiology of TRALI. It also discusses some of the difficulties in diagnosing TRALI, compares some of the important components in the differential diagnosis, and describes some of the efforts being implemented for patient safety.

[Hypotension and adverse transfusion reactions: from the associated clinical signs to the hypotensive transfusion reaction]

OBJECTIVE

The first aim of this study was to confirm the presence of hypotension blood transfusion reactions and to assess the part of hypotension as a principal event, as defined by the literature but not characterized in French haemovigilance data. As well, recent series of several cases led us to consider a possible incidence increase.

STUDY DESIGN

Using a retrospective observation, the haemovigilance data from 2000 to the end of 2007 of two French regions were reviewed. During this period, 1159657 blood units were transfused by nearly 100 hospitals and 3727 adverse reactions observed.

RESULTS

One hundred and sixty-eight adverse reactions with hypotension were noticed and analyzed, representing 4.5% of all transfusion reactions and revealing an incidence of 14.5 for 100000 blood units transfused. It turned out to be mostly male recipients, severe reactions and appearing rather in the beginning of transfusions. Although platelets having greater incidence, all types of blood products may be involved. The clinical diagnosis was the following: 40 to 47% were classified as febrile reactions, 13 to 17% were allergic reactions, 8 to 9% were due to immunologic and/or haemolytic reactions, 5 to 7% resulted of cardiologic disorders, 5% resulted of hypovolemic contexts and 22% were unexplained hypotensive transfusion reactions.

CONCLUSION

In about three cases out of four, transfusion-induced hypotension was associated with other clinical reactions. Indeed, hypotensive transfusion reactions were identified, having an incidence of 3.2 for 100000 blood units transfused. Furthermore, there was no explanation found for the incidence increase in our region during 2007. A national study was suggested to analyse the national data as well as a prospective study to clear out this type of transfusion reactions.

Difference in autologous blood transfusion-induced inflammatory responses between acute normovolemic hemodilution and preoperative donation

PURPOSE

The inflammatory response triggered by transfusion is implicated in the pathophysiology of transfusion-related immunomodulation. The authors hypothesized that two distinctive autotransfusion methods, acute normovolemic hemodilution (ANH) and preoperative donation (PD), have different influences on both inflammatory mediator generation during storage and the inflammatory response after a transfusion. The purpose of this study was to compare the plasma concentrations of neutrophil elastase (NE), interleukin (IL)-6, IL-8, and IL-10 in patients who underwent either of these two autologous transfusion methods.

METHODS

With institutional review board approval, the plasma concentrations of the above inflammatory mediators were determined in 23 patients with ANH and 8 patients with PD at the following time points: after anesthetic induction, at the end of the operation, and the morning of postoperative day 1. The concentrations of these inflammatory mediators were also measured in the donated blood obtained by either ANH or PD before retransfusion.

RESULTS

The mean storage durations were 3.7 h and 6.1 days for ANH and PD, respectively. Higher concentrations of NE and IL-10 were detected in the PD blood than in the ANH blood. Long duration of storage and/or low temperature may have been responsible for the increased NE and IL-10 concentrations in the PD blood. However, the difference between the two groups in the extent of increased plasma concentrations of these inflammatory mediators was not statistically significant.

CONCLUSION

Inflammatory mediators were significantly increased in PD blood during storage compared to the blood obtained by ANH. However, their effects on the inflammatory response elicited in the recipients were not significantly different.

Plasma from stored packed red blood cells and MHC class I antibodies causes acute lung injury in a 2-event in vivo rat model

Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion death. We hypothesize that TRALI requires 2 events: (1) the clinical condition of the patient and (2) the infusion of antibodies against MHC class I antigens or the plasma from stored blood. A 2-event rat model was developed with saline (NS) or endotoxin (LPS) as the first event and the infusion of plasma from packed red blood cells (PRBCs) or antibodies (OX18 and OX27) against MHC class I antigens as the second event. ALI was determined by Evans blue dye leak from the plasma to the bronchoalveolar lavage fluid (BALF), protein and CINC-1 concentrations in the BALF, and the lung histology. NS-treated rats did not evidence ALI with any second events, and LPS did not cause ALI. LPS-treated animals demonstrated ALI in response to plasma from stored PRBCs, both prestorage leukoreduced and unmodified, and to OX18 and OX27, all in a concentration-dependent fashion. ALI was neutrophil (PMN) dependent, and OX18/OX27 localized to the PMN surface in vivo and primed the oxidase of rat PMNs. We conclude that TRALI is the result of 2 events with the second events consisting of the plasma from stored blood and antibodies that prime PMNs.

Endothelial pathomechanisms in acute lung injury

Acute lung injury (ALI) and its most severe extreme the acute respiratory distress syndrome (ARDS) refer to increased-permeability pulmonary edema caused by a variety of pulmonary or systemic insults. ALI and in particular ARDS, are usually accompanied by refractory hypoxemia and the need for mechanical ventilation. In most cases, an exaggerated inflammatory and pro-thrombotic reaction to an initial stimulus, such as systemic infection, elicits disruption of the alveolo-capillary membrane and vascular fluid leak. The pulmonary endothelium is a major metabolic organ promoting adequate pulmonary and systemic vascular homeostasis, and a main target of circulating cells and humoral mediators under injury; pulmonary endothelium is therefore critically involved in the pathogenesis of ALI. In this review we will discuss mechanisms of pulmonary endothelial dysfunction and edema generation in the lung with special emphasis on the interplay between the endothelium, the immune and hemostatic systems, and highlight how these principles apply in the context of defined disorders and specific insults implicated in ALI pathogenesis.

Transfusion-related acute lung injury: a clinical challenge

Transfusion-related acute lung injury is a life-threatening clinical syndrome. In the last 3 years, it has become the leading cause of reported transfusion-related deaths in the United States. This syndrome is characterized by acute hypoxemia and noncardiogenic pulmonary edema directly linked in time to a blood transfusion. All types of blood products have been implicated in transfusion-related acute lung injury, but transfusion of plasma-containing products from multiparous women seems to carry the highest risk. The purpose of this article is to raise awareness of this syndrome for the critical care nurse. This article discusses the widely accepted clinical features of transfusion-related acute lung injury, its pathogenesis, differential diagnosis, and treatment.

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.

Preoperative autologous blood donation in primary total knee arthroplasty: critical review of current indications

Preoperative autologous blood donation (PABD) is a well established transfusion practice in elective orthopaedic surgery, involving immunologic and infective advantages but also involving exposure to not negligible risks, and costs as well. The aim of this study was to assess the real need for blood transfusions in primary total knee arthroplasty (TKA). Between January 2000 and July 2005, 214 patients underwent primary unilateral TKA. Altogether, 416 autologous blood units were collected, however only 47 (11.3%) were transfused. Thirty-eight patients (17.8%) received autologous blood, while 4 of them (10.5%) also received allogeneic blood. Based on the results of this study, PABD should be recommended in well selected patients undergoing TKA: older female patients with a low basal haemoglobin level.

Nineteen years of experience with autotransfusion for elective surgery in children: more troublesome than we expected

BACKGROUND

Under the rationale that children undergoing elective surgery are the best candidates for autologous blood donors because of their long life expectancy, aggressive donations of autologous blood, even from infants, have been reported. A number of problems are associated with the procedure, however, whereas the risks of homologous blood are very low.

STUDY DESIGN AND METHODS

From 1987 through 2005, of 5792 patients referred to blood transfusion services at two Japanese university hospitals for autologous blood donations, 314 children younger than 16 years old served as subjects for assessment.

RESULTS

Of 314 children, 7 were not suitable as autologous donors. In most cases this was due to uncooperative behavior. Over a follow-up period of 19 years, the authors encountered 53 cases (17.3%) of donation-related problems, and this rate was higher than the 6 percent rate recorded for adult cases (316/5305). Nine children suffered crucial complications such as vasovagal reactions, and one 14-year-old boy required a vasopressor drug. Important findings were that 6 of these were first-time donors, and the amount of blood drawn was under 10 percent of their estimated blood volume.

CONCLUSION

Of 53 donation-related problems, 9 (17.0%) were accompanied by marked hypotension. Drawing autologous blood from children has become easier with advanced devices; however, lessening of anxiety and tension are essential for the safety of children's autologous blood donation programs. Aggressive donation should be avoided.

Recurrent transfusion-related acute lung injury after a two-year interval

Transfusion-related acute lung injury (TRALI) is a life-threatening complication of blood transfusion. The epidemiology and pathogenesis of TRALI are not well established. A Medline literature search shows only rare reports of recurrent TRALI, all occurring soon after the first episodes. We report a case of recurrent TRALI after a 2-year interval. A patient developed TRALI after transfusion of 4 units of fresh frozen plasma for gastrointestinal bleeding due to oesophageal varices in September 2002. The patient required mechanical ventilation but recovered completely. Two years later, in October 2004, the patient experienced a second episode of TRALI during liver transplantation for hepatitis C virus /alcoholic cirrhosis. Again, the patient recovered after ventilator support. Laboratory investigation of the first TRALI episode (2002) showed antibodies against class II human leukocyte antigens (HLA) in three female donors. Laboratory investigation of the second episode (2004) showed anti-DR52 (HLA class II) antibodies in one female donor matching the DR-52 HLA class II antigen in the recipient. TRALI can rarely recur. Consideration of future blood needs for patients experiencing recurrent TRALI should include preventive measures against further TRALI reactions, such as blood from male donors or blood less than 14 days old.

The pathogenesis of transfusion-related acute lung injury (TRALI)

In recent years, transfusion-related acute lung injury (TRALI) has developed from an almost unknown transfusion reaction to the most common cause of transfusion-related major morbidities and fatalities. A clinical definition of TRALI was established in 2004, based on acute respiratory distress, non-cardiogenic lung oedema temporal association with transfusion and hypoxaemia. Histological findings reveal lung oedema, capillary leucostasis and neutrophil extravasation. However, the pathogenesis of TRALI remains controversial. Leucocyte antibodies, present in fresh frozen plasma and platelet concentrates from multiparous donors, and neutrophil priming agents released in stored cellular blood components have been considered to be causative. As neutrophils and endothelial cells are pivotal in the pathogenesis of TRALI, a threshold model was established to try to unify the various reported findings on pathogenesis. This model comprises the priming of neutrophils and/or endothelium by the patient's co-morbidity, neutrophil and/or endothelial cell activation by the transfused blood component, and the severity of the TRALI reaction.

Indecency/decency in cardiac surgery: a memoir of my education at a Super-Esteemed Medical Place

OBJECTIVES

This article aims to define and analyze indecency in heart surgery, propose a partial remedy to it, stimulate ethics in the surgery literature, and reflect on the cultural background of heart surgery.

BACKGROUND

After 30 years of teaching ethics in medical schools, I provide a semi-insider's impression of being a patient in heart surgery.

METHODS

I define types of indecency, apply them to my case, and reflect on the culture (nature) of surgery.

CONCLUSIONS

Anecdotally, heart surgeons need much improvement. One way to do so is by helping patients prepare for their postoperative experiences and support them when troubling aftereffects arise.

Indications for Blood Transfusion in Cardiac Surgery

In addition to its life-saving effect in hemorrhagic shock, transfusion of allogenic packed red blood cells can be beneficial in situations where a critically low hematocrit is contributing to a state of oxygen-supply dependency. These benefits are countered by the risks of transfusion-associated lung injury, transfusion-associated immunomodulation, and cellular hypoxia after RBC transfusion. The critical hematocrit is patient and organ specific, and varies intraoperatively according to the duration and temperature of bypass, as well as for a variable postoperative period. Future randomized studies must prospectively evaluate regional indicators of tissue oxygenation in transfusion algorithms.

Laryngospasm after autologous blood transfusion

Although perioperative autologous blood transfusions are associated with few side effects, transfusion reactions can occur and can be life-threatening. We report the occurrence of postoperative laryngospasm in a patient who underwent spinal anesthesia for hip surgery. The laryngospasm could not be attributed to any cause other than the autologous blood transfusion and recurred when the transfusion was restarted. Laryngospasm was successfully treated both times with positive pressure ventilation. Autologous transfusions can trigger febrile nonhemolytic transfusion reactions, which may result in airway compromise.

Transfusion-related acute lung injury (TRALI)--an important, severe transfusion-related complication

BACKGROUND

Transfusion-related acute lung injury (TRALI) is an immune-mediated transfusion reaction that can cause severe complications or even death. It is now the leading cause of transfusion-related death in the United States.

METHODS

The TRALI syndrome is presented in two cases in a surgical intensive care unit and discussed against the background of the present literature. In both cases, concomitant diseases led to an extremely difficult course of TRALI.

CONCLUSIONS

Knowledge of the TRALI syndrome is necessary to enable early diagnosis and treatment. It should be taken into consideration at any time when cardiopulmonary instability occurs after transfusion of blood products, which is a frequent event on surgical Intensive Care Units. TRALI remains a clinical diagnosis supported by serologic studies if these are available. Against the background of this potentially life-threatening complication, every single indication to transfuse blood products needs to be scrutinized carefully.

TRALI in 2 cases of leukemia

We describe transfusion-related acute lung injury (TRALI) in 2 acute leukemia cases to increase awareness of this under reported serious transfusion complication syndrome in multitransfused patients. There are a number of reports in multitransfused patients with nonmalignant disorders. However, reports of pediatric oncology patients are few, suggesting a lack of recognition or misdiagnosis of the syndrome. A disproportionately high number of fatalities in children is recorded in the literature. This highlights the need for increased awareness and appropriate treatment of this serious complication of transfusion. Although TRALI is initially a clinical diagnosis, the laboratory investigation is vital as it contributes to defining the pathogenesis of the syndrome and importantly facilitates the effective management of implicated donations and donors. An investigational strategy for suspected cases is presented and the results are discussed in the context of current proposed mechanisms for TRALI. As each transfused blood product is associated with a potential risk of TRALI, more frequent reports in patients receiving large volume or recurrent transfusion would be expected.

The two-event model of transfusion-related acute lung injury

The objective of this review is to present the two-event model of transfusion-related acute lung injury (TRALI), a life-threatening complication of transfusions that has been the most common cause of transfusion-related death over the past 2 yrs in the United States. The two-event model of TRALI, which is identical to the pathogenesis of the acute respiratory distress syndrome (ARDS), is reviewed and contrasted to antibody-mediated TRALI. Laboratory studies, both in vitro and in vivo, are discussed as well as human studies of TRALI. Methods to avoid patient exposure to blood components that may cause TRALI are also discussed.

Animal models of transfusion-related acute lung injury

OBJECTIVE

To examine the existing animal models of transfusion-related acute lung injury (TRALI) for insight into disease pathogenesis.

DATA SOURCE

The data were taken from published research and from our own experimental results.

RESULTS

Animal models have disproved the microaggregate theory of acute lung injury from blood transfusions. The two major hypotheses of TRALI, passively transfused neutrophil and human leukocyte antigen antibodies and biologically active lipids that accumulate in older, cellular blood products, have been replicated in animal models. The proposed two-hit model of TRALI is also supported by animal studies. A new in vivo mouse model of TRALI based on major histocompatibility complex (MHC) I antibodies has replicated several features of human TRALI, focusing prominently on the role of neutrophils.

CONCLUSIONS

Experimental animal models support both the antibody and lipid theories of TRALI. The essential role of neutrophils to producing lung injury is common to all existing models of TRALI. There is a lack of clinically relevant animal models that explain why transfusion of donor antibodies to cognate antigens in the recipient does not always lead to TRALI.

Preoperative autologous blood donation in primary total knee arthroplasty: a single-centre experience on 214 consecutive patients

BACKGROUND AND OBJECTIVES

Although preoperative autologous blood donation (PABD) is a widespread practice in elective orthopedic surgery, it is controversial whether this procedure avoids allogeneic blood transfusions in patients undergoing total knee arthroplasty (TKA).

PATIENTS AND METHODS

We performed a retrospective study on 214 consecutive patients undergoing PABD before elective primary TKA.

RESULTS

Thirty-eight patients (17.8%) were transfused with autologous red blood cells (RBC), while four of them (10.5% of those requiring transfusions, 1.9% of all patients) also received allogeneic RBC. The transfused patients were, in most cases, female and had significantly lower basal and preoperative haemoglobin levels.

CONCLUSIONS

Based on the results of this study, PABD is not necessary in most patients undergoing TKA, although older female patients with low basal haemoglobin levels could benefit from a predeposit programme and/or erythropoietin support in order to reduce the risk of exposure to allogeneic blood.

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.

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.

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.

Transfusion-related acute lung injury

Transfusion-related acute lung injury (TRALI) is a life-threatening adverse effect of transfusion that is occurring at increasing incidence in the United States and that, in the past 2 reporting years, has been 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 the transfusion of blood/blood components. In prospective studies, 2 patient groups, 1 requiring cardiac surgery and 1 with hematologic malignancies and undergoing induction chemotherapy, were predisposed. Two different etiologies have been proposed. The first is a single antibody-mediated event involving the transfusion of anti-HLA class I and class II or antigranulocyte antibodies into patients whose leukocytes express the cognate antigens. The second is a 2-event model: the first event is the clinical condition of the patient resulting in pulmonary endothelial activation and neutrophil sequestration, and the second event is the transfusion of a biologic response modifier (including lipids or antibodies) that activates these adherent polymorphonuclear leukocytes (PMNs), resulting in endothelial damage, capillary leak, and TRALI. These hypotheses are discussed, as are the animal models and human studies that provide the experimental and clinical relevance. Prevention, treatment, and a proposed definition of TRALI, especially in the context of ALI, are also examined.