Transfusion related acute lung injury with massive pulmonary secretion during cardiac surgery. A case report

Anesthetic Management of a Patient With Massive Pulmonary Secretion During Cardiopulmonary Bypass Probably Due to Transfusion-Related Acute Lung Injury Type Ⅱ

Transfusion-related acute lung injury (TRALI) is potentially life-threatening adverse reaction associated with blood transfusion and can induce perioperative pulmonary secretion. TRALI that develops during cardiopulmonary bypass (CPB) may be difficult to detect; however, the pathophysiology might manifest as derangements in CPB operations. A 79-year-old man was scheduled to undergo partial replacement of the aortic arch with CPB. Two units of red blood cells were loaded into the priming solution. Although the vital signs, including oxygenation, remained stable in the prebypass period, perfusionists noticed a decreasing trend in the venous reservoir level early in the CPB operations. The trend continued even during circulatory arrest with selective cerebral perfusion, resulting in the termination of the modified hemofiltration. Surgical procedures were accomplished uneventfully; however, a large amount of fluid was required to maintain the minimal reservoir level and CPB flow. The total fluid balance during CPB was +8,233 mL, which was quite unusual in our practice. When 800 mL of massive pulmonary secretion was detected before CPB withdrawal, the etiology could not be determined simultaneously; nonetheless, systemic vascular hyperpermeability was speculated to be the underlying pathophysiology. Our therapeutic approach following the treatment of acute respiratory distress syndrome contributed to halting the deterioration of lung injury. Although the pneumothorax developed on the first postoperative day, the patient was treated with the insertion of a chest drainage tube. Subsequently, the patient had a good course and was discharged without respiratory complications. In conclusion, massive pulmonary secretion, probably due to TRALI type II, was associated with derangements in CPB operations. Prompt identification of the underlying pathophysiology and appropriate intervention is crucial.

Trauma-induced capillary leak syndrome after penetrating chest injury: Manifestation of massive ascites and pulmonary secretions aggravated by transfusion

Trauma with prolonged shock can cause systemic capillary leak syndrome regardless of the site of injury and a transfusion can aggravate it. The systemic capillary leak induces both an abdominal compartment syndrome and pulmonary edema, and a transfusion can aggra-vate these sequelae within hours. In our case, 21-year-old man with a penetrating injury in his left thorax experienced delay in rescue and definitive surgery. To manage life-threatening shock, massive blood transfusion and crystalloids had been infused. Cardiopulmonary cerebral resuscitations were performed 2 times during the surgery. Massive amount of pulmonary secretions emitted from his airways with severe hypoxia along with development of massive ascites causing abdominal compartment syndrome, while the surgery was underway. After temporary abdominal closure, he was moved to the intensive care unit and underwent venovenous extracorporeal membranous oxygenation. He recovered without any notable complications. It is important to prevent and correct the shock rapidly by appropriate rescue, controlling the source and infusing less amount of crystalloid and transfusion.

Transfusion-related Acute Lung Injury in the Perioperative Patient

Transfusion-related acute lung injury is a leading cause of death associated with the use of blood products. Transfusion-related acute lung injury is a diagnosis of exclusion which can be difficult to identify during surgery amid the various physiologic and pathophysiologic changes associated with the perioperative period. As anesthesiologists supervise delivery of a large portion of inpatient prescribed blood products, and since the incidence of transfusion-related acute lung injury in the perioperative patient is higher than in nonsurgical patients, anesthesiologists need to consider transfusion-related acute lung injury in the perioperative setting, identify at-risk patients, recognize early signs of transfusion-related acute lung injury, and have established strategies for its prevention and treatment.