Diagnosis Of Transfusion-related Acute Lung Injury Research Articles

Acute Lung Injury Associated with Blood Transfusion in a Hysterectomy Patient: A Case Report

This case report presents a case of transfusion-related acute lung injury (TRALI) in a 50-year-old female patient who underwent total hysterectomy due to multiple fibromyomas. The patient developed dyspnea, heart palpitations, and fatigue postoperatively, with SpO2 dropping to 61%. Despite initially suspecting pulmonary embolism, the normal D-dimer level and characteristic changes observed on X-ray facilitated the diagnosis of TRALI. The patient was successfully treated with oxygen supplementation, intravenous corticosteroids, and thromboembolism prophylaxis, resulting in complete recovery. This case underscores the importance of considering TRALI in the differential diagnosis when patients exhibit respiratory distress following transfusion.

Transfusion reaction: A blind spot in autopsy

Although blood transfusion is generally safe, there are adverse events with varying severity even that can lead to death including Acute Haemolytic Transfusion Reaction (AHTR), anaphylaxis, bacterial sepsis, Transfusion Related Acute Lung Injury (TRALI) and Transfusion Associated Circulatory Overload (TACO). Transfusion Associated Graft vs Host Disease (TAGVHD) is a delayed type of reaction that can lead to death. Ascertaining the cause of death is complicated in such situations and multidisciplinary investigations are needed.Serological investigations should be performed in the transfusion laboratory to detect haemolysis, immunological incompatibility, and bacterial contamination. In the postmortem examination AHTR can be diagnosed with serological investigations and presence of incompatible red cells can be identified in postmortem tissue samples by immune-histochemical methods. Detection of HLA antibodies in the respiratory tract tissues and intended donor investigations can confirm the diagnosis of TRALI. In a case of suspected bacterial contamination isolation of same organism in the postmortem blood and in the intended pack can conclude the diagnosis. In anaphylaxis, inflammation of the respiratory tract with eosinophilia can be seen and measuring the serum tryptase level is useful. In TAGVHD host tissue necrosis and lymphocyte infiltration are +seen and that can be confirmed by showing the DNA chimerism by PCR analysis.Further studies are recommended to establish protocols and guidelines for postmortem examination following a transfusion reaction.

Extracellular Vesicles - Effectors of Transfusion-related Acute Lung Injury.

Respiratory transfusion reactions represent some of the most severe adverse reactions related to receiving blood products. Of those, transfusion-related acute lung injury (TRALI) is associated with elevated morbidity and mortality. TRALI is characterized by severe lung injury associated with inflammation, pulmonary neutrophil infiltration, lung barrier leak, and increased interstitial and airspace edema which cause respiratory failure. Presently, there are few means of detecting TRALI beyond clinical definitions based on physical examination and vital signs or preventing/treating TRALI beyond supportive care with oxygen and positive pressure ventilation. Mechanistically, TRALI is thought to be mediated by the culmination of two successive pro-inflammatory hits, which typically comprise a recipient factor (1st hit - e.g. systemic inflammatory conditions) and a donor factor (2nd hit - e.g. blood products containing pathogenic antibodies or bioactive lipids). An emerging concept in TRALI research is the contribution of extracellular vesicles (EVs) in mediating the 1st and/or 2nd hit in TRALI. EVs are small, sub-cellular, membrane-bound vesicles which circulate in donor and recipient blood. Injurious EVs may be released by immune or vascular cells during inflammation, by infectious bacteria, or in blood products during storage, and can target the lung upon systemic dissemination. This review assesses emerging concepts such as how EVs: i) mediate TRALI, ii) represent targets for therapeutic intervention to prevent or treat TRALI, and iii) serve as biochemical biomarkers facilitating TRALI diagnosis and detection in at-risk patients.

Medical chart validation of inpatient diagnosis codes for transfusion-related acute lung injury 2013-2015.

Transfusion-related acute lung injury (TRALI), an adverse event occurring during or within 6 hours of transfusion, is a leading cause of transfusion-associated fatalities reported to the US Food and Drug Administration. There is limited information on the validity of diagnosis codes for TRALI recorded in inpatient electronic medical records (EMRs). We conducted a validation study to establish the positive predictive value (PPV) of TRALI International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes recorded within a large hospital system between 2013 and 2015. A physician with critical care expertise confirmed the TRALI diagnosis. As TRALI is likely underdiagnosed, we used the specific code (518.7), and codes for respiratory failure (518.82) in combination with transfusion reaction (999.80, 999.89, E934.7). Among almost four million inpatient stays, we identified 208 potential TRALI cases with ICD-9-CM codes and reviewed 195 medical records; 68 (35%) met clinical definitions for TRALI (26 [38%] definitive, 15 [22%] possible, 27 [40%] delayed). Overall, the PPV for all inpatient TRALI diagnoses was 35% (95% confidence interval (CI), 28-42). The PPV for the TRALI-specific code was 44% (95% CI, 35-54). We observed low PPVs (<50%) for TRALI ICD-9-CM diagnosis codes as validated by medical charts, which may relate to inconsistent code use, incomplete medical records, or other factors. Future studies using TRALI diagnosis codes in EMR databases may consider confirming diagnoses with medical records, assessing TRALI ICD, Tenth Revision, Clinical Modification codes, or exploring alternative ways for of accurately identifying TRALI in EMR databases. In 169 hospitals, we identified 208 potential TRALI cases, reviewed 195 charts, and confirmed 68 (35%) cases met TRALI clinical definitions. As many potential TRALI cases identified with diagnosis codes did not meet clinical definitions, medical record confirmation may be prudent.

Transfusion-Related acute lung injury in a patient with hellp syndrome: A case report

Transfusion-related acute lung injury (TRALI) is a serious adverse reaction associated with the transfusion of plasma-containing blood components, and presents as hypoxemia and non-cardiogenic pulmonary oedema within 6 hrs of transfusion. Here we are reporting a case of TRALI in 24-year-old pregnant Female presented with HELLP (haemolysis, elevated liver enzymes, and low platelet count) syndrome, an emergency caesarean section delivery was performed, and blood was transfused. In such cases, clinicians should strictly monitor the patient's condition at least during the 6 hrs while the patient receives blood transfusion, and should suspect TRALI. The patient's rapid clinical deterioration with falling O2 saturation and other respiratory symptoms after transfusion supports the diagnosis of TRALI.

PRS1 - Transfusion-Related Acute Lung Injury (Trali) Occurrence Among Inpatient Medicaid Beneficiaries, Under 65 Years of Age, As Recorded By Large Administrative Databases During 2007-2010

Transfusion-Related Acute Lung Injury (TRALI) is a serious transfusion complication resulting in pulmonary edema and respiratory failure. The study objectives were to assess TRALI occurrence and potential risk factors among inpatient Medicaid beneficiaries under 65 years of age, during 2007-2010. This retrospective claims-based study utilized large Medicaid databases. Transfusions were identified by recorded procedure and revenue center codes, while TRALI was ascertained via ICD-9-CM diagnosis code. Revenue center units were used to quantify blood use. Study evaluated TRALI rates (per 100,000 transfusion stays) among Medicaid beneficiaries, overall and by year, age, sex, race, number of units and blood components transfused. Of 1,123,113 inpatient transfusion stays for Medicaid beneficiaries during 2007-2010, 162 had TRALI diagnosis recorded, an overall rate of 14.42 per 100,000 stays. Annual TRALI rates were 12.70, 10.67, 16.60, and 18.14, respectively. TRALI rates for ages 0-9, 10-19, 20-29, 30-39, 40-49, 50-59, and 60-64 were 5.15, 13.41, 17.22, 19.59, 19.44, 13.66, and 10.54. Rates for females and males were 12.78 and 17.28, whereas for whites and non-whites were 15.55 and 13.45. TRALI rates by number of units were: 9.56 for 1 unit, 7.72 for 2-4 units, 17.70 for 5-9 units, and 62.12 for >9 units. Rates by blood component groups were: 13.86 for RBCs only, 4.93 for plasma only, 23.22 for platelets only, 37.37 for platelets and plasma, 56.02 for RBCs and plasma, 43.12 for RBCs and platelets, and 74.75 for RBCs, plasma, and platelets. This is the first and largest-to-date claims-based TRALI study among Medicaid beneficiaries. The results show a possible trend of increasing TRALI occurrence over time. The findings also suggest that TRALI rates vary by age, sex, race, number of units, and blood components transfused, with highest rates for stays with >9 units transfused and for stays with RBCs transfused in combination with plasma and platelets.

TRALI in the perioperative period

TRALI in the perioperative period Mohamed Adnane Berdai, Smael Labib, Mustapha HarandouChild and Mother Intensive Care Unit, University Hospital Hassan II, Fes, MoroccoBackground: Transfusion-related acute lung injury (TRALI) is one of the leading causes of transfusion-related morbidity and mortality. Although it is a serious complication of blood transfusion, it is still underestimated because of underrecognition and misdiagnosis, which can lead to inappropriate management.Case report: We report the case of a 34-year-old female, who presented with hemorrhagic shock during cesarean section and was transfused with packed red blood cells and fresh frozen plasma. Three hours after the end of transfusion, while still intubated, the patient developed acute respiratory failure, with diffuse crackles at auscultation and bilateral lung infiltrations on chest radiography. The ratio of the arterial partial pressure of O2 and the fraction of inspired O2 (PaO2/FiO2) was 51. The diagnosis of TRALI was made after excluding other possible causes of acute lung injury. She was managed symptomatically with ventilatory support and vasopressors. The patient later died secondary to multiple organ failure.Conclusion: The diagnosis of TRALI relies on the exclusion of other causes of acute pulmonary edema following transfusion. All plasma-containing blood products have been involved in the genesis of this syndrome. This is a relatively common and serious adverse transfusion reaction that requires prompt diagnosis and management. Challenges are ahead as preventive strategies have reduced but not eliminated the onset of TRALI.Keywords: acute lung injury, transfusion related acute lung injury, anti-human leukocyte antigen antibody, pulmonary edema, transfusion accident

Perioperative transfusion-related acute lung injury: the Canadian Blood Services experience.

Transfusion-related acute lung injury (TRALI) is a devastating transfusion-associated adverse event. There is a paucity of data on the incidence and characteristics of TRALI cases that occur perioperatively. We classified suspected perioperative TRALI cases reported to Canadian Blood Services between 2001 and 2012, and compared them to non-perioperative cases to elucidate factors that may be associated with an increased risk of developing TRALI in the perioperative setting. All suspected TRALI cases reported to Canadian Blood Services (CBS) since 2001 were reviewed by two experts or, from 2006 to 2012, the CBS TRALI Medical Review Group (TMRG). These cases were classified based on the Canadian Consensus Conference (CCC) definitions and detailed in a database. Two additional reviewers further categorized them as occurring within 72 h from the onset of surgery (perioperative) or not in that period (non-perioperative). Various demographic and characteristic variables of each case were collected and compared between groups. Between 2001 and 2012, a total of 469 suspected TRALI cases were reported to Canadian Blood Services; 303 were determined to be within the TRALI diagnosis spectrum. Of those, 112 (38%) were identified as occurring during the perioperative period. Patients who underwent cardiac surgery requiring cardiopulmonary bypass (25.0%), general surgery (18.0%) and orthopedics patients (12.5%) represented the three largest surgical groups. Perioperative TRALI cases comprised more men (53.6% vs. 41.4%, p=0.04) than non-perioperative patients. Perioperative TRALI patients more often required supplemental O2 (14.3% vs. 3.1%, p=0.0003), mechanical ventilation (18.8% vs. 3.1%), or were in the ICU (14.3% vs. 3.7%, p=0.0043) prior to the onset of TRALI compared to non-perioperative TRALI patients. The surgical patients were transfused on average more components than non-perioperative patients (6.0 [SD=8.3] vs. 3.6 [5.2] products per patient, p=0.0002). Perioperative TRALI patients were transfused more plasma (152 vs. 105, p=0.013) and cryoprecipitate (51 vs. 23, p<0.01) than non-perioperative TRALI patients. There was no difference between donor antibody test results between the groups. CBS data has provided insight into the nature of TRALI cases that occur perioperatively; this group represents a large proportion of TRALI cases.

Possible transfusion-related acute lung injury (TRALI) in cardiac surgery patients

AimTo determine the incidence of possible transfusion-related acute lung injury (TRALI) and related risk factors in cardiac surgery patients.MethodsA single-center prospective cohort study was conducted from January 2009 to March 2010 at the Zagreb University Hospital Center, Croatia. Patient-, transfusion-, and surgery-related data were collected. The study included 262 patients who were observed for respiratory worsening including measurements of arterial oxygen saturation (SaO2), fraction of inspired oxygen (FiO2), and partial pressure of arterial oxygen (PaO2). Possible TRALI was defined according to the Toronto Consensus Conference definition broadened for 24-hour post-transfusion. This cohort was divided in two groups. TRALI group included 32 participants with diagnosis of TRALI and the control group included 220 patients with or without respiratory worsening, but with no signs of ALI.ResultsPossible TRALI was observed in 32 (12.2%) patients. Compared with the control group, possible TRALI patients had higher American Association of Anesthesiology scores, higher rate of respiratory comorbidity (43.8% vs 15.5%), and required more red blood cells (median 4, range [2.5-6] vs 2 [1-3]), plasma (5 [0-6] vs 0 [0-2]), and platelet units (0 [0-8] vs 0 [0-0]) (P < 0.001 all). Risk factors for possible TRALI were total number of transfused blood units (odds ratio [OR] 1.23; 95% confidence interval [CI] 1.10-1.37) and duration of cardiopulmonary bypass (OR 1.08; 95% CI 1.05-1.11). Post-transfusion PaO2/FiO2 ratio was significantly decreased in possible TRALI patients and significantly increased in transfused controls without acute lung injury.ConclusionWe observed a higher rate of possible TRALI cases than in other studies on cardiac surgery patients. Serial monitoring of PaO2/FiO2 ratio and detection of its post-transfusion worsening aids in identification of possible TRALI cases.

Transfusion‐related acute lung injury and potential risk factors among the inpatient US elderly as recorded in Medicare claims data, during 2007 through 2011

Transfusion-related acute lung injury (TRALI) is a serious complication leading to pulmonary edema and respiratory failure. This study's objective was to assess TRALI occurrence and potential risk factors among inpatient US elderly Medicare beneficiaries, ages 65 and older, during 2007 through 2011. This retrospective claims-based study utilized large Medicare administrative databases. Transfusions were identified by recorded procedure and revenue center codes. TRALI was ascertained via ICD-9-CM diagnosis code. The study evaluated TRALI rates among the inpatient elderly overall and by calendar year, age, sex, race, blood components, and units transfused. Logistic regression analyses were used to assess potential risk factors. Of 11,378,264 inpatient transfusion stays for elderly Medicare beneficiaries, 2556 had a recorded TRALI diagnosis code, an overall rate of 22.46 per 100,000 stays. TRALI rates were higher for platelet (PLT)- and plasma-containing transfusions and increased by year and number of units transfused (p < 0.0001). Significantly higher odds of TRALI were also found for persons ages 65 to 79 years versus more than 79 years (OR, 1.19; 95% confidence interval CI, 1.09-1.29), females versus males (OR, 1.26; 95% CI, 1.16-1.38), white versus nonwhite (OR, 1.43; 95% CI, 1.27-1.66), and with 6-month histories of postinflammatory pulmonary fibrosis (OR, 1.89; 95% CI, 1.52-2.20), tobacco use (OR, 1.16; 95% CI, 1.00-1.26), and other diseases. Our study among the elderly suggests TRALI to be a severe event and identifies a substantially increased TRALI occurrence with greater number of units and with PLT- or plasma-containing transfusions. The study also suggests importance of underlying health conditions, prior recipient alloimmunization, and nonimmune mechanism in TRALI development among the elderly.

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Introduction: Transfusion Related Acute Lung Injury (TRALI) is a form of acute lung injury (ALI) seen after exposure to blood products. We present a case of respiratory failure secondary to TRALI in an 18 year old status post scoliosis surgery. We review the medical literature and present diagnostic criteria, pathophysiology and differential diagnosis of TRALI. An 18 year old male with severe spastic quadraparesis and scoliosis with scoliotic curve 80 degrees and restrictive lung disease without prior respiratory requirement was admitted to our pediatric critical care unit (PCCU) status post posterior spinal fusion of T2-S1. Operative course was significant for coagulopathy causing approximate blood loss of 2 liters requiring transfusion of 6 units of packed red blood cells, 4 units of fresh frozen plasma and 2 units of platelets. While in the recovery room his oxygen was easily weaned to a Fi02 of 40%. In the PCCU, he remained intubated and sedated. Three hours after arrival, he developed significant hypoxia with a PaO2/FiO2 ratio of less than 300 suggestive of ALI. His x-ray 4 hours post transfusion revealed diffuse bilateral infiltrates consistent with pulmonary edema and no cardiomegaly. His ventilator requirements significantly increased to a PEEP of 15 and FiO2 of 80% to maintain oxygen saturation above 90%. He remained afebrile and hemodynamics remained stable off vasoactive medications. There were no findings of infection. On post-operative day 2, he tolerated weaning of oxygen. His imaging revealed improvement of pulmonary edema. He was extubated successfully on post-operative day 3 and was transferred to the pediatric floor on postoperative day 4. Our patient met all the criteria for TRALI (acute onset ALI within 6 hours of exposure to blood products, bilateral pulmonary infiltrates and no evidence of fluid overload or cardiogenic pulmonary edema. Given his surgery he fits the two hit theory hypothesized as pathophysiology of TRALI. Non-immune mediated cases are thought to be due to bioreactive lipids and cytokines that accumulate during the storage of blood products. These are referred to as biologic response modifiers (BRM). The non-immune reaction is not caused solely by BRMs. The proposed hypothesis involves a preceding event presensitzing a patient's lungs and leukocytes to this transfusion reaction. This theory is often referred to as the two hit theory. The first hit includes a predisposing event such as infection, a malignancy or a surgery as in our patient above. This first hit activates neutrophils in the pulmonary endothelium. The second hit involves the transfused BRMs causing further neutrophil activation and endothelial damage. The mortality rate from TRALI ranges from 5% to 25%. Most patients recover within 72 hours; as did our patient. However, there have been cases of severe TRALI lasting about 7 days cited in the literature. Morbidity and mortality may be underappreciated because of lack of recognition and underreporting of this diagnosis. Since TRALI is a transient form of ALI, management is usually supportive with mechanical ventilatory support. The pulmonary infiltrates and hypoxemia usually resolve completely without sequelae.

Human neutrophil antibodies in a blood donor population: a lookback study.

Human neutrophil antibodies (HNA) have been associated with severe transfusion-related acute lung injury (TRALI). We identified HNA antibodies in a blood donor population and performed an observational lookback on patients who received products from these donors to determine whether TRALI was associated with these transfusions. Human neutrophil antibodies were determined in 1171 blood donors (388 non-transfused males, 390 human leucocyte antigen (HLA) antibody-negative females and 393 HLA antibody-positive females) for IgG and IgM antibodies using a flow cytometric assay. Selected positive samples had a monoclonal antibody immobilization of granulocyte antigen (MAIGA) and neutrophil genotyping performed to confirm specificity. Lookback was performed on patients receiving blood from donors with positive samples by extracting recipient data from hospital medical records. An expert panel of three pulmonary critical care physicians reviewed the summarized data and assigned a diagnosis of TRALI, possible TRALI, cannot distinguish between TRALI and TACO, TACO and other. Eight donors had HNA antibodies of which five contributed to this lookback (3-HNA-specific antibodies, 2-HNA non-specific antibodies). Seventy-six blood products were transfused from these donors into individual patients. One patient developed TRALI that was associated with a donor with a non-specific HNA antibody as well as class-I and class-II HLA antibodies. The incidence of TRALI in this lookback was low and combined with low frequency of HNA antibodies in the donor population suggests not screening donors for HNA antibodies at this time is acceptable.

A patient with possible TRALI who developed pulmonary hypertensive crisis and acute pulmonary edema during cardiac surgery

There are very few case reports of transfusion-related acute lung injury (TRALI) under close hemodynamic monitoring. We encountered a case of possible TRALI during on-pump coronary artery bypass grafting (CABG). A 66-year-old man who had undergone on-pump CABG was administered fresh frozen plasma (FFP). One hour after FFP transfusion, pulmonary hypertensive crisis and subsequent hypoxic decompensation occurred. A second cardiopulmonary bypass (CPB) was needed for circulatory and respiratory deterioration. Extracorporeal life support (ECLS), intraaortic balloon pumping (IABP), and nitric oxide therapy were required after the surgery. Despite the severity of the initial state, his recovery was comparatively smooth. ECLS and IABP were removed on postoperative day (POD)1; the patient was extubated and discharged from the ICU on POD7 and POD12, respectively. The diagnosis of TRALI was confirmed by human leukocyte antigen antibody detection in the administered FFP. In addition, lymphocytic immunofluorescence test showed that a cross-match of the plasma from the pooled FFP against the recipient leukocytes was positive. The clinical course of the pulmonary artery hypertension was followed by a decrease in dynamic lung compliance. The mechanism of this phenomenon is unclear. However, it might suggest the possibility of vasoconstriction or obstruction of the peripheral pulmonary artery preceding lung damage, as in the case in animal models reported previously.

Transfusion-related acute lung injury: clues to diagnosis

Transfusion-related acute lung injury (TRALI) is a known cause of transfusion-related morbidity and mortality. TRALI occurs during or within 6 hours of transfusion with clinical features that include respiratory distress, pulmonary oedema and hypoxaemia. This case report will be followed by a discussion that will include general pathophysiology and clinical features of TRALI. The diagnosis is considered to be under-reported. Potential clues available to the pathologist will be discussed, specifically in relation to autopsy. The diagnosis of TRALI is a significant one, as donors of implicated blood products can be identified with the prevention of further potential transfusion reactions.

Transfusion-related acute lung injury: clues to diagnosis

Transfusion-related acute lung injury (TRALI) is a known cause of transfusion-related morbidity and mortality. TRALI occurs during or within 6 hours of transfusion with clinical features that include respiratory distress, pulmonary oedema and hypoxaemia. This case report will be followed by a discussion that will include general pathophysiology and clinical features of TRALI. The diagnosis is considered to be under-reported. Potential clues available to the pathologist will be discussed, specifically in relation to autopsy. The diagnosis of TRALI is a significant one, as donors of implicated blood products can be identified with the prevention of further potential transfusion reactions.

A suspected case of transfusion-related acute lung injury

Transfusion-related acute lung injury (TRALI) is a rare but serious complication of blood transfusion. We present a suspected case of TRALI in a 39-year-old female patient who underwent total abdominal hysterectomy under uneventful general anesthesia. The patient developed acute desaturation due to noncardiogenic pulmonary edema while receiving compatible blood transfusion on the second postoperative day. As her symptoms were refractory to supportive treatment, she was mechanically ventilated for 3 days and successfully extubated on the fourth day. By exclusion, a clinical diagnosis of TRALI was made. The treatment for TRALI requires discontinuing transfusion and giving respiratory and cardiovascular support. Most cases show clinical improvement in first few hours and resolve completely within 96 h.

Transfusion-Related Acute Lung Injury After Transfusion of Maternal Blood

This is a single-center retrospective case-control study of 7 transfusion-related acute lung injury (TRALI) cases and 28 controls in the pediatric spinal surgery population. To determine the association between maternal transfusion and risk of TRALI in pediatric spinal surgery patients. Previous studies support a "2-hit" model for the pathogenesis of TRALI-activation and sequestration of neutrophils in the pulmonary vasculature followed by transfusion of a biologic response modifier such as antileukocyte antibodies. Maternal donation of blood products is a potential risk factor for TRALI because of the development of antileukocyte antibodies during pregnancy. Until now there have been no studies specifically addressing the risk of TRALI following maternal transfusions. This is a retrospective case-control study of 7 TRALI cases with 4 controls per case, matched by strata for volume of plasma transfused. All cases identified by the Transfusion Biology and Medicine Specialized Center of Clinically Oriented Research with a TRALI diagnosis were eligible for inclusion. Electronic medical records and operative notes were reviewed to obtain demographic data, diagnosis, surgical approach, and number of spine levels for each operation. An increased prevalence of maternal blood transfusion was found among the TRALI cases compared with the control cases: 43% (3 of 7) versus 7% (2 of 28), P = 0.044. There were otherwise no statistical differences between the groups, including age, gender, surgical approach, number of spinal levels, or type of blood product transfused. Pediatric patients undergoing spinal surgery may be at increased risk for the development of TRALI following the transfusion of maternal blood products. Accordingly, we recommend that directed donation of maternal blood products should be avoided in this population. This study also found that TRALI may be underrecognized and underreported to the transfusion service.

Transfusion and Pulmonary Morbidity After Cardiac Surgery

True lung injury is among the leading causes of transfusion-related mortality. Pulmonary morbidity after cardiac surgery has been related to damaging effects of cardiopulmonary bypass and transfusion, but is confounded by cardiac-related events that may not reflect true lung injury. Thus, cardiac surgery poses unique challenges to criteria-specific diagnosis of transfusion-related acute lung injury (TRALI). Our objective was to determine the prevalence of pulmonary morbidity related to transfusion and whether TRALI consensus-criteria are applicable to cardiac surgery. A total of 16,847 patients underwent on-pump, coronary artery bypass grafting (CABG), valve, or CABG-valve surgery from September 1998 to February 1, 2006. We performed four propensity-score-matching analyses with logistic regression on probability of receiving a transfusion: total hospital red blood cell (RBC) and fresh frozen plasma (FFP) transfusion and intraoperative RBC and FFP transfusion. Outcomes included traditional cardiac-surgery-defined pulmonary morbidity and ratio of arterial partial pressure of oxygen to fractional inspired oxygen concentration (PaO(2)/FiO(2)), a criterion for TRALI. Patients receiving RBC transfusion had more risk-adjusted pulmonary complications: respiratory distress 4.8% vs 1.5%, p < 0.001; respiratory failure 2.2% vs 0.39%, p < 0.0001; longer intubation times, 9.9 hours vs 7.5 hours, p < 0.0001; acute respiratory distress syndrome, 0.64% vs 0.21%, p = 0.015; and reintubation, 5.6% vs 1.3%, p < 0.0001. The FFP was similarly related to more pulmonary complications after surgery. By TRALI criteria, the majority manifested "lung injury" (PaO(2)/FiO(2) ratio < 300) but unrelated to transfusion (65% vs 64%). Transfusion is associated with many measures of postoperative pulmonary morbidity. Yet the PaO(2)/FiO(2) ratio as important criterion of TRALI is unrelated to transfusion. Thus, due to the nature of cardiac surgery, application of consensus guided diagnosis of TRALI is problematic.

Recommendations of the ISBT Working Party on Granulocyte Immunobiology for leucocyte antibody screening in the investigation and prevention of antibody‐mediated transfusion‐related acute lung injury

Transfusion-related acute lung injury (TRALI) is currently one of the most common causes of transfusion-related major morbidity and death. Among the many TRALI mediators, leucocyte antibodies have been identified as important triggers of severe TRALI. These recommendations were compiled by experts of the ISBT Working Party on Granulocyte Immunobiology, based on the results obtained in eight international granulocyte immunology workshops, their personal experiences and on published study results. Leucocyte antibody screening has to include the detection of human leucocyte antigen (HLA) class I, class II and human neutrophil alloantigen antibodies using established and validated techniques. HLA class I antibody detection should be restricted to antibodies clinically relevant for TRALI. To avoid unnecessary workload, TRALI diagnosis should be assessed by consultation with the reporting clinician and thorough exclusion of transfusion-associated circulatory overload/cardiac insufficiency. In patients diagnosed with TRALI having donors with detectable leucocyte antibodies, evidence of leucocyte incompatibility should be provided by either cross-matching or typing of patient for cognate antigen. Leucocyte antibody screening for the immunological clarification of TRALI cases as well as for identification of potentially alloimmunized blood donors is feasible and can be performed in a reasonable and quality assured manner. This practice can contribute to the prevention of antibody-mediated TRALI.

Transfusion related acute lung injury

Transfusion related acute lung injury (TRALI) is an uncommon but potentially fatal adverse reaction to transfusion of plasma containing blood components. We describe a case of 10-year-old male child with aplastic anemia, platelet count of 7800/l, B positive blood group who developed fever (39.2C), difficulty in breathing and cyanosis within 2 hrs after transfusion of a random platelet concentrate. Despite the best resuscitative efforts, the child died within next 24 hrs. The present case highlights the fact that TRALI should be kept as a differential diagnosis in all patients developing acute respiratory discomfort within 6 hrs of transfusion. Without a 'gold standard' the diagnosis of TRALI relies on a high index of suspicion and on excluding other types of transfusion reactions. Notification to transfusion services is crucial to ensure that a proper investigation is carried out and at-risk donor and recipients can be identified, and risk reduction measures can be adopted.