Transcript trali - Dartmouth

Haney A. Mallemat, MD
Department of Critical Care
Dartmouth-Hitchcock Medical Center
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77 M
AAA repair
• POD #3
Extubated
• Stable vitals
• Hb 8.1
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2U PRBC
• No indication documented
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Respiratory distress
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85% sat
85/50
P: 125
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STAT Airway
Levophed
Definition
• Epidemiology
• Pathogenesis
• Diagnosis
• Treatment
• Prognosis
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Definition
• Epidemiology
• Pathogenesis
• Diagnosis
• Treatment
• Prognosis
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Pulmonary Hypersensitivity Reaction
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Allergic Pulmonary Edema
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Non-Cardiogenic Pulmonary Edema
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Pulmonary Leucoagglutinin Reaction
Transfusion-Associated
Popovoskitis
• TRansfusion
• Associated
• Lung
•Injury
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No formal definition
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ALI from blood products
• P/F ratio <300
• B/L infiltrates
• No circulatory overload
• No previous ALI
• No causes ALI
 “Classic” TRALI
< 6 h
▪~30-120 min
 “Delayed” TRALI
 6 – 72 h
Definition
Epidemiology
• Pathogenesis
• Diagnosis
• Treatment
• Prognosis
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#1 transfusion-related mortality
• >Infection
• >ABO mismatch
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Under recognized / reported
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Mortality 5-10%
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PRBC  1 in 5000
Plasma  1 in 2000
Platelets  1 in 2000
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IVIG
Cryoprecipitate
Stem cells
HOST
M=F
• Recent surgery
• Active infections
• Recent transfusion
• Cytokine treatment
• Thrombocytopenia
• Increased age
• Ethanol use
• Tobacco
• Severe illness
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DONOR
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Multi-parous female donors
Prolonged blood storage
Definition
• Epidemiology
Pathogenesis
• Diagnosis
• Treatment
• Prognosis
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1. Anti-granulocyte antibody
2. Endothelial-cell priming
3. “Two-hit” hypothesis
Definition
• Epidemiology
• Pathogenesis
Diagnosis
• Treatment
• Prognosis
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Mild symptoms
Death
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Fever
• No S3
Dyspnea
• Frothy sputum
Tachypnea
• Cough
Tachycardia
• No JVD
Hypotension
• No cardiomegaly
Hypertension
• Non-cardiac edema
No lung findings • Leukopenia
Crackles
• Thrombocytpoenia
Retractions
• Hyponatremia
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<6 hours
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Hypoxemia
• P/F <300
• O2sat <90%
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B/l infiltrates
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No evidence of HF
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Aspiration
Pneumonia
Toxic inhalation
Lung contusion
Near drowning
Severe sepsis
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Shock
Trauma
Burns
Pancreatitis
Bypass surgery
Drug overdose
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CHF
Nephrotic syndrome
Fluid overload
• Post-sepsis
• ESRD
• AKI
• Frothy sputum
• Hypoxia
• Tachycardia
• Hypotension
• Fever
• CXR
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Rare and subtle diagnosis
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Subtlety is your specialty
• Notice changes first
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Key to diagnosis
Stick to your guns
Definition
• Pathogenesis
• Epidemiology
• Diagnosis
Treatment
• Prognosis
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Stop transfusion!
• Report reaction
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Supportive Care
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Hemodynamic support
• Fluids +/- pressors
• No diuresis!
• “Wet” CXR  confusing
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Ventilatory support
• NIPPV vs. Intubate
• Lung protective strategy
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Need transfusion?
• Single donor units
• Leukodepleted blood
• Newer blood
Definition
• Pathogenesis
• Epidemiology
• Diagnosis
• Treatment
Prognosis
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Live
Die
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Recovery  24 – 96
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No long-term sequelae
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CXR lingers
Transfusion + Clinical decline =
TRALI
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What is the #1 cause of #1 transfusion related
mortality?
What transfusion reaction is very under
reported and under-recognized?
What can any blood product cause?
What should you think about if there is any
clinical change within 6 hours of transfusion?
Who is the most important person to
recognize TRALI?
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Supportive  Good prognosis
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Question all transfusions!