The Science Journal of the American Association for Respiratory Care

2009 OPEN FORUM Abstracts

TRANSFUSION RELATED ACUTE LUNG INJURY: A COMPLEX CASE STUDY

Damien P. Beilman1, Mark L. Wencel2,1, Donald G. Vasquez3, William M. Palko4; 1Respiratory Care, Wesly Medical Center, Wichita, KS; 2Pulmonary, Wichita Clinic, Wichita, KS; 3Trauma Services, Wesley Medical Center, Wichita, KS; 4Pathology/Blood Bank, Wesley Medical Center, Wichita, KS

Introduction: First identified in 1951(1), transfusion-related acute lung injury (TRALI) is a rare, but potentially fatal adverse event that affects about 1 in 5000 patients who receive transfusions.(2) TRALI is characterized by the sudden onset of respiratory failure, severe hypoxemia and pulmonary edema despite normal cardiac function.(2) We present a case in a surgical patient to bring to light the pulmonary challenges and complications with TRALI. Case Summary: A 24-year-old female, gravida 2, para 0, patient was admitted from an outlying facility, status post resection of an ectopic pregnancy with acute pulmonary edema and hypoxemia requiring mechanical ventilation with a PEEP of 24 cmH2O. Patient had received 6 units of red blood cells and 2 plaetletpheresis packs. Human leukocyte antigen (HLA) antibody screen was positive. Chest radiograph revealed ARDS. Despite aggressive mechanical ventilation hypoxemia persisted with PaO2 47 mmHg. Ventilator mode was changed to APRV with PEEP 37/0 and PaO2 improved to 126 mmHg. Ventilatory status slowly improved, but patient’s clinical course was complex and included complications of septic superficial thrombophlebitis, thrombosis of the superior vena caval catheter, right atrium and right pulmonary artery, pericardial effusion, right pneumothorax, systemic inflammatory response syndrome, and excision of right median basilica vein. Patient had a tracheostomy tube placed. Length of stay was 51 days. Patient was discharged to a LTAC hospital where she was liberated from mechanical ventilation, received rehabilitation and was discharged home. Discussion: Two basic mechanisms have been proposed for immunocompetent hosts. One hypothesis is TRALI is secondary to a single antibody-mediated event involving HLA antibodies.(3,4) Stronger data suggests that TRALI is a multi-factorial syndrome occuring when a patient is at increased risk for transfusion reaction.(5) Activation of the pulmonary endothelium resulting in polymorphonuclear neutrophil (PMN) sequestration occurs first followed by activation of primed PMNs resulting in endothelial damage, capillary leak and ALI. This case illustrates the importance of recognizing the complications that can occur with transfusion and that unless a patient is symptomatic for anemia, the benefits of transfusion should be carefully weighed against the risks.(5) Sponsored Research - None

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