Ver el código de «Transfusion-related acute lung injury»

==Background==
[[File:Lung and diaphragm.jpg|thumb|Lobes of the lung with related anatomy.]]
===Epidemiology===
*Leading cause of transfusion related mortality in the US – 5-8% <ref>Fatalities Reported to FDA Following Blood Collection and Transfusion: Annual Summary for Fiscal Year 2011. Available at www.fda/gov/biologicsbloodvaccines/safetyavailability/reportaproblem/transfusiondonationfatalities/ucm302847.htm</ref><ref name="sixteen">Looney MR, et al. Transfusion-related acute lung injury: a review. Chest. 2004;126:249</ref>
*Occurs at a rate of 0.04-0.1%, or 1/5000, transfused blood components <ref name="four">Silliman CC, et al. Transfusion-related acute lung injury: epidemiology and a prospective analysis of etiologic factors. Blood. 2003;101:454</ref><ref>Popovsky MA, et al. Diagnostic and pathogenietic considerations in transfusion-related acute lung injury. Transfusion. 1985;25:573</ref><ref>Wallis JP. Transfusion-related acute lung injury (TRALI) - under-diagnosed and under-reported. Br J Anaesth. 2003;90:573</ref><ref name="seven">Rana R, et al. Transfusion-related acute lung injury and pulmonary edema in critically ill patients: a retrospective study. Transfusion. 2006;46:1478</ref>
**Higher in critically ill

===Pathophysiology===
*Two-hit mechanism <ref name="four"></ref><ref>Sillman CC. The two-event model of transfusion-related acute lung injury. Crit Care Med. 2006;34:S124</ref><ref>Bux J, et al. The pathogenesis of transfusion-related acute lung injury (TRALI). Br J Haematol. 2007;136:788</ref>
**Neutrophil sequestration and priming in lung microvasculature
**Recipient neutrophil activation by factor in the blood product (i.e. antibodies in blood component directed at recipient antigens, bioactive lipids, etc.)
***Neutrophils release cytokines, reactive oxygen species, etc. that damage pulmonary capillary endothelium
****Leads to inflammatory pulmonary edema

===Risk factors===
====Recipient factors<ref name ="twelve">Vlaar AP, et al. Risk factors and outcome of transfusion-related acute lung injury in the critically ill: a nested case-control study. Crit Care Med. 2007;176:886</ref><ref name="thirteen">Gajic O, et al. Transfusion-related acute lung injury in the critically ill: prospective nested case-control study. Am J Respir Crit Care Med. 2007;176:886</ref><ref name="fifteen">Toy P, et al. Transfusion-related acute lung injury: incidence and risk factors. Blood. 2012;119:1757</ref><ref>Benson AB, et al. Transfusion-related acute lung injury in ICU patients admitted with gastrointestinal bleeding. Intensive Care Med. 2010;36:1710</ref>====
*Liver disease
*Hematologic malignancy
*[[Ethanol toxicity|Alcohol abuse]]
*High peak airway pressures on mechanical ventilation
*Current smoking
*Positive fluid balance
*[[Massive transfusion]]
*Critical illness
*[[Sepsis]]
*[[Shock]]

====Blood component factors<ref name="fifteen"></ref>====
*Plasma or whole blood from female donor
*Volume of HLA class II antibody reactive to recipient HLA antigen
*Volume of transfused anti-human neutrophil antigen antibody
*Highest risk components (though can occur with any, including pRBC)
**Plasma
**Apheresis platelet concentrates
**Whole blood

==Clinical Features==
*Acute onset hypoxemic respiratory failure due to non-cardiogenic pulmonary edema occurring during or shortly after transfusion
**Majority of cases present within minutes of initiating transfusion <ref name="four"></ref>
**Some present 1-2 hours post-transfusion and up to 6 hours after <ref name="one">Kleinman S, et al. Toward an understanding of transfusion-related acute lung injury: statement of a consensus panel. Transfusion. 2004;44:1774</ref><ref>Sillman CC, et al. Transfusion-related acute lung injury. Blood. 2005;105:2266</ref>
*Most common signs/symptoms<ref>van Stein D, et al. Transfusion-related acute lung injury reports in the Netherlands: an observational study. Transfusion. 2010;50:213</ref>
**[[Hypoxemia]]
**New pulmonary infiltrates
**Pink frothy secretions via ETT
**[[Fever]] (as opposed to [[TACO]], where fever is uncommon)
**[[Hypotension]]
**Cyanosis
*Other Symptoms
**[[Tachypnea]]
**[[Tachycardia]]
**Elevated peak/plateau pressures on ventilator
**Transient drip in peripheral neutrophil count (from neutrophil sequestration in lung)

==Differential Diagnosis==
{{Transfusion reaction types}}

{{Acute Allergic DDX}}

==Evaluation==
[[File:Transfusion-related acute lung injury chest X-ray.gif|thumb|Chest X-ray of transfusion-related acute lung injury (TRALI syndrome) compared to chest X-ray of the same subject afterwards.]]
===Workup===
*ABG
*[[CXR]]
*Rule out other possible etiologies (i.e. CHF, TACO, anaphylaxis, sepsis, etc.)

===Diagnosis===
*Clinical diagnosis
**Consider in any patient during/post-transfusion who develops hypoxemic respiratory insufficiency
**Diagnostic criteria (NHLBI working group and Canadian Consensus Conference on TRALI): <ref name="one"></ref><ref>Toy P, et al. Transfusion-related acute lung injury: definition and review. Crit Care Med. 2005;33:721</ref>

===[[TRALI]] and Possible TRALI===
*ALI/[[ARDS]] risk factor*- aspiration, toxic inhalation, pneumonia, pulmonary contusion, near drowning, shock, severe sepsis, multiple trauma, burn injury, acute pancreatitis, cardiopulmonary bypass, drug overdose
**Diagnosis of "possible TRALI" (aka "transfused ARDS") made when temporal relationship to an alternative cause for ARDS exists

{{TRALI vs TACO}}

==Management==
*STOP the transfusion and report to the blood bank for transfusion reaction work-up
**Typically includes CBC, bilirubin, haptaglobin, direct Coombs test, BNP, HLA antigen typing
*Supportive care (i.e. treat like ARDS)
**[[O2]] supplementation
**[[NIPPV|NIV]] pressure support or [[mechanical ventilation]]
***If mechanical ventilation required, ARDSnet guidelines for ventilator management
**BP support
**Consider [[diuretics|diuresis]] ''only'' after demonstrated hemodynamic stability 
***'''no early empiric administration''' - associated with hypotension <ref name="sixteen"></ref><ref>Levy GJ, et al. Transfusion-associated non-cardiogenic pulmonary edema. Report of a case and warning regarding treatment. Transfusion. 1986;26:278</ref>
**[[ECMO]] <ref>Worsley MH, et al. Non-cardiogenic pulmonary edema after transfusion with granulocyte antibody containing blood: treatment with extracorporeal membrane oxygenation. Br J Anaesth. 1991;67:116</ref>
*Additional transfusions
**For those who recover, no increased risk for recurrent episode from other donors
***Transfusion of needed blood products from other donors should not be withheld

==Disposition==
*Majority require ICU admission and mechanical ventilation <ref name="twelve"></ref>
**Mean duration of mechanical ventilation 40 hours, upwards of 10 days <ref name="four"></ref><ref name="twelve"></ref>

==Prognosis==
*Mortality
**Non-critically ill with TRALI - 5-7% <ref>Looney MR, et al. Prospective study on the clinical course and outcomes in transfusion-related acute lung injury. Crit Care Med. 2014;42:1676</ref><ref>Popovsky MA, et al. Transfusion-related acute lung injury: a neglected serious complication of hemotherapy. Transfusion. 1992;32:589</ref><ref>Sillman CC, et al. Transfusion-related acute lung injury (TRALI): current concepts and misconceptions. Blood Rev. 2009;23:245</ref>
**Critically ill with TRALI - 41-67% <ref name="seven"></ref><ref name="twelve"></ref><ref name="thirteen"></ref><ref>Wallis JP, et al. Single hospital experience of TRALI. Transfusion. 2003;43:1053</ref>

==See Also==
*[[Transfusion reaction]]

==External Links==

==References==
<references/>

[[Category:Pulmonary]]