SHOT Annual Report 2009 - Serious Hazards of Transfusion
SHOT Annual Report 2009 - Serious Hazards of Transfusion
SHOT Annual Report 2009 - Serious Hazards of Transfusion
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13. <strong>Transfusion</strong>-Related Acute Lung Injury (TRALI)<br />
Definition<br />
<strong>Transfusion</strong>-related acute lung injury (TRALI) is defined as acute dyspnoea with hypoxia and bilateral pulmonary<br />
infiltrates during or within 6 hours <strong>of</strong> transfusion, not due to circulatory overload or other likely causes.<br />
DATA SUMMARY<br />
Total number <strong>of</strong> cases 21 Implicated components Mortality/morbidity<br />
Highly likely/probable 9 Red cells 2 Deaths due to transfusion 0<br />
Possible/unlikely 12 FFP 2<br />
Deaths in which reaction was<br />
implicated<br />
Platelets 3 Major morbidity 18<br />
Red cells and cryo 1<br />
2<br />
Unknown 13<br />
Gender<br />
Age<br />
Emergency vs. routine and core<br />
hours vs. out <strong>of</strong> core hours<br />
Where transfusion took place<br />
Male<br />
Female<br />
Unknown<br />
9<br />
12<br />
0<br />
18 years+<br />
16 years+ to 18 years<br />
1 year+ to 16 years<br />
28 days+ to 1 year<br />
Birth to 28 days<br />
Unknown<br />
Total<br />
19<br />
2<br />
0<br />
0<br />
0<br />
0<br />
21<br />
Emergency<br />
Routine<br />
Not known<br />
In core hours<br />
Out <strong>of</strong> core hours<br />
Not known/applicable<br />
21<br />
21<br />
ED<br />
Theatre<br />
ITU/NNU/HDU/Recovery<br />
Wards<br />
Community<br />
Outpatient/day unit<br />
Not known 21<br />
In all, 32 questionnaires were received in <strong>2009</strong>: 7 were transferred to other categories – 5 to TACO, 1 to TAD and 1 to<br />
ATR – and 4 were withdrawn, leaving 21 reports in this section.<br />
Two <strong>of</strong> the 4 withdrawn cases were withdrawn by the hospital reporter. One occurred before transfusion and the other<br />
was found to have bronchopneumonia. The other 2 cases were withdrawn by the analyst because they did not meet<br />
the <strong>SHOT</strong> definition for TRALI:<br />
■■ 1 reaction occurred more than 6 hours after transfusion (12 to 24 hours) and there had been no change in<br />
respiratory status.<br />
■■ 1 patient with severe alcoholic liver disease developed worsening respiratory function before transfusion<br />
began. This patient had been treated with palliative care because <strong>of</strong> poor prognosis.<br />
Twenty-one cases were analysed and the assessed probability <strong>of</strong> TRALI is shown in Figure 15. Two patients died, 1 had<br />
probable TRALI after RBC (Case 1, page 113) and the other had possible TRALI after RBC and FFP (Case 3). All other<br />
patients recovered fully from the event. Seven <strong>of</strong> 21 analysed cases concerned late reporting <strong>of</strong> incidents which had<br />
occurred in 2008.<br />
13. <strong>Transfusion</strong>-Related Acute Lung Injury (TRALI) 107