Journal of Medicine Vol 2 - Amrita Institute of Medical Sciences and ...

Amrita Journal of Medicine
CASE REPORT
Transfusion-related Acute Lung Injury:
A Case Report and Review of Recent Advances
S. Sharma, A.Gauhar, D.K. VijayKumar, J. Paul*
ABSTRACT
Transfusion-related acute lung injury (TRALI) is an emerging as a common cause of transfusion related adverse events. However the awareness
about this entity in medical fraternity is low and consequently it is an under diagnosed and very underreported complication of transfusion
therapy. We report a case of 46-year old lady who developed acute hemodynamic and respiratory instability following a single unit blood
transfusion in the postoperative period. She responded to symptomatic management with vasopressor and ventilator support. The diagnosis of
TRALI relies on excluding other diagnoses such as sepsis, volume overload, and cardiogenic pulmonary edema. All plasma-containing blood
products have been implicated in TRALI, with the majority of cases linked to whole blood, packed RBCs, platelets, and fresh-frozen plasma.
The pathogenesis of TRALI may be explained by a “two-hit” hypothesis, involving priming of the inflammatory machinery and then activation
of this primed mechanism. Treatment is supportive, with a prognosis substantially better than most causes of clinical acute lung injury.
KEY WORDS: Transfusion-related; acute lung injury, blood transfusion, acute respiratory distress syndrome; non-cardiogenic pulmonary
edema.
KEY MESSAGES: The article is written with an intention to spread awareness among the medical fraternity to this often missed, misdiagnosed
entity that is more frequent than we would like ourselves to believe.
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INTRODUCTION
Transfusion related acute lung injury
(TRALI) is a frequently
misdiagnosed, yet potentially fatal
reaction following transfusion of blood
products. There is a lot of confusion
in the literature regarding this entity
because till recently there was no uniform
nomenclature, definition or
diagnostic features described in relation
to it.
We describe a case report of TRALI,
not because it is infrequent, unique
or has never been described before,
but to familiarize our colleagues with
it. The intention of this article is to
compile available information to selfeducate
ourselves to a potentially
preventable life-threatening condition
and the current guidelines for its management.
CASE HISTORY
A 46-year-old lady, who had undergone
surgery for ovarian
Dept. of Surgical Oncology, AIMS, Kochi.
* Dept. of Anaesthesia, AIMS, Kochi.
malignancy, reported breathlessness on
the first post-operative day. Her complaints
had started within 20-25
minutes of completion of a transfusion
of single unit of packed red blood
cells (PRBC). She also had chest discomfort
and rapidly progressed to
become unstable haemodynamically
with a falling oxygen saturation
(30/min),
and mild fever (100° F). Immediate
investigations done are shown in
Table1.
The patient required ventilatory
support with a positive end expiratory
pressure (PEEP) of 10 for 3 days along
with a hemodynamic support with
Dopamine, Dobutamine and Noradrenaline
(these could be tapered and
withdrawn within the next 48 hours).
The initial differential diagnosis
was between a transfusion mismatch,
myocardial infarction, pulmonary
embolism or a fluid overload. Post
transfusion recipient and bag blood
sample were sent immediately to the
blood bank where a mismatch was
ruled out. Also patient had no typical
features of a cross match reaction like
bronchospasm, rashes, hemoglobinuria,
renal shutdown, or falling
hemoglobin levels, etc. Fluid overload
was ruled out in face of a normal CVP
and normal ECHO. A normal ECG,
normal ECHO and near normal cardiac
enzymes ruled out the possibility
of an acute myocardial ischemic
event. Pulmonary embolism was
eliminated from the differential diagnosis
on the basis of bilateral extensive
pulmonary infiltrates, normal D-
dimer values and no clinical signs of
deep vein thrombosis.
In this setting a possibility of
TRALI was raised. Patient’s clinical
features, course of events, response of
the acute episode to supportive management,
all were supportive of this
diagnosis.
The patient eventually recovered
from this acute reaction over next 5
days and was discharged to home on
the 10 th postoperative day.