TRALI TRANSFUSION RELATED ACUTE LUNG INJURY

Italo E. Vsquez Vargas R2 EMG Hospital Nacional Arzobispo Loayza

TRALI Transfusion related acute lung injury

DEFINITION

TRALI EL CONCEPTO
Sndrome clnico que se presenta como hipoxemia aguda y edema pulmonar no cardiognico durante o tras una transfusin de productos hemticos.

EVOLUCIN HISTRICA
1957.

Transfusin de 50 ml de sangre total de un paciente que contena leucoaglutininas.

Fiebre, hipotensin, insuficiencia respiratoria, infiltrado pulmonar bilateral en la radiologa de trax y leucopenia transitoria.
Recuperacin completa en 3 das.
Brittingham TE, Chaplin H Jr. Febrile transfusion reactions caused by sensitivity to donor leuckocytes and platelets. JAMA 1957;165:819-825

EVOLUCIN HISTRICA
1966: Primera serie de casos: Philipps E, Fleischner FG. Pulmonary edema in the course of a blood transfusion without over-loading the circulation. Dis Chest 1966;50:619-23 1970-1971: Leucoaglutininas a antigenos HLA y no HLA como agentes etiolgicos: Ward HN. Pulmonary infiltrates associated with leukoagglutinin transfusion reactions. Ann Intern Med 1970;73:689-694. Thompson JS et al. Pulmonary hypersensitivity reactions induced by transfusion of non-HLA leukoagglutinins. N Engl J Med 1971;284;1120-5.

1985: TRANSFUSION

RELATED ACUTE LUNG INJURY

36 casos entre 1982-84 (mayoritariamente quirrgicos 31-).

TRALI: dificultad respiratoria, hipoxemia, e hipotensin sin causa hemodinmica y entre 1-6 horas tras la transfusin de componentes sanguneos. En el 72% de los casos se precis ventilacin mecnica. Resolucin: 81% en 96 horas.

Mortalidad: 6%

Popovsky MA, Moore SB. Diagnostic and pathogenetic considerations in transfusion-related acute lung injury. Transfusion 1985;25:573-577.

DEFINITION NHLBI 2003 WORKING GROUP ON TRALI

Toy P, Popovsky MA, Abraham E, Ambruso DR, Holness LG, Kopko PM, et al. National Heart, Lung and Blood Institute working group on TRALI, Transfusion-related acute lung injury: Definition and review. Crit Care Med. 2005;33:7216.

2004 CANADIAN BLOOD SERVICE & HEMA QUEBEC

Kleinman S, Caulfield T, Chan P, Davenport R, McFarland J, McPhedran S, et al. Toward an understanding of transfusion-related lung injury: Statement of a consensus panel.Transfusion. 2004;44:177489.

DEFINITION

Marik PE, Corwin HL. Acute lung injury following to transfusion: Expanding the definition. Crit Care Med. 2008;36:30804.

DEFINITION

Marik PE, Corwin HL. Acute lung injury following to transfusion: Expanding the definition. Crit Care Med. 2008;36:30804.

LIMITACIONES DE LA DEFINICIN
Slo identifica casos nuevos y graves de hipoxemia . Las formas leves de TRALI (ej: SaO2>90% respirando aire ambiente) no se incluiran. Se necesita fijar criterios de empeoramiento

LIMITACIONES DE LA DEFINICIN
El diagnostico de TRALI en pacientes con otros factores de riesgo de LPA requiere una experta valoracin y an as existen casos indeterminados La definicin no incluye pruebas de laboratorio El lmite de 6 horas puede no detectar casos que se desarrollen ms tarde.

ANNUAL REPORT 2010

DEFINITION
SERIOUS HAZARDS OF TRANSFUSION (SHOT) DEFINITION Acute dyspnea with hypoxia and bilateral pulmonary infiltrates during or within six hours of transfusion, not due to circulatory overload or other likely cause

TRALI Transfusion related acute lung injury

EPIDEMIOLOGA

Casos de probable lesin pulmonar aguda producida por transfusin y muertes atribuidas, publicados por ao. Tomado de Serious Hazards Of Transfusion. Annual report 2010 (URL: www.shotuk.org).

EPIDEMIOLOGIA
Transfusion related deaths by events 1996-2009

RIESGO DE TRALI

TRALI

RIESGO DE TRALI

An JM et al. Lesin pulmonar aguda producida por transfusin. Med Intensiva.2010;34(2):139149

TRALI Transfusion related acute lung injury

HEMOVIGILANCIA

DEFINIENDO: SHOTs
IBCT: Incorrect blood/component transfused ATR: Acute Transfusion Reaction DTR: Delayed Transfusion Reaction TA-GvHD: Transfusion-Associated Graftversus-Host Disease TTI: Transfusion Transmitted Infection TRALI: Transfusion Related Acute Lung Injury TAD: Transfusion-Associated Dyspnoea HSE: Handling and Storage Errors Autoloogus: Autologous Transfusion TACO: Transfusion-Associated Circulatory Overload HTR: Haemolytic Transfusion Reactions I&U: Inappropriate, Unnecessary and Under/Delayed Transfusion

TRENDS IN REPORT TYPES 19962010

TRENDS IN REPORT TYPES 19962010

TRALI Transfusion related acute lung injury

FISIOPATOLOGA

PATHOPHYSIOLOGY

Modificado de Swanson K, Dwyre DM, Krochmal J, Raife TJ.Transfusion-related acute lung injury (TRALI): Current clinical and pathophysiologic considerations. Lung.2006;184:17785.

PATHOPHYSIOLOGY

Leukocyte Antibodies

Neutrophil in pulmonary capillary pulmonar damage & capillary leak Antibody to donor leukocyte Ab to HLA I, II, granulocyte, monocyte, IgA Transient leukopenia
Patients condition

Biologically Active Substance

Sepsis, surgery Lipid & cytokines Ab: 3.6% of TRALI reaction

Active substance

C = complement; HLA = human leukocyte antigen; IL = interleukin; LPS = lysophosphatidil choline; PAF = platelet activating factor; TNF = tumor necrosis factor; 5b, NA, NB = neutrophil antigens

TRALI Transfusion related acute lung injury

CLINICAL FEATURES

A CLASSICAL CASE
Teenage boy with history of liver disease transfused with female apheresis platelets for an elective surgical procedure.

Developed hypoxia, hypotension and pyrexia within 30 minutes of transfusion. Hb increased from 8g/dl before procedure to 18 after.
Required cardio-respiratory support on ITU but full subsequent recovery.

30 POST TRANSFUSION TRALI

4H POST TRANSFUSION (TRALI)

20H POST TRANSFUSION (TRALI)

TRALI Transfusion related acute lung injury

DIAGNSTICO DIFERENCIAL

Boshkov LK. Transfusion-related acute lung injury and the ICU. Crit CareClin.2005;21:47995.

DIFFERENTIAL DIAGNOSIS IN SUSPECTED TRALI

Pulmonary edema due to circulatory overload (TACO). ALI due to other causes

Other causes of bilateral infiltrates

Other transfusion related adverse events: eg bacterial contamination

TRALI vs. TACO

TRALI Transfusion related acute lung injury

MANEJO

TRATAMIENTO

Soporte hemodinmico Compromiso Soporte ventilatorio respiratorio

grave Compromiso respiratorio moderado

LPA/SDRA de otra etiologa

Compromiso respiratorio leve

Subclnico

SUGGESTED CLINICAL MANAGEMENT OF SUSPECTED TRALI

Boshkov LK. Transfusion-related acute lung injury and the ICU. Crit CareClin.2005;21:47995.

SUGGESTED CLINICAL MANAGEMENT OF SUSPECTED TRALI

Boshkov LK. Transfusion-related acute lung injury and the ICU. Crit CareClin.2005;21:47995.

SUGGESTED CLINICAL MANAGEMENT OF SUSPECTED TRALI

Boshkov LK. Transfusion-related acute lung injury and the ICU. Crit CareClin.2005;21:47995.

TRALI Transfusion related acute lung injury

PREVENTION

PREVENCIN DE LA LESIN PULMONAR AGUDA PRODUCIDA POR TRANSFUSIN

An JM et al. Lesin pulmonar aguda producida por transfusin. Med Intensiva.2010;34(2):139149

POLTICA DE EXCLUSIN DE DONANTES

Mujeres con embarazos previos Donantes implicados en casos de TRALI

An JM et al. Lesin pulmonar aguda producida por transfusin. Med Intensiva.2010;34(2):139149

POLTICA DE EXCLUSIN DE DONANTES

Mujeres con embarazos previos: formacin de Ac como resultado de exposicin a Ag leucocitarios durante el embarazo 55% de las mujeres pueden presentar leucoaglutininas hasta 8 aos tras la ltima exposicin.

Wright et al. Acute lung injury after ruptured abdominal aortic aneurysm repair: the effect of excluding donations from females from the production of fresh frozen plasma. Crit Care Med 2008; 36:17961802 La exclusin de mujeres donantes redujo LPA del 36% al 21% (p=0,04) en pacientes que recibieron mltiples transfusiones por reparacin quirrgica de rotura de Ao abdominal

Vlaar et al. Preventing TRALI: Ladies first, what follows?. Crit Care Med 2008; 36: 3283-3284 Exclusin de mujeres donantes. Investigacin de posible TRALI antes y despus. Resultado: Disminucin de posible TRALI despus de la exclusin (n=6) comparado con un periodo de tiempo similiar previo a la misma (n=17) (p<0,03)

ACTUACIN SOBRE EL ALMACENAMIENTO

1. Uso de productos hemticos depleccionados de leucocitos (leucorreduccin).

2. Uso de concentrados de hemates < 14 das de almacenamiento.

3. Plaquetas obtenidas por afresis (< 3 das)

An JM et al. Lesin pulmonar aguda producida por transfusin. Med Intensiva.2010;34(2):139149

Hebert PC et al. Clinical outcomes following institution of the canadian Universal leukoreduction program for red blood cell transfusions. JAMA 2003; 289:1941-1949.

N: 14.786 pacientes. 6.982 periodo control. 7.804 leucorreduccin

Disminucin de la mortalidad tras la instauracin del programa de leucorreduccin comparado con el periodo control (6,19% vs 7,03% p=0,04)

EVITAR LAS TRANSFUSIONES INNECESARIAS

TRALI Transfusion related acute lung injury

CONCLUSIONES

CONCLUSIONES
TRALI constituye hoy da una de las ms graves complicaciones de la transfusin de productos hemticos. Aunque se ha progresado en el conocimiento de su fisiopatologa y su clnica todava quedan preguntas sin responder. Se necesita una estrecha colaboracin entre: clnicos-servicios de hematologa-redes de hemovigilancia para establecer medidas de prevencin.

La Lesin Pulmonar Aguda por Transfusin (TRALI) se ha convertido en algo demasiado importante como para no tenerla en cuenta

GRACIAS