TACO and TRALI: visualising transfusion lung injury on plain film

Supportive treatment for TRALI includes supplemental oxygen, judicious fluid administration and in severe instances ventilatory and pharmacologic pressure ... Skiptomaincontent YouarehereHome Archive Volume13, Issue4 TACOandTRALI:visualisingtransfusionlunginjuryonplainfilm Emailalerts ArticleText Articlemenu ArticleText Articleinfo CitationTools Share RapidResponses Articlemetrics Alerts PDF XML Imagesin… TACOandTRALI:visualisingtransfusionlunginjuryonplainfilm CarolineEMurphy,ColinMKennyandKevinFBrownTriplerArmyMedicalCenter,Tripler,Hawaii,USACorrespondencetoDr CarolineE Murphy,caroline.e.murphy.mil{at}mail.mil http://dx.doi.org/10.1136/bcr-2019-230426 StatisticsfromAltmetric.com respiratorysystemintensivecareadultintensivecareDescriptionA63-year-oldwomanwithpoorlycontrolledtype2diabetesmellituswasadmittedtotheintensivecareunitforincreasedrespiratorysupportfollowinglarge-volumefluidadministrationtotreatdiabeticketoacidosis.Thepatientwasintubatedanddiagnosedwithmildacuterespiratorydistresssyndrome;theclinicalstatuswasimprovingwhenaunitofbloodwasadministeredforchronicanaemia.Tenminutesintobloodadministration,thepatientbecameacutelyhypoxic(SpO270%)andhypertensive(200/100 mm Hg).Administrationwashalted,andastatchestX-ray(CXR)obtained.Clinicalexaminationwasnotableforprominentjugularvenousdistension,unremarkableonearlierexamination.AmorningCXRobtained90 minprior(figure1)wascomparedwiththeoneobtainedpost-reaction(figure2),demonstratingsudden,dramaticworseningofbilaterallungopacities.Supportivecarewasinitiatedwithoxygenanddiuresis,andthesymptomsresolved30minfollowingcessationofbloodproductadministration.Investigationofbloodproductsforhumanleukocyteantigen(HLA) antibodies andhumanneutrophilantigen(HNA)antibodieswasinitiatedandultimatelywasnegative.Itwasdeterminedthattheclinicalpresentationandsymptomsweremostconsistentwithtransfusion-associatedcirculatoryoverload(TACO).Downloadfigure Openinnewtab Downloadpowerpoint Figure1Portableanteroposterior (AP)chestX-raypriortotransfusion.Diffusebilateralairspaceopacities. Downloadfigure Openinnewtab Downloadpowerpoint Figure2PortableAPchestX-raypost-transfusion.Completebilateralairspaceopacities.TACOandtransfusion-relatedacutelunginjury(TRALI)areacuterespiratorydistresssyndromesthatareoftendifficulttodistinguish.1SeveraldifferentclinicaldefinitionsofTACOandTRALIhavebeenproposedbyvarioussocieties.1However,unifyingthemesamongthemareacuterespiratorydistress,newonsethypoxemiaandbilateralpulmonaryinfiltratesonCXRthatoccurwithin6 hoursofabloodtransfusion.12TACOisthemostfrequentpulmonary-relatedtransfusioncomplicationandhasrecentlysurpassedTRALIastheleadingcauseoftransfusion-relatedfatalitiesintheUSA.3TheclinicalpresentationofTACOisrelatedtopulmonaryhydrostaticoedemaandincludesdyspnea,tachypnea,jugularvenousdistensionandelevatedsystolicbloodpressure.2Conversely,theclinicalpresentationofTRALIisrelatedtopulmonarypermeabilityoedema,thoughttooccursecondarytothereleaseofvariousleucocyteinterleukins,andmayincludefever,hypotension,tachycardiaandrarelyatransientdropintheperipheralneutrophilcount,thoughthesefeaturesareoftennotpresent.2B-typenatriureticpeptide(BNP)maybeadistinguishingbiomarker,asincreasedmyocardialstretchinginTACOcanbeassessedwithanincreaseinpre-transfusiontopost-transfusionBNP.2Frustratingly,treatmentissupportiveforbothsyndromes.Whenanytransfusionlunginjuryissuspected,thetransfusionshouldbeimmediatelystopped.WhenTACOissuspected,treatmentincludessupplementaloxygen,diuresisandassistedventilationwhenindicated.SupportivetreatmentforTRALIincludessupplementaloxygen,judiciousfluidadministrationandinsevereinstancesventilatoryandpharmacologicpressuresupport.StrategiestopreventTACOincludescreeningtransfusionrecipientsforoccultcardiacinsufficiencyandreducingthevolumeandrateoftransfusions.1StrategiestopreventTRALIincludeincreaseddonorHLAantibodyscreening,usingmaleonlyplasmadonors,anddonordeferralbasedonhistoryoftransfusion.1TheseTRALImitigationstrategieshavedrasticallyreducedtheincidenceofTRALIwith35casesin2006comparedwith9cases in2017,asreportedbytheFoodandDrugAdministration.3Cliniciansshouldbeawareof TRALIandTACOandstrategiestoavoidthesecomplicationspriortoorderingbloodtransfusions. LearningpointsTransfusion-associatedcirculatoryoverload(TACO)andtransfusion-relatedacutelunginjury(TRALI)areacuterespiratorydistresssyndromeswhichoccurwithin6 hoursofabloodtransfusionandassociatedwithhighmortality.TreatmentofTACOandTRALIislargelysupportivebutintubationwithpharmacologicpressuresupportmayberequired.TheincidenceofTRALIcanbereducedwithincreaseddonorscreening.TheincidenceofTACOcanbereducedwithincreasedrecipientscreening.References↵SempleJW,RebetzJ,KapurR.Transfusion-associatedcirculatoryoverloadandtransfusion-relatedacutelunginjury.Blood2019;133:1840–53.doi:10.1182/blood-2018-10-860809OpenUrlAbstract/FREEFullText↵GajicO,GropperMA,HubmayrRD.Pulmonaryedemaaftertransfusion:howtodifferentiatetransfusion-associatedcirculatoryoverloadfromtransfusion-relatedacutelunginjury.CritCareMed2006;34(5Suppl):S109–13.doi:10.1097/01.CCM.0000214311.56231.23OpenUrlCrossRefPubMedWebofScience↵FatalitiesReportedtoFoodandDrugAdministration(FDA)FollowingBloodCollectionandTransfusion;AnnualSummaryforFiscalYear2017.2019www.fda.gov/media/124796/downloads. FootnotesContributorsCMKcontributedtothemanuscript.CEMtreatedthepatientandcontributedtothemanuscript.KFBprovidededits.FundingTheauthorshavenotdeclaredaspecificgrantforthisresearchfromanyfundingagencyinthepublic,commercialornot-for-profitsectors.CompetinginterestsNonedeclared.ProvenanceandpeerreviewNotcommissioned;externallypeerreviewed.PatientconsentforpublicationNotrequired. RequestPermissions IfyouwishtoreuseanyorallofthisarticlepleaseusethelinkbelowwhichwilltakeyoutotheCopyrightClearanceCenter’sRightsLinkservice.Youwillbeabletogetaquickpriceandinstantpermissiontoreusethecontentinmanydifferentways. 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