A Suspected Case of TRALI

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A Suspected Case of TRALI
DR R. SIVASANKAR MO Blood Bank T.H. Jaffna
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Clinical History

• Ms. U.Urmila, 27 years old
• P3C2 _at_ 32 weeks POA
• ANC Jaffna _at_ 32 weeks ( Late visit)
• Fundal Ht gt POA Scan Twin (?Dichorionic)
• Pallor Hb 6 g/dl

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Management

• Haematology referral done
• Microcytic hypochromic anemia
• Suggested for two packs of blood transfusion
  with frusemide cover

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Management cont.

• Blood transfusion started _at_ 10.00 am
• Pt developed chills rigors with dyspnoea
  Spo2-80 -11.20am
• Managed _at_ ETU
• Pt intubated ventilated _at_ ICU

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Management cont.

• Hemorrhagic suction through the ET tube. Needed
  to suck out, interrupted ventilation.
• Developed Hypotension inotropics infusion started
  
• Supportive management cont.,but Pt died _at_ 3.30pm.

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Autopsy finding

• Severe lung injury with haemorrhagic pleural
  effusion

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Thank you
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Transfusion Related Acute Lung Injury - TRALI

• Not rare but under diagnosed
• A potently fatal condition
• Presents as pulmonary oedema
• Occurs within 1-4 hrs of starting transfusion

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Clinical Features

• Acute respiratory distress
• Fever with chills
• Non productive cough
• Cyanosis
• Hypotension
• Chest pain
• Bilateral pulmonary oedema
• Chest X ray bilateral pulmonary infiltrates in
  hilar region

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CXR in TRALI

• Bilateral pulmonary infiltrates
• in hilar region

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• Differential Diagnosis
• Other courses of pulmonary oedema
• Volume Overload
• Congestive heart failure
• Myocardial infarction

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Investigation for Suspected TRALI
Screen donor samples for HLA and granulocyte
antibodies Type patient WBC for HLA and
granulocyte antigens If antibody specificity is
not identified do crossmatch
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Pathophysiology

• Two different causes have been proposed
• Classical theory antibody mediated-Immune
  TRALI
• 2 Hit model-Non-immune TRALI

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Classical Theory(Immune TRALI)

• Donor antibodies react with patient neutrophils
• Neutrophils sequestrate in pulmonary vasculature
• Complement and cytokines liberated
• Damage to endothelium
• Results in pulmonary oedema

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Two Hit Theory(Non-immune TRALI)

• Predisposing Conditions
• Sepsis
• Surgery
• Haematological malignancies
• Trauma
• Pulmonary endothelial activation and neutrophil
  sequestration
• Lipids and WBC antibodies activate neutrophils
  which then causes endothelial damage

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Immune TRALI
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Non-immune TRALI
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Management - TRALI

• No specific treatment
• Largely supportive
• Respiratory support with O2
• Most cases require mechanical ventilation
• Steroids
• Clinical staff who administer transfusions must
  be aware how to diagnose manage promptly

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OUTCOME OF TRALI

• Prognosis - 80symptoms resolve within 96
  hour
• - 20protracted course
• - No residual damage
• Mortality - 5-10

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Further Transfusion Support for suspected TRALI
cases

• Leucodepleted SAGM RBCs less than 10 days old
• Apheresis from male donors 2 days old
• From male donors

• RBC
• Platelets
• FFP

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Action on implicated Donors

• Donors removal from panel
• Unused product recalled
• The donor should receive leucocyte depleted blood
  products if required for a blood transfusion