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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 6  |  Issue : 2  |  Page : 119-122

Transfusion-related acute lung injury (TRALI) in post-partum bleeding patient: A case report


1 Department of Anesthesiology and Reanimation, Universitas Airlangga, Campus A, Jl. Mayjen Prof. Dr. Moestopo 47, Surabaya, Indonesia
2 Faculty of Medicine, Universitas Airlangga, Campus A, Jl. Mayjen Prof. Dr. Moestopo 47, Surabaya, Indonesia

Date of Submission06-Jan-2022
Date of Decision02-Mar-2022
Date of Acceptance11-Mar-2022
Date of Web Publication09-May-2022

Correspondence Address:
Dewi Rosita Hendriana
Faculty of Medicine, Universitas Airlangga, Campus A, Jl. Mayjen Prof. Dr. Moestopo 47, Surabaya
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjoa.bjoa_7_22

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  Abstract 

Transfusion-related acute lung injury (TRALI) is a rare but fatal complication of blood transfusion. However, it is frequently under-reported and not diagnosed. We reported a 32-year-old pregnant woman at 30/31 gestational weeks who developed acute respiratory distress and hemodynamic instability during transfusion in the post-operative period. Diagnosis of TRALI was made after excluding other possible causes of acute lung injury. We treated the patient with conservative treatment in the obstetrics emergency room based on the initial examination results and scheduled for an elective cesarean section (C-section). Transfusions of packed red blood cells were planned to increase the Hb level. The patient suddenly experienced shortness of breath during the transfusion with a relative risk of 30–36×/min. The patient was given 10 lpm oxygen via a non-rebreathing mask, and oxygen saturation was 86%. The patient’s blood pressure was 88/40 mmHg, and heart rate was 126×/min. The transfusion was immediately stopped. Fluid resuscitation with a crystalloid solution for hemodynamic improvement was given when the patient was intubated. After several treatments, the patient’s condition was getting better. On day 4, hemoglobin level increased to 9.1 mg/dL, hematocrit 27.6%, leukocytes 9.660/µL, and platelets 72,000/µL. Ventilator weaning was done gradually, and the patient was finally extubated on the 5th day of treatment.

Keywords: Acute lung injury, post-partum, pulmonary edema, transfusion, transfusion-related acute lung injury


How to cite this article:
Maulydia M, Airlangga PS, Siregar MI, Hendriana DR. Transfusion-related acute lung injury (TRALI) in post-partum bleeding patient: A case report. Bali J Anaesthesiol 2022;6:119-22

How to cite this URL:
Maulydia M, Airlangga PS, Siregar MI, Hendriana DR. Transfusion-related acute lung injury (TRALI) in post-partum bleeding patient: A case report. Bali J Anaesthesiol [serial online] 2022 [cited 2022 May 27];6:119-22. Available from: https://www.bjoaonline.com/text.asp?2022/6/2/119/344890




  Background Top


Transfusion-related acute lung injury (TRALI) is one of the severe complications of blood transfusion, the leading cause of the highest mortality. According to the Canadian Consensus Conference 2004, TRALI was defined based on the clinical and radiographic diagnosis as a recent ALI or acute respiratory distress syndrome (ARDS) condition that occurs during or within 6 h of completed transfusion.[1] TRALI incidence is estimated to occur in 15% of transfused patients.[2] Another study estimates the incidence of TRALI to be around 0.1% in transfused patients, however, up to 5–8% in groups of intensive care unit patients.[2],[3] According to a cohort study, the risk of transfusion reaction in post-partum patients is two-fold higher than that in non-pregnant women and those who had received three or more bags of red blood cells (RBCs) have a higher risk of developing TRALI.[4]


  Case Report Top


A woman, 32 years old, was referred from a district hospital with active vaginal bleeding. She is currently pregnant, a second child at 30/31 gestational weeks with placenta accrete and severe oligohydramnios. The patient had no history of hypertension and diabetes mellitus.

The patient’s condition was stable when examined at obstetrics ER at RSUD Dr. Soetomo. From the primary survey, patient’s airway was free, vesicular breath sounds were normal, and vital signs remained stable. The warm perfusion was obtained with a capillary refill time (CRT) of <2 s. At the same time, uterine fundal height was found following gestational age. Scanty active vaginal bleeding was found.

The patient received conservative treatment in the obstetrics ER based on the initial examination results. Dexamethasone 2 × 6 mg i.v. was given for lung maturation. The patient was scheduled for an elective cesarean section (C-section). However, on the 3rd day of conservative treatment, active vaginal bleeding occurred; hence emergency C-section was performed as soon as possible [Table 1].
Table 1: Laboratory results when the patient was admitted to the obstetrics ER

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The operation lasted for 4 h, and a hysterectomy was performed. Estimated blood loss during the operation was 4200 mL, about 93% of the patient’s estimated blood volume. The patient was given five bags of whole blood (WB), 1000 mL Gelofusine (B Braun, Indonesia), and 3500 mL of Ringer’s lactate and normal saline during the operation. No transfusion reaction was found. After the operation, the patient was admitted to the intensive care unit.

Postoperative day 0, the patient breathed spontaneously, respiratory rate 20×/min, SpO2 98% with 3 lpm oxygen via nasal cannula. The patient was fully aware, blood pressure 115/62 mmHg, heart rate 112×/min, and temperature 37.2oC. The patient underwent laboratory examination immediately after surgery.

Transfusion of packed RBCs (PRBCs) was planned to increase the Hb level. The patient suddenly experienced shortness of breath during the transfusion with a relative risk of 30–36×/min. The patient was given 10 lpm oxygen via a non-rebreathing mask (NRM), and oxygen saturation was 86%. The patient’s blood pressure was 88/40 mmHg, and heart rate was 126×/min. The transfusion was immediately stopped. Fluid resuscitation with a crystalloid solution for hemodynamic improvement was given when the patient was intubated. Also, a nasogastric tube was inserted [Table 2].
Table 2: Laboratory results post-operatively

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The patient breathed on a ventilator with pressure-controlled ventilation mode: pressure control at 18 cm H2O, positive end-expiratory pressure at 8 cm H2O, fraction of inspired oxygen (FiO2) 60%, respiration rate 20/min, and the vital signs were as follows: blood pressure of 108/72 mmHg, heart rate 112×/min, and warm perfusion with CRT less than 2 s. Norepinephrine 100 ng/h was given via infusion pump. Methylprednisolone 125 mg was given, besides fluid infusion and analgetic. Urine output in the last 3 h was 150 mL. The patient then immediately underwent a chest X-ray examination [Figure 1].
Figure 1: Chest X-ray showing bilateral lung infiltrate

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On the first day of treatment, the patient was still on the ventilator and under sedation. Vital signs were within normal limits, with norepinephrine 50 ng/h. Nutrition was started enterally and through maintenance infusion. The laboratory examination results showed that the hemoglobin level dropped to 6.1 mg/dL, hematocrit 19.5%, leukocyte 10,180/µL, and platelets 51,000/µL. Blood gas analysis showed average results. The patient was considered for transfusion with leukodepleted PRBCs.

Sedation was stopped on the second day, and Glasgow Coma Scale was 3 × 5. Norepinephrine administration was discontinued. Two bags of leukodepleted PRBCs were transfused safely. Evaluation on the third day of treatment showed that the hemoglobin level increased to 8.8 mg/dL, hematocrit 27.2%, leukocytes 9.660/µL, and platelets decreased to 19,000/µL. The patient then received a transfusion of thrombocyte concentrate at a dose of 10 mL/kg body weight.

The patient’s condition was getting better. On day 4, the hemoglobin level increased to 9.1 mg/dL, hematocrit 27.6%, leukocytes 9.660/µL, and platelets 72,000/µL. Ventilator weaning was done gradually, and the patient was finally extubated on the 5th day of treatment. Serial chest X-ray evaluations while the patient was in the intensive care unit are shown in [Figure 2].
Figure 2: From left to right: serial chest X-ray evaluation on the 3rd, 4th, and 5th day of treatment in the intensive care unit

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  Discussion Top


TRALI is a complex clinical syndrome that arises after transfusion of fresh frozen plasma, platelets, or PRBCs.[5] TRALI occurs approximately once in every 5000 transfusions.[6] However, the following years showed that numbers rose to 1 case in 4000 U transfused.[7]

The vast majority of TRALI cases after the transfusion of plasma are associated with antibodies in the transfused component. These antibodies are directed against human leukocyte antigens (HLAs) class I and class II or human neutrophil antigens (HNAs) present on the recipient’s cells. Antibodies to HLA class II and antibodies to HNA-3a are most frequently associated with TRALI.[8] A two-hit hypothesis applies in this clinical syndrome. Neutrophil sequestration occurs in the pulmonary vasculature, and neutrophils activate to damage the endothelial layer, causing leakage of protein, and fluid into the alveolar space became pulmonary edema.[9] Although it is known that a trace amount of plasma triggers TRALI pathogenesis, the relationship between the administered dose and the severity is not particular.

TRALI can be diagnosed by clinical and radiographic diagnosis and is not dependent on the results of a laboratory test or pathophysiologic mechanism. The chest radiograph should show bilateral infiltrates that may be patchy, homogeneous, diffuse, or asymmetric and suggestive of alveolar or interstitial disease. Our patient chest X-ray showed bilateral pulmonary infiltrates, suggesting pulmonary edema.

Hypoxemia in ALI can be defined as a ratio of the partial pressure oxygen to the fractional inspired oxygen concentration (PaO2/FiO2) of less than 300 mmHg or as oxygen saturation <90% when a patient is breathing on room air.[1] Oxygen saturation of our patient remained at 84% despite NRM 10 lpm, and PaO2/FiO2 showed 201 mmHg. The patient can develop a body temperature greater than 37°C or hypotension.[10] However, there was no significant increase in body temperature in our patient.

Differentiating TRALI from transfusion-associated circulatory overload (TACO) challenges clinicians. The National Healthcare Safety Network defined TACO as pulmonary edema primarily related to circulatory overload, including three or more of the following within 6 h of transfusion: acute respiratory distress, radiographic pulmonary edema, elevated central venous pressure, evidence of left heart failure, positive fluid balance, and elevated B-type natriuretic peptide. Some patients will have a history of congestive heart failure, decreased left ventricular ejection, or diastolic dysfunction.[11] Clinical evidence of hypoxemia in our patient who has not shown hypertension related to pulmonary edema or the left atrium led us to diagnose as TRALI.

There is no specific treatment for TRALI. Immediately, transfusion should be stopped, oxygen should be administered, the intravenous line should be kept open, and supportive therapy should be done. The patient’s vital signs should be monitored and recorded at 15-min intervals. In this case, we immediately stopped the transfusion after our patient experienced respiratory distress and gave supportive treatment, as explained earlier. In most cases, mechanical support is required.[12],[13] A low-tidal volume strategy is essential to minimize additional ventilator-induced lung injury.[14] However, we used a normal-tidal volume strategy for our patients.

We administered methylprednisolone 125 mg i.v. However, the efficacy of steroids is still controversial. High-dose steroids have been used, partly because of the assumption of an immunological cause, but there is no direct evidence of benefit.[6] Administration of diuretics is detrimental and should generally be avoided, as the pulmonary edema is not due to fluid overload.[15] Hence, we did not administer diuretics because we did not discover the signs of fluid overload in our patient. A post-transfusion blood sample should be drawn and sent to the laboratory.


  Conclusion Top


TRALI is a severe complication of transfusion. It is an underestimated healthcare problem. The effort to further decrease the risk of TRALI needs increased awareness of this syndrome among physicians. Appropriate and adequate supportive management will lower the morbidity and mortality of TRALI incidences.

Acknowledgment

Not applicable.

Financial support and sponsorship

Nil.

Conflicts of interest

The authors declared that there is no conflict of interest in this study.

Authors’ contribution

M, PSA, MITS, and DRH have made substantial contributions to the conception; design of the work; the acquisition, analysis, interpretation of data; the creation of new software used in the work; have drafted the work or substantively revised it.

Consent to participate

The authors certify that they have obtained all appropriate patient consent forms. In the form, the parents have given their consent for images and other clinical information to be reported in the journal. The family understand that names and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Ethical approval

Not applicable.



 
  References Top

1.
Kleinman S, Caulfield T, Chan P, Davenport R, McFarland J, McPhedran S, et al. Toward an understanding of transfusion-related acute lung injury: Statement of a consensus panel. Transfusion 2004;44:1774-89.  Back to cited text no. 1
    
2.
Bosboom JJ, Klanderman RB, Zijp M, Hollmann MW, Veelo DP, Binnekade JM, et al. Incidence, risk factors, and outcome of transfusion-associated circulatory overload in a mixed intensive care unit population: A nested case–control study. Transfusion 2018;58:498-506.  Back to cited text no. 2
    
3.
Gajic O, Rana R, Winters JL, Yilmaz M, Mendez JL, Rickman OB, et al. Transfusion-related acute lung injury in the critically ill: Prospective nested case–control study. Am J Respir Crit Care Med 2007;176:886-91.  Back to cited text no. 3
    
4.
Thurn L, Wikman A, Westgren M, Lindqvist PG. Incidence and risk factors of transfusion reactions in postpartum blood transfusions. Blood Adv 2019;3:2298-306.  Back to cited text no. 4
    
5.
Sayah DM, Looney MR, Toy P. Transfusion reactions: Newer concepts on the pathophysiology, incidence, treatment, and prevention of transfusion-related acute lung injury. Crit Care Clin 2012;28:363-72, v.  Back to cited text no. 5
    
6.
Popovsky MA. Transfusion-related acute lung injury: Incidence, pathogenesis and the role of multicomponent apheresis in its prevention. Transfus Med Hemother 2008;35:76-9.  Back to cited text no. 6
    
7.
Toy P, Gajic O, Bacchetti P, Looney MR, Gropper MA, Hubmayr R, et al; TRALI Study Group. Transfusion-related acute lung injury: Incidence and risk factors. Blood 2012;119:1757-67.  Back to cited text no. 7
    
8.
Reil A, Keller-Stanislawski B, Günay S, Bux J. Specificities of leucocyte alloantibodies in transfusion-related acute lung injury and results of leucocyte antibody screening of blood donors. Vox Sang 2008;95:313-7.  Back to cited text no. 8
    
9.
Sachs UJ. Recent insights into the mechanism of transfusion-related acute lung injury. Curr Opin Hematol 2011;18:436-42.  Back to cited text no. 9
    
10.
Kim KN, Kim DW, Jeong MA. The usefulness of a classification and regression tree algorithm for detecting perioperative transfusion-related pulmonary complications. Transfusion 2015;55:2582-9.  Back to cited text no. 10
    
11.
Roubinian N. TACO and TRALI: Biology, risk factors, and prevention strategies. Hematol Am Soc Hematol Educ Program 2018;2018:585-94.  Back to cited text no. 11
    
12.
Goldberg AD, Kor DJ. State of the art management of transfusion-related acute lung injury (TRALI). Curr Pharm Des 2012;18:3273-84.  Back to cited text no. 12
    
13.
Voelker MT, Spieth P. Blood transfusion associated lung injury. J Thorac Dis 2019;11:3609-15.  Back to cited text no. 13
    
14.
Cho M, Sharma S. Transfusion-related acute lung injury (TRALI). StatPearls. Accessed October 29, 2018. https://www.ncbi.nlm.nih.gov/books/NBK507846/.  Back to cited text no. 14
    
15.
Kopko PM, Holland PV. Transfusion-related acute lung injury. Br J Haematol 1999;105:322-9.  Back to cited text no. 15
    


    Figures

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  [Table 1], [Table 2]



 

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