taco vs trali

7/26/2019 Taco vs Trali

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TACO vs. TRALI:Recognition, Differentiation, and Investigation

ofPulmonary Transfusion Reactions

Shealynn Harris, M.D.

Assistant Medical DirectorAmerican Red Cross Blood Services

Southern Region


2/42

Case Presentation

74 year-old female with GI bleed Transfused

1 unit Apheresis Platelets

4 units RCs

!urin" transfusion

!iffi#ulty breathin"

$ypo%ia

In#reased respiratory rate


3/42

Considerations&

Transfusion Rea#tion

Pulmonary Transfusion Reacion

Transfusion-asso#iated #ir#ulatory o'erload

(TAC)*

Transfusion-related a#ute lun" in+ury (TRA,I*

Transfusion Reacion !ih Pulmonary

Sym"oms

Aller"i# (anaphyla%is*

epti# Transfusion Rea#tion


4/42

)ther Considerations

Myocar#ial infarcion

Acue res"iraory #isress

syn#rome $ARDS%

Se"sis

Dru& reacion

Pneumonia


5/42

Challen&es in Characeri'in&

Pulmonary Sym"oms

Associae# !ih Transfusion

Re#o"ni.in" a transfusion rea#tion

!ifferentiatin" between possible etiolo"ies

Criteria for dia"nosis !ia"nosti# tools

Contributin" fa#tors (e/"/0 underlyin" disease*

)btainin" #omplete #lini#al and laboratory

information

In'esti"atin" donors and understandin" results

of in'esti"ation


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Case Presentation



4 units RCs

!urin" transfusion


$ypo%ia



7/42

Pre(Transfusion

op2o P30 $olland P/ Br J Haematol/ 1555618&9::-9:5/


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Pos(Transfusion

op2o P30 $olland P/ Br J Haematol/ 1555618&9::-9:5/


9/42

Transfusion(Associae#

Pulmonary )#ema:

TACO vs TRALI


10/42

Pulmonary ;dema

A*normal accumulaion of flui# in he lun&


11/42

Pulmonary ;dema

Car#io&enic $hy#rosaic%

TAC)

3yo#ardial Infar#tion

+on(car#io&enic $"ermea*iliy%

TRA,I

AR!


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Transfusion-Asso#iated

Cir#ulatory )'erload (TAC)*

olume o'erloadtemporally asso#iated withtransfusion

Si&ns an# Sym"oms hortness of breath In#reased respiratory rate

$ypo%emia

In#reased left atrial

pressure


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Inci#ence

)'erall& /1= - 1=

;lderly& up to >=

Criti#al Care& := - 11=

Moraliy

;stimated 8 - 18=


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Treamen

)%y"en

Possible intubation and me#hani#al 'entilation

!iuresis to redu#e 'olume

Also consi#er Myocar#ial Infarcion


15/42

Transfusion-Related

A#ute ,un" In+ury (TRA,I*

,ea2a"e of fluid into

al'eolar spa#e due to

diffuse al'eolar #apillary

dama"e? Si&ns an# Sym"oms

hortness of breath


$ypo%emia

$ypotension

)##asionally fe'er


16/42

Transfusion-Related


Inci#ence

)'erall& /1@= per patient

Criti#al Care& />= per unit transfused

Tertiary Care& /4= per unit transfused

Moraliy

;stimated 8= - 1=


17/42

Transfusion-Related


Treamen

)%y"en

Possible intubation and me#hani#al 'entilation

Possible fluids to treat hypotension

Also consi#er ARDS


18/42

Transfusion-Related


$,I !efinition

BTRALI is #efine# as ne! acue lun&

inury occurrin& #urin& or !ihin -hrs afer a ransfusion, !ih a

clear em"oral relaionshi" o he

ransfusion/D

Crit Care 3ed/ :8 Apr699(4*&7:1-@/


19/42

Transfusion-Related

A#ute ,un" In+ury (TRA,I*Canadian TRA,I Consensus Conferen#e !efinition

TRA,I

ew o##urren#e of a#ute onset a#ute lun" in+ury (withhypo%emia and bilateral infiltrates on #hest %-ray butno e'iden#e of left atrial hypertension

ot pree%istin" ET

;mer"in" durin" or within @ hours of the end of

transfusion A!

$a'in" no temporal relationship to an alternati'e

a#ute lun" in+ury ris2 fa#tor


20/42

Transfusion-Related


Canadian TRA,I Consensus Conferen#e !efinition

Possible TRA,I

Cases in whi#h there was a temporal asso#iation withan alternati'e ris2 fa#tor


21/42

TRALI is a Dia&nosis of

)clusion/e mus rule ou all oher

"ossi*le eiolo&ies *eforeren#erin& a #ia&nosis of TRALI

TAC) TRA,I


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TAC) 's/ TRA,I

!ia"nosti# Tools& Chest F-ray Pros&

Identify pulmonary edema

Identify pleural effusions (more #onsistent

with TAC)*

ee e'iden#e of other pulmonary disease

Cons& !oes not show spe#ifi# me#hanism of

edema

Radiolo"y reports are often 'a"ue

u""ested to measure 'as#ularpedi#le width and #ardiothora#i# ratioto impro'e spe#ifi#ity (ne'er seen this*

TAC) 's TRA,I


23/42

TAC) 's/ TRA,I

!ia"nosti# Tools&

Pulmonary Artery )##lusion Pressure Insertion of #atheter into

pulmonary artery tomeasure ba#2 pressurefrom heart

Pros !efiniti'e measurement Cons

In'asi'e

In#reased morbidity andmortality www/emedi#ine/#om

Interobser'er 'ariability

,a#2s sensiti'ity andspe#ifi#ity

TAC) 's TRA,I
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=%5Cwebsites%5Cemedicine%5Cmed%5Cimages%5CLarge%5C32033203swan_ganz_catheter.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=%5Cwebsites%5Cemedicine%5Cmed%5Cimages%5CLarge%5C32033203swan_ganz_catheter.jpg&template=izoom2


24/42

TAC) 's/ TRA,I

!ia"nosti# Tools& Pulmonary ;dema luid

Protein Con#entration mall #atheter inserted into the al'eoli to

measure lun" fluid protein #on#entration lood sample to measure plasma protein

#on#entration

Cal#ulate ratio pulmonary edemaHplasma protein#on#entration

Pros& ensiti'e measurement

Cons& 3ostly used in resear#h ot 'ery feasible in #lini#al settin"

3ust sample as soon as patient is intubated (diffi#ulttimin"*

TAC) TRA,I


25/42

TAC) 's/ TRA,I

!ia"nosti# Tools&;#ho#ardio"raphy ound wa'es used to measure

heart fun#tion

Pros

ot in'asi'e ensiti'e and spe#ifi# for measurin" left

heart fun#tion (e+e#tion fra#tion*

Cons

ormal test !); )T rule out #ardio"eni#

pulmonary edema

TAC) s TRA,I


26/42

TAC) 's/ TRA,I

-type atriureti# Peptide (P* $ormone released from heart with 'olume e%pansion in

'entri#les from pressure o'erload

P :8 p"Hm, more #onsistent with TRA,I

Pros&

;asy to measure ensiti'e and spe#ifi# indi#ator of #ardio"eni# pulmonary

symptoms

Pre-transfusion to post-transfusion ratio has relati'ely "ood sens

and spe#

Can be used to rule out TAC) Cons&

iolo"i#al 'ariability

Jho measures P before transfusionK

ew onset hypo%emia& Pa):HI): 9 or Arterial )%y"en aturation 5= on


27/42

y y"room air

Chest %-ray& new or worsenin" bilateral infiltrates #onsistent with pulmonary edema

ymptoms started within @h of transfusion

;demaHplasma protein #on#entration L/@8

Pulmonary artery o##lusion pressure 1> mm$"

P :8 or preHpost transfusion P ratio 1/8

Absen#e of rapid impro'ement with 'olume redu#tion (diureti#s*

Two of the followin"&

?ystoli# e+e#tion fra#tion L48 and no se'er 'al'ular heart

disease ?ystoli# P 1@

?as#ular Pedi#le Jidth @8 mm and Cardio-thora#i# ratio /88

+O 0)S

CARDIO1)+IC +O+(CARDIO1)+IC

P2LMO+AR0 )D)MA P2LMO+AR0 )D)MA


28/42

CARDIO1)+IC

P2LMO+AR0 )D)MA

ew ;CG is#hemi# #han"es )R

ew Troponin T L /8

0)S +O

Car#iac TACO

Ischemia

+O+(CARDIO1)+IC

P2LMO+AR0 )D)MA

Clear temporal relationship to

another A,I ris2 fa#tor (sepsis0

aspiration*

+O 0)S

TRALI Possi*le

TRALI

Gajic O et al. Crit Care Med 2006;34(5) Suppl: 109-113.

TRALI TACO


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TRALI TACO

Dyspnea M; M;

Arterial blood gas $ypo%emia $ypo%emia

Blood Pressure ,ow to ormal ormal to $i"h

Temperature ormal to ;le'ated ormal

Chest X-ray Jhite out/ ormal heart Jhite out/ ormal tosi.e/ o 'as#ular in#reased heart si.e/#on"estion/ as#ular #on"estion/

Pleural effusions/

BNP ,ow (:8 p"Hm,* $i"h

Pulm artery occlusion ,ow to ormal $i"hpressureEchocardiogram ormal heart fun#tion Abnormal heart

fun#tionesponse to Jorsens Impro'esDiuretics

eponse to !luids Impro'es Jorsens


30/42

/ha a*ou Tesin& for Donor

Leu3ocye Ani*o#ies4

Ani(HLA

Ani(1ranulocye $ani(H+A%


31/42

TRA,I and ,eu2o#yte Antibodies

Patho"enesis of TRA,I is not #lear

ew #ontrolled e%perimental studies ofTRA,I

,a#2 of in 'i'o animal model Two $ypotheses

!onor leu2o#yte antibodies bind to re#ipient

neutrophils whi#h #ause a#ute lun" in+ury ioa#ti'e lipids in stored blood BprimeD

neutrophils whi#h #ause a#ute lun" in+ury

Popo's2y et al Trans#usion6 15>8 :8&879 877


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Popo's2y et al" Trans#usion6 15>8/ :8&879-877/

Test n =

Granulo#yte antibodies

Patient : @

Donor 9: >5

,ympho#ytoto%i# :@ 7:antibodies (donor*

$,A-spe#ifi# antibodies 11N @8

$,A-anti"en 1N 85(patient*Hantibody#orresponden#e


33/42

!ensmore et al"Pre'alen#e of $,A sensiti.ation in female


34/42

apheresis donors/ Trans#usion"1555695&19-1@/

Pre&nancies +um*er +um*er Percena&e

Tese# Sensii'e# of /omen

Sensii'e#

19 > 7/>

1 99 8 18/:: 7 1 14/9

9 8> 18 :8/5

4 99 1 9/9

L8 :7 @ ::/:

All women 9:4 84 1@/@


35/42

E $)T !ata

TRA,I ris2 is 8 to 7 fold "reater in#omponents #ontainin" hi"h 'olume

of plasma

3a+ority of TRA,I #ases in'ol'edleu2o#yte-antibody positi'e female donors

)#t :9& E mo'ed to male-only plasma

i"nifi#ant redu#tion in TRA,I #ases in Esin#e


36/42

ARC !ata

TRA,I reports :9-:8 (n O 88*

9> #ases of probable TRA,I

:4 related to plasma transfusion

78= #ases in'ol'ed plasma from

leu2o#yte-antibody positi'e female donors

;der A et al/ Transfusion :7 in press/

TRA,I& In i'o 3ouse 3odel


37/42

TRA,I& In i'o 3ouse 3odel

heppard CA et al/ $ematol )n#ol Clin Am :76:7&1@9-17@/

ray RA0 $arris 0


38/42

for transplant patients& $,A antibodies in blood #omponents/

$um Immunol :46@8(9*&:4-4/

Class I Class II Class I 5 ToalCom"onens $n% n $6% n $6% Class II n $6%

n $6%

R7Cs $89-% 7 (7* > (>* 9 (9* 1> (17*

Cryo $--% 9 (8* 9 (8* 1 (18* 1@ (:4*

Pls $;% 7 (1:* 8 (5* 1 (:* 19 (::*


39/42

Challen"es

o #lear test for TRA,I

,eu2o#yte antibody positi'e donor !); )T

eual TRA,I dia"nosis

In#iden#e of $,A antibodies in donors is 'eryhi"h relati'e to number of TRA,I #ases

3any TRA,I #ases are not asso#iated with

leu2o#yte antibodies

3assi'e transfusion& odds are hi"h that at least

one donor will be positi'e

C P t ti


40/42

Case Presentation



4 units RCs !urin" transfusion


$ypo%ia In#reased respiratory rate

In'esti"ation of Pulmonary


41/42

In'esti"ation of Pulmonary

Transfusion Rea#tions Rule out ;;RMT$IG before dia"nosin"

TRA,I

Clini#al Presentation& eed as mu#h informationas possible

Timeline of ;'ents& Temporal relationship oftransfusion to symptoms

!ia"nosti# tudies& Chest %-ray0 P0;#ho#ardio"ram0 lood #ultures

!onor Testin"& only if hi"hly suspi#ious forTRA,I 3ale donor& no testin" unless transfusion h%

emale donor& if test positi'e0 then defer

$,A #rossmat#h positi'e& more supporti'e of TRA,I


42/42

ummary

e'eral etiolo"ies to #onsider with pulmonarysymptoms durin" transfusion

Pulmonary edema within @ hrs of transfusion

#onsider TAC) and TRA,I Consider #lini#al presentation and all dia"nosti#

studies

o spe#ifi# dia"nosti# study

TRA,I is a !IAG)I ) ;FC,EI)

TRA,I is not dia"nosed by positi'e leu2o#yte

antibody test alone

taco vs trali

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