TACO and TRALI: visualising transfusion lung injury on plain film

Transfusion-associated circulatory overload (TACO) and transfusion-related acute lung injury (TRALI) are acute respiratory distress syndromes which occur within ... 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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