Fatalities caused by TRALI

doi:10.1016/j.tmrv.2004.03.004

Transfusion Medicine Reviews

Volume 18, Issue 3, July 2004, Pages 184-188

https://doi.org/10.1016/j.tmrv.2004.03.004 Get rights and content

Abstract

This article includes a retrospective review of fatalities caused by transfusion-related acute lung injury (TRALI) over a 5-year period (from 1997 to 2002) that were reported to the Center for Biologics Evaluation and Research involving 58 recipient deaths and the corresponding 63 blood component donors. Descriptive statistics are presented. Recipient characteristics include age, sex, and admitting diagnosis. Cardiovascular disease, pulmonary disorders, and cancer were the most frequent diagnoses of transfusion recipients. Reported deaths did not appear to be associated with age, sex, reason for transfusion, or transfusion component. Implicated blood component(s) and clinical symptoms at the time of reaction were recorded. Fresh frozen plasma was implicated in one half of the cases, whereas red blood cells played a role in approximately one third. The clinical characteristics described most often in TRALI reports included shortness of breath, frothy sputum, pulmonary infiltrates, and hypoxia. Donor variables included age, sex, parity, and laboratory tests for antibodies to HLA and/or antigranulocyte antibodies. Laboratory tests showed HLA antibodies and/or antigranulocyte antibodies were positive in the majority of donors tested. More data are needed to better describe the role of antibodies in these reactions. Greater awareness is crucial for the practitioner to be alert for signs and symptoms of TRALI and to be aware of the necessary steps in treatment.

Section snippets

Methods

When a complication from blood transfusion is confirmed to be fatal, the blood establishment is required to notify the CBER/FDA within 24 hours.12 The CBER gathers specific information regarding the recipient, circumstances of the hospitalization, need for transfusion, specifics about the blood components transfused, and the cause of death, if known. Donor information is also gathered. The reporter is asked to submit a written report within 7 days of the fatality as well as copies of the

Recipients

The most commonly reported clinical signs and symptoms of TRALI were shortness of breath, frothy sputum, pulmonary infiltrates, hypotension, hypoxia, tachycardia, tachypnea, respiratory arrest, and fever. Recipient ages ranged from 3 to 90 years with a median age of 61; cases were evenly divided between males and females (Table 1). Various admitting diagnoses were reported (Table 2).

Implicated blood components

FFP was the most frequently implicated blood component followed by red blood cells, platelets, and

Discussion

The findings in this study are consistent with TRALI case reports in the literature. TRALI fatalities occurred equally in males and females and throughout all age groups. Blood components implicated in these fatalities all contained plasma. FFP was implicated twice as often as any other component. This is consistent with the premise that donor antibodies are transfused in the plasma fraction of blood products. Although FFP is transfused less often than red blood cells and/or platelets, half of

Conclusions

The prevalence and morbidity of nonfatal TRALI reactions is not known. Blood banks, transfusion services, and blood centers are required to investigate and document adverse transfusion reactions, but unless the transfusion results in a fatality, blood establishments are not currently required to report adverse reactions to the CBER. In some cases, blood bank directors, physicians, or quality-assurance specialists have voluntarily reported nonfatal TRALI reactions, but, in general, this

References (17)

R.D Barnard
Pulmonary edema associated with transfusion
N Y State J Med
(1951)
M.A Popovsky et al.
Transfusion related acute lung injuryA neglected, serious complication of hemotherapy
Transfusion
(1992)
M.A Popovsky et al.
Diagnostic and pathogenetic considerations in transfusion-related acute lung injury
Transfusion
(1985)
M.A Popovsky
Case 40-1998
N Engl J Med
(1998)
P.M Kopko et al.
Transfusion related acute lung injuryReport of a clinical look back investigation
JAMA
(2002)
Some unfavourable effects of transfusion
M.A Popovsky et al.
Transfusion-related acute lung injuryFemme fatale?
Transfusion
(2001)
A Rizk et al.
Transfusion-related acute lung injury after infusion of IVIG
Transfusion
(2001)

There are more references available in the full text version of this article.

Cited by (291)

EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis
2022, Journal of Hepatology
The prevention and management of bleeding and thrombosis in patients with cirrhosis poses several difficult clinical questions. These Clinical Practice Guidelines have been developed to provide practical guidance on debated topics, including current views on haemostasis in liver disease, controversy regarding the need to correct thrombocytopenia and abnormalities in the coagulation system in patients undergoing invasive procedures, and the need for thromboprophylaxis in hospitalised patients with haemostatic abnormalities. Multiple recommendations in this document are based on interventions that the panel feels are not useful, even though widely applied in clinical practice.
Tranexamic acid reduced blood transfusions in acute burn surgery: A retrospective case-controlled trial
2022, Burns
Early excision and grafting of burn wounds are key for reducing prevalence of infection and sepsis. However, it is associated with massive blood loss and patients frequently require large numbers of blood transfusions. This study aimed to evaluate the effect of tranexamic acid (TXA) on blood transfusion requirements in acute burn surgery.
Patients admitted to the burn intensive care unit between January 2018 and May 2021 and received TXA before first surgery for wound excision and grafting were matched in a 1:2 ratio to patients that did not receive TXA (confounders age,sex,total body surface area (TBSA) burned). Primary endpoint of the analysis was the total number of transfused units of red blood cells (RBC) intra- and postoperatively up to 48 h. Fresh frozen plasma (FFP) and platelets were evaluated. Endpoints were compared between groups using van Elteren tests adjusting for strata variable age, gender, TBSA.
Twenty-six TXA patients were matched with 52 control patients resulting in similar distributions of gender (77.9%(TXA)vs. 82.7%(control) males, p=0.542), age (51.7±21.3vs.48.3 ±17.4years,p = 0.459) and %TBSA burned (33.5%(IQR34)vs. 38.5% (IQR 30.5),p = 1.000). TXA group received significantly less RBC units intraoperatively (2.5(IQR 2.0)vs.4.0 units (IQR4.0), p = 0.038) and in total (4.0(IQR3.0)vs.6.0(IQR4.0),p = 0.017). TXA patients also received less blood products in general (RBC, FFP, platelets) in each period and in total. We found no significant difference in length of stay (24.0(IQR26.0)vs.33.0 days (IQR 0.5),p = 0.367) or mortality (15.4%vs.21.2%, p = 0.542).
This study shows that necessity for blood transfusions in acute burn surgery may be reduced significantly by administration of TXA perioperatively. Randomized-controlled trials are needed to prove these findings.
Fresh frozen plasma-to-red blood cell ratio is an independent predictor of blood loss in patients with neuromuscular scoliosis undergoing posterior spinal fusion
2020, Spine Journal
In major trauma with massive blood loss, higher fresh frozen plasma (FFP)-to-red blood cell (RBC) ratios have been associated with improved morbidity and mortality. Our population of patients with neuromuscular scoliosis undergoing posterior spinal fusion (PSF) often lose volumes of blood considered massive, that is, half a blood volume in 3 hours. In this retrospective cohort study, we examined the association of FFP ratio with blood loss in this elective surgical population.
Patients with neuromuscular scoliosis undergoing PSF with unit rod fixation were identified from our anesthesia cases database. The patients were divided into two groups: the low FFP group received FFP-to-RBC≤0.5, and the high FFP group received FFP-to-RBC>0.5. After controlling for a false discovery rate in the univariate analysis, a logistic and linear regression was performed to understand the contribution of the significant factors associated with increased blood loss.
Risk estimation showed that patients in the low FFP group were more likely to lose >120% blood volume (odds ratio, 3.87; 95% confidence interval, 2.03–7.38). Linear regression revealed that each unit of increase in FFP-to-RBC ratio was associated with a 27.5% (95% confidence interval, −43.12–11.89) mean reduction in blood volume loss.
In our retrospective study, we found that FFP-to-RBC ratio was significant independent predictor of blood loss in this group of complex spine patients undergoing PSF. Thus, in patients with neuromuscular scoliosis undergoing posterior spine fusion, use of higher ratio of FFP to RBC may decrease blood loss.
Transfusion-Related Acute Lung Injury
2020, Immunologic Concepts in Transfusion Medicine
As early as 1957, the entity that would become known as transfusion-related acute lung injury (TRALI) was recognized as a potential adverse reaction from blood transfusion. However, poor understanding of the mechanism behind this entity led to its underrecognition for decades. TRALI is defined as acute lung injury (ALI) occurring within 6 h of cessation of transfusion and the presence of hypoxemia. Hypoxemia is defined by any of the following methods: the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO₂/FiO₂) less than or equal to 300 mm Hg, oxygen saturation less than 90% on room air, or other clinical evidence. Additionally, radiographic evidence of bilateral pulmonary infiltrates needs to be identified with no previous evidence of ALI before the transfusion and no evidence for left atrial hypertension leading to circulatory overload.
Secular trends in the distribution of allogeneic blood components in Taiwan
2019, Journal of the Formosan Medical Association
Recent blood distribution profiles for transfusions in Taiwan have not been comprehensively documented. This study aimed to analyze trends in red blood cell (RBC), platelet, and plasma distribution rates, and compares these profiles with those in other countries. The distribution rates of RBC, platelets, and plasma in Taiwan during 2015 were 47.6, 11.1, and 26.8 units per 1000 population, respectively. At least 1.5 and 2.5-fold higher platelet and plasma distribution rates were observed than other selected countries. During 2007–2015, there was no significant change in RBC distribution. However, we observed a significant increase of 0.20 (95% CI: 0.11–0.30) adult doses of platelets, and a significant decrease of 1.69 (95% CI: 1.45–1.93) units of plasma per 1000 population per annum. Seven other countries showed a general significant decreasing trend of RBC distributions. Higher blood distribution rates were observed in Taiwan. Therefore, the adoption of patient blood management is essential.
Impact of Blood Donor Sex on Transfusion-Related Outcomes in Preterm Infants
2018, Journal of Pediatrics
Explore the role of red blood cell donor sex on preterm infant neonatal outcomes.
In a retrospective, exploratory, cohort study, the hospital blood bank database was queried for units of blood released to neonatal intensive care unit patients in 2009-2010. The state blood center provided donor sex, and a department database provided neonatal characteristics and morbidities. Comparisons were made for 2 groups: those who ever received female blood and those who did not.
Among 462 infants <32 weeks of gestation, 190 (41%) received >1 blood transfusion. In univariate analyses, compared with infants who received only male blood, infants who received female donor blood had higher rates of bronchopulmonary dysplasia (38% vs 22%; P = .03), spontaneous intestinal perforation/necrotizing enterocolitis (17% vs 6%; P = .04), and death or any morbidity (60% vs 38%; P < .01), respectively. In adjusted analyses, female blood was associated with any morbidity (P = .0251) and 21 days longer hospitalization (P = .0098). After adding total number transfusions to the model, only an increased number of transfusions was associated with bronchopulmonary dysplasia (P = .0009), any morbidity (P = .0001), and length of stay (P = .0001). In subset regressions comparing exclusively female donor blood with male donor blood, there was a significant interaction of female donor blood and number of transfusions for any morbidity (OR 2.6 95% CI 1.2-5.7, P = .01).
Preliminary findings suggest that female donor blood was associated with preterm vulnerability to neonatal morbidities.

View all citing articles on Scopus

View full text

Fatalities caused by TRALI

Abstract

Section snippets

Methods

Recipients

Implicated blood components

Discussion

Conclusions

Pulmonary edema associated with transfusion

N Y State J Med

Transfusion related acute lung injuryA neglected, serious complication of hemotherapy

Transfusion

Diagnostic and pathogenetic considerations in transfusion-related acute lung injury

Transfusion

Case 40-1998

N Engl J Med

Transfusion related acute lung injuryReport of a clinical look back investigation

JAMA

Some unfavourable effects of transfusion

Transfusion-related acute lung injuryFemme fatale?

Transfusion

Transfusion-related acute lung injury after infusion of IVIG

Transfusion