Question

You are caring for a 72-year-old male patient admitted to a medical unit with an exacerbation of chronic obstructive pulmonary disease. He is anemic, and you are transfusing him with 2 units of PRBCs. The second unit is almost completed when he complains of more shortness of breath and appears anxious. His pulse is 118 bpm, respirations 28 per minute, BP 104/60, and temperature 37.2° C (99° F). What might be the etiology of his respiratory distress? How will you distinguish between transfusion associated circulatory overload (TACO), hemolytic transfusion reaction, and further exacerbation of his underlying pulmonary disease? What are the appropriate interventions to initiate? How will you prioritize your care for this patient?

Answer 1

The patient undergoing tranfusion with PRBCs suddenly developed acute dyspnea(difficulty in breathing), tachycardia(increased HR), hypotension(low bp), which are the clinical features of Transfusion related acute lung injury (TRALI)

TRALI is mostly immune mediated.Antibodies directed toward human leukocyte antigens (HLA) or human neutrophilantigens (HNA) have been implicated.

Difference between TACO, Hemolytic transfusion reaction and TRALI;

TRALI may be distinguished from TACO by the absence of signs of circulatory overload such as a normal central venous pressure (CVP) and normal pulmonary capillary wedge pressure (PCWP). Clinical response to diuretics also suggests a diagnosis of TACO rather than TRALI.

Hemolytic transfusion reaction presents with fever, back pain, chilla, fainting or dizziness etc. which are absent here

INTERVENTION;

• Stop the transfusion immediately if TRALI is suspected.

Supportive care is the mainstay of therapy in TRALI. Oxygen supplementation is employed in cases of TRALI and aggressive respiratory support is needed. Corticosteroids can be beneficial.

Once the immediate intervention is done,

• Obtain a white blood cell count and chest radiograph.

• Request Blood Bank to quarantine other units from the same donation(s).

• Request other units for transfusion if indicated (no special requirements).

• Follow institutional polices for a transfusion reaction workup.

• Return bags of units of blood transfused in the last 6 hours, indicating the last unit transfused prior to onset of signs or symptoms