A patient with possible TRALI who developed pulmonary hypertensive crisis and acute pulmonary edema during cardiac surgery

Abstract

There are very few case reports of transfusion-related acute lung injury (TRALI) under close hemodynamic monitoring. We encountered a case of possible TRALI during on-pump coronary artery bypass grafting (CABG). A 66-year-old man who had undergone on-pump CABG was administered fresh frozen plasma (FFP). One hour after FFP transfusion, pulmonary hypertensive crisis and subsequent hypoxic decompensation occurred. A second cardiopulmonary bypass (CPB) was needed for circulatory and respiratory deterioration. Extracorporeal life support (ECLS), intraaortic balloon pumping (IABP), and nitric oxide therapy were required after the surgery. Despite the severity of the initial state, his recovery was comparatively smooth. ECLS and IABP were removed on postoperative day (POD)1; the patient was extubated and discharged from the ICU on POD7 and POD12, respectively. The diagnosis of TRALI was confirmed by human leukocyte antigen antibody detection in the administered FFP. In addition, lymphocytic immunofluorescence test showed that a cross-match of the plasma from the pooled FFP against the recipient leukocytes was positive. The clinical course of the pulmonary artery hypertension was followed by a decrease in dynamic lung compliance. The mechanism of this phenomenon is unclear. However, it might suggest the possibility of vasoconstriction or obstruction of the peripheral pulmonary artery preceding lung damage, as in the case in animal models reported previously.

Transfusion-related acute lung injury in cardiac surgery

“…Twelve studies were included in the qualitative synthesis. Eight of them [16][17][18][19][20][21][22][23] were case reports, while the others were case-control [24] prospective cohort [25] and randomized-controlled trials. [26,27] Trials were at a level of IIb according to the definition of 'levels of evidence'.…”

“…Blood transfusion was determined as one of the main risk factors for new-onset of atrial fibrillation, [29] development of infections, [30] prolonged mechanical ventilation, [31,32] acute renal injury, [31] decreased quality of life, [33] mortality, [33][34][35][36] and ARDS. [16][17][18][19][20][21][22][23] The records of ARDS mainly encompass the case reports. [16][17][18][19][20][21][22][23] Although 56.4% of patients needed blood transfusion in the first 72 hours of postoperative period [34] and transfusion increased the pulmonary morbidity [25] in cardiac surgery patients as well, it is obvious that TRALI has not been adequately investigated in prospective trials.…”

“…[16][17][18][19][20][21][22][23] The records of ARDS mainly encompass the case reports. [16][17][18][19][20][21][22][23] Although 56.4% of patients needed blood transfusion in the first 72 hours of postoperative period [34] and transfusion increased the pulmonary morbidity [25] in cardiac surgery patients as well, it is obvious that TRALI has not been adequately investigated in prospective trials.…”

“…[16][17][18][19][20][21][22][23] The leading cause of TRALI was described as FFP. [17][18][19]21,22] In addition to FFP, cases due to transfusion of platelet and RBC alone were also reported. [16,23] Singh and Zeltsman [23] performed blood transfusion intraoperatively, while the others used blood products postoperatively.…”

“…Brander et al [18] 46/M FFP/1 Yes Aort surgery Postoperative NA Discharged third hour Nouraei et al [19] 4/F FFP/2 Yes Ross procedure Postoperative NA Discharged RBC/1 Bawany and Sharif [20] 68/M PLT/6 Yes CABG Postoperative No Exitus second hour Kojima et al [21] 66/M FFP/1 Yes CABG Postoperative Asthma Discharged first hour Lecamwasam et al [22] 66/M FFP/2 Yes CABG and Postoperative AF Discharged MVR Singh and Zeltsman [23] 22 Koch et al [25] 16847/0 NA RBC Heart failure, CABG, ARDS cases were not NA FFP smoking, Valve, related to transfusions PLT prior MI, CABG+valve of blood products diabetes mellitus, COPD Nakazawa et al [27] 82 Tuinman et al [24] 45…”