1 Regional Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK. 2 Department of Haematology, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK
Corresponding author: smnouraei@yahoo.co.uk
Accepted for publication: March 3, 2003
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Abstract |
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Br J Anaesth 2003; 91: 2924
Keywords: complications, transfusion-related acute lung injury; surgery, cardiovascular
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Introduction |
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We present a case of TRALI in a 4-yr-old cardiac patient, which was refractory to standard therapy but was successfully managed with prolonged cardiopulmonary bypass support. To our knowledge, this is the first report of successful management of TRALI with extracorporeal oxygenation.
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Case report |
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At 4 yr and 7 months she was noted to have a puffy face, and ankle and abdominal swelling, and to be reluctant to run, play or climb the stairs. Examination revealed bilateral pedal oedema to mid-calf, a distended abdomen and elevated jugular venous pressure, but no shortness of breath. The patient received furosemide and was referred for echocardiography and cardiac catheterization, which revealed high right ventricular conduit velocity (5 m s1) and a high right ventricular pressure (70/6 mm Hg) respectively, caused by the narrowing of the conduit base. This was attributed to the patient outgrowing the conduit, and arrangements for elective replacement of the conduit were made.
At operation, the cardiopulmonary bypass circuit was primed with 2 units of leucocyte-depleted fresh frozen plasma (FFP), plus crystalloid, and the patient received 1 unit of packed red cells, also leucocyte-depleted, during the procedure. The operation was completed successfully and a transoesophageal echocardiogram, performed on the operating table immediately at the end of the operation before cessation of bypass, showed normal cardiac function with excellent conduit placement and function. Cardiopulmonary bypass was easily weaned after 97 min, with normal oxygen saturation and arterial oxygen tension. Five minutes later, however, ventilation became increasingly difficult, and she became severely hypoxic with massive pulmonary oedema on tracheal tube suction. Albumin concentrations of plasma and pulmonary exudates were 6 and 10 g litre1 respectively. No haemodynamic cause was found for her frank pulmonary oedema. Left ventricular function remained normal on repeat transoesophageal echocardiography, with a right atrial pressure of 7 cm H2O, right ventricular pressure of 47/9 mm Hg (preoperative value 70/8 mm Hg) and an aortic pressure of 91/51 mm Hg obtained using direct needle measurements. Cardiopulmonary bypass was reinstituted and, because there was no evidence of early lung resolution, cardiopulmonary bypass was continued and eventually weaned after 893 min.
Post-bypass ventilation with an initial PEEP of 14 cm H2O and FIO2 of 0.8 were required to maintain the arterial oxygen tension above 10 kPa. These were weaned after 7 days. The patient made an uneventful recovery and was discharged home 8 days later.
The units of FFP were investigated for antibodies against recipient leucocytes and HLA tissue type, as such antibodies are thought to be causative in cases of TRALI. One of the FFP units, from a multiparous female donor, was found to contain antibodies against HLA class I antigens A2 and A9, and against HLA class II antigen DR4. The patient was found by HLA typing to carry antigens A2 and DR4. No neurophil-specific antibodies were found. A clinical and immunological diagnosis of TRALI was therefore made.
The patient is now very well and is able to run and participate normally in school activities. She will receive all future transfusions from untransfused male donors, as they have the lowest incidence of antigen exposure from fetuses or from allogenic transfusions, and therefore have the lowest chance of harbouring anti-leucocyte antibodies.
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Discussion |
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The differential diagnosis includes cardiogenic pulmonary oedema and high-flow pulmonary oedema as a result of increased pulmonary artery pressure. These were excluded on the evidence of normal cardiac function and perioperative right atrial and right ventricular chamber values obtained by direct needle measurements.
Our case is unique among reported cases of TRALI in its management with extracorporeal oxygenation. Maximal ventilatory support instituted immediately after the initial cessation of bypass was insufficient to maintain oxygen saturation. Without the timely reinstitution of bypass, the patient would not have survived. After 893 min of cardiopulmonary bypass, ventilation was reinstituted and the patient then maintained adequate arterial oxygen saturation. It appears that this period of bypass was sufficient to allow pulmonary function to recover sufficiently to allow mechanical ventilation, which nevertheless had to be continued for a further 7 days.
Other treatments that have been used for TRALI include high-dose steroids and plasmapheresis.7 There is no evidence that steroids are effective in established disease. Plasmapheresis has been reported in a single case and was associated with clinical improvement 6 days after the initial insult. As most cases show recovery at 2448 h, it seems likely that plasmapheresis will only be valuable when the antibody titre is very high and there is evidence of continuing damage. At present, it does not form part of the routine management of TRALI.
This case has implications for the management of TRALI in general, as current interventions do not routinely go beyond mechanical ventilation. The fact that this was a cardiac case was fortuitous as it allowed the patient to continue to be supported by extracorporeal oxygenation through the acute episode. Extracorporeal membrane oxygenation has, however, been used in clinical practice for a number of years. It has been used successfully in the management of acute reversible pulmonary failure, such as post-lung transplantation acute respiratory failure.8 The use of extracorporeal oxygenation may be particularly valuable in severe cases of TRALI, as it is a transient condition and the patient is expected to make a full recovery after the acute episode. We therefore recommend that, where facilities exist, extracorporeal membrane oxygenation or cardiopulmonary bypass should be considered seriously in the management of patients with TRALI when conventional treatment is proving insufficient.
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References |
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