An adverse effect of transfusion

The results of the above trial suggest that administration of rFVIIa would reduce patient exposure to the perils of blood-product transfusion, which are only now being fully recognized. 

Increased awareness of the morbidity and mortality associated with transfusion of blood products has led to the implementation of restrictive transfusion policies in recent years, and treatment strategies like rFVIIa are to be welcomed in this context. A recent case-study report highlights transfusion-related acute lung injury (TRALI), the second most common cause of transfusion-related death after ABO mismatch.

The patient, a 41-year-old man was recovering in intensive care from uneventful cardiac surgery. During the first hour after admission to ICU, 500 mL blood drained from chest tubes installed during surgery, and coagulation studies suggested the need for 2 units of fresh frozen plasma (FFP), which was duly transfused. 

Within 1 hour of completion of the transfusion, the patient’s condition suddenly and dramatically deteriorated with development of acute respiratory failure. Arterial pO₂ before transfusion was 227 mmHg (30 kPa) falling to 34 mmHg (4.5 kPa) 2 hours after transfusion. 

Blood pressure dropped from 100/60 mmHg to 62/20 mmHg. Chest X-ray taken 1 hour after transfusion revealed extensive bilateral pulmonary infiltrates consistent with pulmonary edema. Leucocyte count was normal (5.4 × 10⁹/L) before transfusion; 2 hours later it was markedly and potentially dangerously reduced (0.9 × 10⁹/L).

Between 5 and 14 % of patients who suffer TRALI do not survive, but for those, like the subject of this case study, who do survive, recovery is usually as dramatically rapid as is the onset. Prompt supportive therapy resulted in complete recovery from TRALI over the following 24-36 hours and the patient was eventually discharged in good health. 

The authors of this case study discuss the pathogenesis of TRALI, which is caused by the presence of white cell (granulocyte) reactive antibodies in donor serum. There is now widespread acceptance that TRALI may present in milder form than the classically severe presentation of this patient. In these circumstances it is underdiagnosed. As the authors of this report observe, TRALI is probably one of the most underdiagnosed adverse effects of transfusion.