TRALI Vs TACO

Preop Eval:

• Date and Time: June 28th 2013 at 07:59
• Proposed Op: Anterograde IMN Rt. Femur, and ORIF of Rt Medial Humoral Condyle and Rt Humerus.
• ASA: 4
• Meds: Oxycodon, Phenytoin, Ancef, Fentanyl gtt, Versed gtt, Morphine PCA Tranexamic Acid of 1000 mg at 2300

Preop Eval Cont...

• weight: 63 kg
• Height: 64 inches
• BP: 73/50 mmhg (10 m later with FFP running 107/70)
• SpO2: 100%
• Resp: Intubated in ED/ Vent dependent
• Mult. rib fx
• FiO2 40%. PRVC-SIMV
• RR: 12, TV=500
• PS=10, PEEP=5

Renal Trauma Gradings:

• Grade I - contusion or non enlarging subcapsular haematoma, but no laceration
• Grade II - superfical laceration <1cm depth and does not involve the collecting system; non expanding perirenal haematoma
• Grade III - laceration >1cm, without extension into the renal pelvis or collecting system and with no evidence of urine extravasation
• Grade IV -laceration extends to renal pelvis or urinary extravasation; vascular : injury to main renal artery or vein with contained haemorrhage
• Grade V - shattered kidney

Preop Eval Cont...

• CV: Pre > 4 Mets
• GI: Gr. 1 Renal laceration
• Liver: Intact
• PE: ETT in situ.
• Rt. SC Cordis

Preop Eval..

• CXR: +ETT, + NG, LLL opacity, atelectasis vs consolidation including aspiration, Subsegmental atelectasis RUL
• CT Head: Traumatic IVH , Mild Bilateral SAH, and Mandibular Ramus Fracture
• C-Spine: No acute

Preop Eval...

Labs: Chemistery:

Na: 145; K: 3.2;Cl: 106; HCO3: 26; BUN: 16; Cr: 1.0 Glu:167

TEG: WNL except R= 4

Labs: CBC/Electrolytes

WBC: 12.7; Hb: 12; Hct:34.8; Plt 127; Ca: 8.3

Mg:2.2; Phosp.:4.4

Morning labs @ 0800:

• LA: 3.4
• H/H: 7.9/23.4
• TEG: R: 0.8, angle: 71, MA: 59, %Ly: 0
• ACT: 121

2 units thawed plasma given in STICU at 0800

• Hematocrit: 17.0
• ABG: 7.41/39/93/25/0/97%/LA: 2.0
• Taken to OR for Ortho at 1134

ABG in OR

• Hematocrit: 15.0
• ABG: 7.34/45/357/24/-1/100%/LA: 1.7
• At the time of arrival to OR:
• BP: 64/44, HR: 114.

Quick summer of Intraop

• STICU team contacted intraop for hypotension, tachycardia, concerns for intraabdominal bleeding
• Massive transfusion protocol 1145-1330
• 12 pRBC, 10 FFP, 2 platelets, 2 cryo
• Bedside FAST exam negative in OR
• SBP: 130, HR: 110
• Ortho finished case- washout of LLE, ex-fix to RLE
• Returned to STICU at 1450

CT Scan with Contrast

• Perivascular hematoma,  and  intraluminal  flap  at  the  takeoff  of the  celiac  artery which is consistent  with vascular injury  and  dissection.
• L1 compression fracture  with 10% height loss.
• Displaced  left  second  through fifth rib fractures  anteriorly with  small adjacent pleural  hematoma. Small  right  pleural effusion.
• Nondisplaced left first  anterior, right first anterior,  and left third  through  tenth posterior rib  fractures.

CT Scan Cont...

• Grade 1 renal laceration. 
• Bilateral retroperitoneal hematoma,largest in the right posterior pararenal  space. 
• No evidence for renal artery or veininjury. 
• No contrast extravasation. 

ECHO:

• Tachycardia: 120 bpm
• LVEF > 70%
• Impaired LV relaxation
• RV mildly dilated
• No pericardial effusion

Patient Condition Continued to Deteriorate

• Placed on VDR at 1600, pink, frothy secretions noted
• Repeat portable head CT: Stable improvement of hemorrhages.
• Nephrology consulted for CVVHD

Shortly After:

• Hypotensive, bradycardic, PEA: 15 minutes of CPR, and she responded with epi, atropine and bicarb
• Patient continued to decline, going into PEA two more times requiring CPR.
• Family meeting held, decision made to withdraw care.
• Patient expired shortly thereafter.

Cardiogenic (hydrostatic)

• TACO
• Myocardial Infarction

Cause :

• Volume overload temporally associated with transfusion

Signs and Symptoms

• Shortness of breath
• Increased respiratory rate
• Hypoxemia
• Increased left atrial pressure
• Jugular venous distension
• Elevated systolic blood pressure

Incidence:

• Overall: 0.1% - 1%
• Elderly: up to 8%
• Critical Care: 2% - 11%

Mortality:

• Estimated 5 - 15%

Non-cardiogenic (permeability)

• TRALI
• ARDS
• 6h

Cause:

• Leakage of fluid into alveolar space due to diffuse alveolar capillary damage

Signs and Symptoms:

• Shortness of breath
• Increased respiratory rate
• Hypoxemia
• Hypotension
• Occasionally fever

Treatment:

• Oxygen
• Intubation and mechanical ventilation
• Fluids to treat hypotension

Treatment:

• Oxygen (FiO2 100%)
• Intubation and mechanical ventilation
• Diuresis to reduce volume

UK Shot Data:

• TRALI risk is 5 to 7 fold greater in components containing high volume of plasma
• Majority of TRALI cases involved leukocyte-antibody positive female donors (multiparous)
• Oct 2003: UK moved to male-only plasma
• Significant reduction in TRALI cases in UK since Jan. 2004

• Patient should have remained in STICU for further resuscitation
• Thoracentesis
• Postponed OR
• Unknown
• More Invasive Monitoring
• Ex. Lap

Refrences:

• Barash, et al. Clinical Anesthesia. 6th edition. Philadelphia; Lippincott Williams & Wilkins, 2009
• Densmore et al. Prevalence of HLA sensitization in female apheresis donors. Transfusion. 1999;39:103-106
• Hussain, Mahamad: Pulmonary Edema: TRALI Vs. TACO. 2013. Houston: University of Texas.
• Jaffe, et al. Anesthesiologist’s Manual of Surgical Procedures. 4th edition. Philadelphia; Lippincot Williams & Wilkins, 2009
• Morgan, Mikhail & Murray. Clinical Anesthesiology. 5th edition. New York; McGraw- Hill Companies, 2013

Pulmonary Edema:

TRALI Vs TACO

Intra-Op

ABG

11335

Intra

7.24

51

58

100%

22

-6

84

154

4.8

143

4.4

1.46

45

1254

Intra

7.17

59

64

100%

22

-7

85

185

4.8

145

4.8

0.96

37

1415

Intra

7.22

60

51

100%

25

-4

77

135

4.0

144

4.0

1.25

42

1238

7.17

57

100

100%

21

-8

96

207

4.3

144

5.1

0.97

34

1226

7.20

57

208

100%

22

-6

100

181

3.2

145

4.4

0.77

26

At 1202

7.27

45

282

100%

21

-6

100

133

2.4

147

3.4

0.83

18

At 1151

PH:7.34

PaCO2:7.45

PaO2: 357

FiO2: 100%

HCO3: 24

BE: -1

O2 Sat:100%

Glu: 127

LA:1.7

Na:145

K:3.5

Ca:0.95

HCT: 15

TEG:1301

R=14.2H

K=7.5H

Angle=18.3L

Max amp=43.8L

G-value=3.9L

C-13.2L

TEG:1209

R-time:12.2H

K-Time:5.1H

Angle:36.8L

Max amp:47.4L

G-Value:4.5L

C-index -9.0L

Trauma

Conclusions

Hay Gary, no questions to our dad!

The Case

Fethi Bekri AAS1

Mentor: Dr. Mahammad Hussain

Initial Encounter and Assesment

Incident

• On June 27, 2013, a 62 y/o female pedestrian got hit by a car. The patient was unconscious upon arrival and was intubated in Ed.
• Upon arrival, the patient was hypotensive and received 1 unit of plasma.

Primary Survey and The Case

Assessment Cont...

• Head: IVH, Bil Mild SAH, Mandibular fx
• Neck: Pt. in C- Collar.
• Chest: Rt. 1st anterior, Lt. 2nd - 5th anterior rib fxs. Lt 3rd to 10th posterior rib fxs. Lung contusion, Lt. Pleural effusion and hematoma, atelectasis.
• Abdomen: Renal lac, Bil. Retroperitoneal hematoma, Celiac artery injury.
• Pelvis: Small pelvic hematoma
• Upper Extremity: Rt. Humerus fx
• Lower Extremity: Rt. Femur fx, Left Tib & Fib fx

Initial Assessments:

• Intact airway, BBS and hypotensive.
• 4 pRBC, 4 plasma, 1 platelet-uncrossmatched
• Labs: H/H: 12/34.8, lactic acid: 3.6
• TEG: R-time=4.0, K-Time=1.0 Angle = 78, max.Amp=70, G-value 11.5, lysis=5.4 ACT=105
• Deformities to right upper extremity and bilateral lower extremities

What Happened?

Pre OP 27th Jun Thursday 0943 PM

Initial assessment

Preop Evaluation

Post-Op

Secondary Survey: Patient Condition in STICU

Transfusion-Associated Circulatory Overload (TACO) OR TRALI

Postop at 816

Transfusion Related Lung Injury (TRALI)

Postop at 1524

Transfusion-Associated Pulmonary Edema (TACO)

Pre-Op at 0943

Intra-Op

Incidence

• Overall: 0.16% per patien
• Critical Care: 0.08% per unit transfused
• Tertiary Care:0.04% per unit transfused
• Mortality
• Estimated 5% - 10%

Small amount of blood  and  stranding in the  left pelvic sidewall without adjacent  fracture  or  solid organ  injury.

Nondisplaced fracture of the coracoid process of  the left scapula.

Nondisplaced T12 spinous process and  L2  left  transverse process fractures.

Cholelithiasis

Objectives

OR

June 28, 0230 am

• Discuss Patient Medical History
• Review Intraoprative Events
• Review Postoprative Events
• Discuss pathophysiology, and managment of TRALI and TACO
• Conclusion

Thank You!