[HSF] A TRALI case

[Ani Anyanwu]

Hal

Was your patient pulmonary hypertensive?

I think one issue your case raises is the problem of unselected diagnostic testing. If you run coagulation tests on everybody during surgery regardless of index of suspicion then you will run into numerous false positives. If these false positive results drive therapy then you will treat many patients unnecessarily. On the other hand if you test only when index of suspicion is high then most positives you pick-up will be true positives. 

On cursory look, there would be no logical reason to expect a patient having an ASD repair and cryomaze to develop hematological bleeding unless coagulation dysfunction preceded surgery - such patients should have bloodless surgery (unless there was an intraoperative event that changed this). Personally I feel (except where the surgeon has strong reason to expect coagulopathy or where intra-operative hemostasis is prolonged) that intraoperative coagulation results (if they must be done) should be 'banked' and the patient sent to ICU - only if they bleed in first hour or two should coagulation by corrected, for, in most patients, abnormality in coagulation profile does not result in significant bleeding. Alternatively, such tests should only be ordered in cases where bleeding is seen or expected.

Regarding management of your patient, given the short operation (so he would not have suffered end-organ compromise during surgery), good heart, isolated lung failure and quick demise after surgery, he would have been a good candidate for ECMO. The effect of TRALI will likely be self limiting and you may be able to support the patient through this. Early ECMO is worth considering when faced with acute lung failure in young patients so soon after surgery.

Ani


  ----- Original Message ----- 
  From: Hgrmd at aol.com<mailto:Hgrmd at aol.com> 
  To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com> 
  Sent: Friday, March 16, 2007 3:40 AM
  Subject: Re: [HSF] A TRALI case


  Ani,
    Yes, it was heartbreaking.  The guy was only 57.   Actually, I did a small 
  incision ASD closure and Cryomaze.  He was in  chronic AF.  He came off with 
  no drips, NSR, and a perfect  TEE.  I do routinely get an intraop fibrinogen 
  and platelet count, so that  I can anticipate the need for blood products.  I 
  know the J.W.'s among us  will disparage this policy, but my blood bank can be 
  slow.  I hate standing  there a couple of hours after CPB, slurping the field 
  and waiting for the blood  products. The platelets were given after the 
  protamine.  The first  hint of trouble was a gush of thin red fluid from the ETT when 
  transferring the  patient from the table to the bed.  The process rapidly 
  progressed, and he  ultimately died 6 hours postop.  
    I'm knowledgeable about a few things- hematology isn't one of  them.  I 
  remember the pathologist saying it was TRALI, as confirmed  histologically.  In 
  21 years of active cardiac surgery, I'd never seen a  case.  Hopefully, it'll 
  be at least another 21 years before I see it  again.  
  Hal 



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