[HSF] A TRALI case

[Ani Anyanwu]

Hal

Try not transfusing some of those patients and you might be surprised how few of them actually bleed. One of my senior colleagues 3 years ago gave products to over 80% of cases gaving same reasons you do; now he uses products in only 20% and realizes that majority of transfusions were unnecessary (and dangerous - was unexplained morbidity that precipitated the change).

 It is true that most bleeding patients have coagulopathy but it is also true that most coagulopathic (by testing) patients do not bleed. If you are concerned about delays in obtaining products on ICU, rather than transfusing those platelets in the OR, send them up with the patient to ICU and if you see 250 plus in first hour then transfuse them, else you have saved your patient exposure to several (donors') life history.

TRALI is not the only danger of blood. I have a patient (operated yesterday!) now near deaths door after intra-op platelet transfusion caused severe pulm hypertension and abrupt failure of an already borderline RV. His lungs did not escape the exposure either. Could not recover from that - needed crash unto CPB and patient now dying on ECMO. In this case, the transfusion was warranted on both clinical and  TEG grounds, but if, as not infrequently seems the case, surgeons transfuse products just to stop that annoying bloody post op drainage, to shorten period of hemostasis, or to minimize the pagers at night then we will from time to time encounter patients who die avoidably because of a blood transfusion.

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 6:44 AM
  Subject: Re: [HSF] A TRALI case


  Ani,
    A few provocative statements, I'd say!  If you think it's  uncommon for 
  abnormal coagulation profiles to cause postop bleeding, then your  experience is 
  significantly different from mine.  I can't tell you the  number of patients 
  I've seen postop with thin bloody drainage who stop bleeding  once the INR or 
  the platelet count has been corrected.
    You are absolutely right that ECMO should have been started.   
  Unfortunately, the nurse taking care of the patient didn't notify me of the  deteriorating 
  oxygenation and hemodynamics until very late in the course.   As soon as I 
  heard what was going on, I ran back to the hospital and inserted an  IABP.  
  Twenty minutes later, the patient coded.  Having never seen or  heard of TRALI, I 
  thought that this must be some sort of cardiac  dysfunction.  In the future, 
  my index of suspicion will always be there,  and, of course, I'll institute 
  ECMO sooner than later.
  Hal



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