Case of transfusion-related acute lung injury associated with severe intraoperative hypoxemia

A 39-year-old woman, undergoing debridement and flap reconstruction for a soft tissue infection in an upper limb, developed transfusion-related acute lung injury (TRALI) and hypoxemia after an intraoperative transfusion. Perioperatively, she received 8 units of packed red blood cells (RBCs) and 5 units of fresh frozen plasma. Shortly thereafter, hemoglobin oxygen saturation decreased from 100% to 94%, as measured with a pulse oximeter. Chest radiography showed diffuse bilateral pulmonary edema without heart enlargement and echocardiography revealed normal cardiac function. Based on the findings and clinical course, we diagnosed TRALI, started respiratory support with positive endexpiratory pressure ventilation, and administrated sivelestat and dopamine. Hemodynamics and pulmonary vascular permeability were assessed using transpulmonary thermodilution method (PiCCO, PULSION Medical Systems), which enabled determination of cardiac output and extravascular lung water index (EVLWI). EVLWI is useful for quantification of pulmonary edema, a beneficial indicator of cardiorespiratory management. Pulmonary edema improved and the trachea was extubated 34 hours after surgery. Antibodies against HLA were detected in the RBC donor serum sample, and a crossmatch test between the patient lymphocytes and donor serum was positive. We concluded that perioperative transfusion of blood components has a potential to provoke serious TRALI.