TRALI: A volley of caution

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The author's explanation of the mechanism of artifact is unlikely. Electrocautery is a high frequency signal. If at all there is an interaction between a genuine.

[Downloaded free from http://www.annals.in on Friday, April 13, 2018, IP: 186.84.132.81] Letters to Editor

The author’s explanation of the mechanism of artifact is unlikely. Electrocautery is a high frequency signal. If at all there is an interaction between a genuine cardiac signal and an electrocautery signal, the most likely scenario would be loss of cardiac signal. The ST segment depression, as shown in ECG by the authors, is more likely due to procession of ECG signal by monitor. The filters within the monitor depending on their cutoff frequency can distort ST segment. “Monitor” mode is more likely to corrupt ST segment, which is a low frequency signal. I agree with the authors that ECG artifacts should be considered when changes are intermittent and coinciding with the use of specific equipment.[3]

Santosh Patel Department of Anaesthesia, Rochdale Infirmary, Rochdale OL12 0NB, United Kingdom Address for correspondence: Dr. Santosh Patel, Department of Anaesthesia, The Royal Oldham Hospital, Oldham, OL1 2JH, United Kingdom. E‑mail: [email protected]

REFERENCES 1. 2. 3.

Jain A, Solanki SL, Sahni N, Sharma A. Artifactual ST segment depression induced by electrocautery. Ann Card Anaesth 2011;14:164‑5. Yang H. Intraoperative automated ST segment analysis: A reliable ‘black box’? Can J Anesthe 1996;43:1041‑51. Patel SI, Souter MJ. Equipment‑related electrocardiographic artifacts: Causes, characteristics, consequences, and correction. Anesthesiology 2008;108:138‑48. Access this article online Quick Response Code:

Website: www.annals.in PMID: 22234030 DOI: 10.4103/0971-9784.91469

TRALI: A volley of caution The Editor, Having read with great interest the article by Scott BH on blood transfusion, [1] I would like to focus on a potentially dangerous complication– Transfusion‑related acute lung injury (TRALI). 86

The incidence of TRALI has been estimated to be 0.014%–0.02% per unit transfused (mortality rate of 5%–8%). A study showed that in critically ill medical patients, development of TRALI, apart from prolonged mechanical ventilation, ICU and hospital lengths of stay, is independently associated with decreased long‑term survival (74.3% mortality at 2 years).[2] Plasma from female donors [relative risk (RR) of 19] is associated with an increased risk of TRALI, compared to RBCs from female donors (RR of 1.2). Maternal donation of blood products in pediatric surgeries is a potential risk factor for TRALI because of the development of antileukocyte antibodies during pregnancy. Leucoreduction is shown to cause a substantial reduction in TRALI rate (83%), especially for red blood cell (RBC) and platelet (PLT) transfusions. Significantly greater accumulation of pulmonary granulocytes and higher serum MIP‑2 in mice with severe combined immunodeficiency, upon infusion of anti‑MHC (H‑2Kd) class I antibody clone34‑1‑2s, points to the protective role of recipient T and B lymphocytes in suppressing TRALI (perhaps by modulating recipient chemokine production). [3] Passive transfer of donor antibodies [HLA class I or II or neutrophil antibodies directed against antigens carried on the recipient’s (patient’s) leukocytes] causes an antigen/antibody interaction resulting in the recipient’s neutrophils to be deposited in the alveolar capillaries. The subsequent damage causes fluid leakage into the air spaces resulting in respiratory distress. Neutrophil antibodies (HNA‑3a) predominate (22%) TRALI compared to HLA class I or HLA class II antibodies (1%). The “2‑hit” model, activation and sequestration of neutrophils in the pulmonary vasculature followed by transfusion of a biologic response modifier such as antileukocyte antibodies, is supported in many studies. A retrospective cohort study showed that the risk factors for TRALI were emergency cardiac surgery, hematologic malignancy, massive transfusion, sepsis, mechanical ventilation, and high acute physiology and chronic health evaluation II score whereas pneumonia was a negative predictive factor. Also, 90‑day survival was lower compared with transfused control subjects and acute lung injury control subjects (53% vs. 75% and 83%).[4] Another study showed that ICU patients with end‑stage liver disease (ESLD) presenting with GI bleed develop TRALI more frequently than those without ESLD (29% versus 1%). Fresh frozen plasma Annals of Cardiac Anaesthesia    Vol. 15:1    Jan-Mar-2012

[Downloaded free from http://www.annals.in on Friday, April 13, 2018, IP: 186.84.132.81] Letters to Editor

(FFP) is temporally associated with TRALI in 86% of the cases. Patient‑specific risk factors include MELD score, admission serum albumin level, and presence of ALI risk factors.[5] Three life‑threatening (refractory to standard therapy) cases of TRALI are reported to have been successfully treated with ECMO (Extracorporeal membrane oxygenation). The longer duration of neutrophil sequestration in the lung without concomitant pulmonary capillary damage may cause absence of CXR (Chest X-ray) infiltrates and hence demands higher index of suspicion in all cases of transient acute leukopenia post transfusion (regardless of CXR findings). TRALI could be a devastating complication of transfusions and appropriate preventive strategies and utmost vigilance can help escape its catastrophes.

Dilip Gude Department of Internal Medicine/Critical Care, Medwin Hospital, Nampally, Hyderabad, Andhra Pradesh, India Address for correspondence: Dr. Dilip Gude, AMC, 3 Floor, Medwin Hospital, Chirag Ali Lane, Nampally, Hyderabad, Andhra Pradesh ‑ 500 001, India. E‑mail: [email protected] rd

REFERENCES 1.

Scott BH. Blood transfusion in cardiac surgery: Is it appropriate? Ann Card Anaesth 2007;10:108‑12. 2. Li G, Kojicic M, Reriani MK, Fernández Pérez ER, Thakur L, Kashyap R, et al. Long‑term survival and quality of life after transfusion‑associated pulmonary edema in critically ill medical patients. Chest 2010;137:783‑9. 3. Fung YL, Kim M, Tabuchi A, Aslam R, Speck ER, Chow L, et al. Recipient T lymphocytes modulate the severity of antibody‑mediated transfusion‑related acute lung injury. Blood 2010;116:3073‑9. 4. Vlaar AP, Binnekade JM, Prins D, van Stein D, Hofstra JJ, Schultz MJ, et al. Risk factors and outcome of transfusion‑related acute lung injury in the critically ill: A nested case‑control study. Crit Care Med 2010;38:771‑8. 5. Antonelli M, Azoulay E, Bonten M, Chastre J, Citerio G, Conti G, et al. Year in review in Intensive Care Medicine 2010: III. ARDS and ALI, mechanical ventilation, noninvasive ventilation, weaning, endotracheal intubation, lung ultrasound and paediatrics. Intensive Care Med 2011;37:394‑410. Access this article online Quick Response Code:

Website: www.annals.in PMID: 22234031 DOI: 10.4103/0971-9784.91471

Annals of Cardiac Anaesthesia    Vol. 15:1    Jan-Mar-2012

Lumbar epidural analgesia in pain management of Nuss procedures: Pediatric case The Editor, The Nuss operation is a minimally invasive technique for repair of pectus excavatum. Postoperative pain is the major problem. [1] Especially, satisfactory postoperative analgesia is essential to enable the pediatric patients to maintain bed rest. In this study, we aimed to present two pediatric cases of Nuss procedure in which effective analgesia was achieved by lumbar bolus dose of an epidural opioid and continuous local anesthetic + opioid infüsion. The pectus index for our two male cases (5 and 6 years old) were 3.5 and 5.8 (normal,