Singh Vijay A, Zeltsman David
Division of Cardiothoracic Surgery, Department of Surgery, North Shore-Long Island Jewish Hospital Systems, New York.
Int J Angiol. 2011 Sep;20(3):173-6. doi: 10.1055/s-0031-1283219.
Transfusion-related acute lung injury (TRALI) is an underdiagnosed and underreported syndrome which by itself is the third leading cause of transfusion-related mortality. The incidence of TRALI is reported to be 1 in 2000 to 5000 transfusions. When combined with uncontrollable bleeding, survival is unachievable. We report the case of a 25-year-old man, who underwent open heart surgery as an infant to correct his congenital heart disease in association with right pulmonary artery atresia. He presented with hemoptysis secondary to aspergilloma and required a pneumonectomy of the nonfunctional right lung. During pneumolysis, significant bleeding occurred from the superior vena cava. The patient required a blood transfusion and was placed on cardiopulmonary bypass to control the bleeding. Simultaneous occurrence of severe pulmonary edema and retroperitoneal bleeding were noted. Approximately 8 L of frothy edema fluid were drained from the only functional left lung starting ~15 minutes after the transfusion and lasting for several hours until the end of the case. It most likely represented TRALI syndrome. Increasing abdominal girth and poor volume return to the pump were consistent with and pathognomonic for retroperitoneal bleeding. Though primary surgical bleeding in the chest was controlled successfully and a pneumonectomy performed without further difficulty, we were unable to separate the patient from cardiopulmonary bypass due to the inability to oxygenate. As a result, we could not reverse the anti-coagulation which potentially exacerbated the retroperitoneal bleeding. After multiple unsuccessful attempts the patient succumbed. This ill-fated case demonstrates the quandary of obtaining vascular access for emergency cardiopulmonary bypass while in the right thoracotomy position. It may be beneficial to have both the femoral artery and vein cannulated before positioning a patient in a lateral decubitus position. In addition, early direct access to the right atrium may obviate a need for femoral venous cannulation. Also, adult extracorporeal membrane oxygenation may be indicated if faced with such a severe pulmonary edema without ongoing hemorrhage.
输血相关急性肺损伤（TRALI）是一种诊断不足且报告不充分的综合征，其本身是输血相关死亡的第三大主要原因。据报道，TRALI的发病率为每2000至5000次输血中发生1例。当合并无法控制的出血时，生存无法实现。我们报告一例25岁男性病例，该患者婴儿期接受了心脏直视手术以纠正其先天性心脏病合并右肺动脉闭锁。他因曲菌球继发咯血，需要对无功能的右肺进行肺切除术。在肺松解术中，上腔静脉发生大量出血。患者需要输血，并进行体外循环以控制出血。同时注意到出现严重肺水肿和腹膜后出血。输血后约15分钟开始，从唯一有功能的左肺引流约8升泡沫状水肿液，持续数小时直至手术结束。这很可能代表TRALI综合征。腹围增加和回输到泵的血量不佳与腹膜后出血一致且具有特征性。尽管胸部原发性手术出血得到成功控制，肺切除术也顺利进行，但由于无法进行氧合，我们无法使患者脱离体外循环。结果，我们无法逆转抗凝，这可能加剧了腹膜后出血。经过多次尝试失败后，患者死亡。这个不幸的病例展示了在右侧开胸位置进行紧急体外循环时获得血管通路的困境。在将患者置于侧卧位之前，同时插管股动脉和静脉可能是有益的。此外，早期直接进入右心房可能无需股静脉插管。另外，如果面临如此严重的肺水肿且无持续出血，可能需要使用成人体外膜肺氧合。
