Cléro B, Celton J L, Atinault A, Cazalaa J B, Barrier G
Service d'Anesthésie-Réanimation, Hôpital Necker-Enfants Malades, Paris.
Ann Fr Anesth Reanim. 1989;8(4):357-8. doi: 10.1016/s0750-7658(89)80078-4.
A case is reported of a 73 year old female patient who died during surgery for enlarged nephrectomy as a result of a massive non-cardiogenic pulmonary oedema. She had been given 2 red cell concentrates (450 g) and 3 fresh frozen plasma units (900 g). A postmortem examination did not reveal any pulmonary embolus, acute myocardial infarct, haemorrhage or cardiac tamponade. Further tests on the sera of the 5 plasma donors revealed a neutrophil-specific anti-NA2 antibody. Alveolar leukostasis was confirmed on the postmortem lung slices. This type of transfusion accident occurs for about 1 in 5,000 units transfused, fortunately not all as serious. This case confirms once more that fresh frozen plasma is not the ideal treatment for acute hypovolaemia, 4% human albumin being safer.
报告了一例73岁女性患者，其在因肾肿大行肾切除术的手术过程中因大量非心源性肺水肿死亡。她输注了2单位红细胞浓缩液（450克）和3单位新鲜冰冻血浆（900克）。尸检未发现任何肺栓塞、急性心肌梗死、出血或心脏压塞。对5名血浆捐献者的血清进行的进一步检测发现了一种中性粒细胞特异性抗NA2抗体。尸检肺切片证实存在肺泡白细胞淤滞。这种输血事故约每5000单位输血中发生1例，幸运的是并非所有事故都如此严重。该病例再次证实新鲜冰冻血浆并非急性血容量不足的理想治疗方法，4%人白蛋白更安全。
