Ever See This?

[aredoubleyou]

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Had an emergent to the room 20 something yr old 240 # guy who got hit by a car with a smashed kidney on CT, went to IR where either things got worse or they determined how significant the bleed was (who knows) - doors swing open, pt on table with 2 iv's and a-line - etomidae, sux, tube, cordis to Right IJ, case starts: Open belly, lots of blood pouring out. Ventelating easily, FIo2 of 100%, sats 100%, paO2 i think 200ish. Give about 5 U RBC's, 5 bags of cell saver, 7-8 FFPs, 2 platlets, obviously coagulopathic by looking at surgical field, intraoperative coags and labs cooking.

Then it gets strange. Trauma surgeon wants to extubate, I say no, my attending says yes, so I let the paralytics wear off and put him on pressure support as the fascia is closed. Pt gradually desats, around upper 80's we bag him and sats back up to 100%, we decide he is not able to be extubated. Back on the vent, 5 minutes later sats trend down again quickly, I bag him, still dropping, try recruitment breaths and still dropping, try fast small breaths, still dropping, try the vent with 10 PEEP, still dropping. Call attending, he trys same thing, sats now 60 and the foam comes: obvious pulmonary oedema bubling up and eventually drowning the circut in fluid. So I change the circut and...yellow foamy fluid comes spraying out like a garden hose - not a sink flowing over, not a shaken pop bottle --- like a garden hose, with a fountain of fluid inches in the air- put the new circut on, instantly filled with fluid, stats in 50's on max PEEP of ventilator and still dropping.

I suspect it was likely TRALI from massive blood infusion (he lost 6 L of blood btw in about 1 hr and got a lot of products quickly) - but never have imagined pulm oedema like that - didnt even know such things were possible. Any one ever see that before? Every time we would disconnect the circut (wised up and clamped it between disconnects eventually), fluid would rush out at least at ~20 cc/ sec. His CXR didnt look that bad either - just run of the mill ARDS appearance.

Anyway, ugly case- that kept getting uglier.

 

[Gern Blansten]

Did he bite down on the tube when you tried to wake him up the initial time?
Did he have a head injury?

 

[pushthesux]

Had an emergent to the room 20 something yr old 240 # guy who got hit by a car with a smashed kidney on CT, went to IR where either things got worse or they determined how significant the bleed was (who knows) - doors swing open, pt on table with 2 iv's and a-line - etomidae, sux, tube, cordis to Right IJ, case starts: Open belly, lots of blood pouring out. Ventelating easily, FIo2 of 100%, sats 100%, paO2 i think 200ish. Give about 5 U RBC's, 5 bags of cell saver, 7-8 FFPs, 2 platlets, obviously coagulopathic by looking at surgical field, intraoperative coags and labs cooking.

Then it gets strange. Trauma surgeon wants to extubate, I say no, my attending says yes, so I let the paralytics wear off and put him on pressure support as the fascia is closed. Pt gradually desats, around upper 80's we bag him and sats back up to 100%, we decide he is not able to be extubated. Back on the vent, 5 minutes later sats trend down again quickly, I bag him, still dropping, try recruitment breaths and still dropping, try fast small breaths, still dropping, try the vent with 10 PEEP, still dropping. Call attending, he trys same thing, sats now 60 and the foam comes: obvious pulmonary oedema bubling up and eventually drowning the circut in fluid. So I change the circut and...yellow foamy fluid comes spraying out like a garden hose - not a sink flowing over, not a shaken pop bottle --- like a garden hose, with a fountain of fluid inches in the air- put the new circut on, instantly filled with fluid, stats in 50's on max PEEP of ventilator and still dropping.

I suspect it was likely TRALI from massive blood infusion (he lost 6 L of blood btw in about 1 hr and got a lot of products quickly) - but never have imagined pulm oedema like that - didnt even know such things were possible. Any one ever see that before? Every time we would disconnect the circut (wised up and clamped it between disconnects eventually), fluid would rush out at least at ~20 cc/ sec. His CXR didnt look that bad either - just run of the mill ARDS appearance.

Anyway, ugly case- that kept getting uglier.

I would have loved to have seen the faces of the attendings that voted for extubation as the pulmonary edema floweth...priceless.

Wow..interesting case. I've heard of this happening and always thought the story had been escalated a little bit, but I guess it's possible.

Luckily TRALI usually resolves in 48-72 hours...doesn't it?

I don't understand the interest in extubating a patient like this. Immediate post-op management of this kind of patient is much better (easier for me...safer for the patient) with controlled situations....desaturation and respiratory failure at 2AM really makes you look dumb when you extubate these patients.

 

[aredoubleyou]

Did he bite down on the tube when you tried to wake him up the initial time?
Did he have a head injury?

No, he was only on pressure support, prolly to weak to bite down even if he wanted to. No head injury that I'm aware of. He was AOX3 coming to the room.

 

[aredoubleyou]

Luckily TRALI usually resolves in 48-72 hours...doesn't it?

.

Textbook TRALI yes. This developed into a cannot oxygenate problem. We called for an ICU vent that could deliver more PEEP, which took him almost up to mid 60's sats. Cardiac surgeons meanwhile canulating for ECMO, which between the two got him to sats of 80's. PaO2s in 30s and 40s for a long, long time. We were absolutely helpless. Multiple sticks of diluted epi pushed for near cardiopulmonary collapse. In multiorgan failure now - but improving. Cant believe he survived at all given the magnitude and length of hypoxia...good to be young I suppose.

 

[OB1🤙]

Neurologic status after all that?

Interesting case.

 

[Gator05]

I may have missed this, but was the fluid pink-tinged at all?

What was the rough ratio of red to yellow transfusion products?

I've seen this once. We didn't make it to ECMO, did attempt iNO however. We also had such instability that it was hard to figure out if the hypoxia was from the V or the Q; likely both, with terrible hemodynamics as you described.

I had a second big trauma case like this a few months later, opening multiple cavities for severe poly-trauma and massive resusc on a younger patient. We didn't run into this problem, and I wonder if it was the 2 rounds for Factor 7 that we gave. We gave the second after 20 minutes (and multiple FMS buckets in the interim; you have to wonder about simple washout of these things...) just before the surgeon commented that things were getting wet again.

We've also moved to nearly 1:1 FFP😛RBC based on some of the preliminary Iraq data.

These are rough cases; kudos to getting to ECMO.

 

[KNC]

Textbook TRALI yes. This developed into a cannot oxygenate problem. We called for an ICU vent that could deliver more PEEP, which took him almost up to mid 60's sats. Cardiac surgeons meanwhile canulating for ECMO, which between the two got him to sats of 80's. PaO2s in 30s and 40s for a long, long time. We were absolutely helpless. Multiple sticks of diluted epi pushed for near cardiopulmonary collapse. In multiorgan failure now - but improving. Cant believe he survived at all given the magnitude and length of hypoxia...good to be young I suppose.

Whats TRALI?....I find this case interesting......

 

[periopdoc]

We've also moved to nearly 1:1 FFP😛RBC based on some of the preliminary Iraq data.

Sounds intriguing, where did you find this data?



pod

 

[Planktonmd]

Whats TRALI?....I find this case interesting......

Transfusion induced lung injury.

 

[Trisomy13]

Transfusion induced lung injury.

or Transfusion Related Acute Lung Injury, if you want the acronym to make sense. 😉

 

[beezar]

Yes, I've seen this twice already; supposedly a rare event, but somehow I managed to be lucky... one guy was able to manage with mechanical ventilation and high PEEP, the other with ECMO. Both improved dramatically in less than a week.

But that stuff just spurts out the ETT like a hose. You will never forget it.

 

[Idiopathic]

ive seen this exact scenario with ABO incompatibility. this looks exactly like massive transfusion reaction.

 

[Planktonmd]

or Transfusion Related Acute Lung Injury, if you want the acronym to make sense. 😉

OK professor 😀

 

[MSU spartan]

As a resident 2 years ago I had a case of Trali. I got called 1 am to intubate a big fat lady who received some FFP. RSI yellow fluid just like you said spews out of ETT. Surgeon yelling your in stomach say no way end tidal and breaths sounds bilateral. Unfortunatly patient did not survive past one day. Definitly Trali come to find out patients family member died from a transfusion as well few years back. It was classic TRALI which i will never forget.

 

[Arch Guillotti]

Sounds intriguing, where did you find this data?

I have seen this data too regardign 1:1 txfusion of FFP/PRBC in traumas as well. Unforunately for the life of me I can't remember where[/I]

 

[Arch Guillotti]

Found it:

Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. The Journal of Trauma, Injury, Infection and Critical Care 2007;63(4):805-813.

Background: Patients with severetraumatic injuries often present with coagulopathyand require massive transfusion.The risk of death from hemorrhagic
shock increases in this population. Totreat the coagulopathy of trauma, some
have suggested early, aggressive correction using a 1:1 ratio

Conclusions: In patients with combat relatedtrauma requiring massive transfusion,a high 1:1.4 plasma to RBC ratiois independently associated with improved survival to hospital discharge, primarily by decreasing death from hemorrhage. For practical purposes, massive transfusion protocols
should utilize a 1:1 ratio of plasma to RBCs for all patients who are hypocoagulable with traumatic injuries.

 

[rsgillmd]

There are a bunch of articles out there including the one Arch cited below. Do a search for massive hemorrhage protocol. I did it when we updated our protocol for OB. I got the idea from an anesthesiologist in Columbia (South America). He had published an article, I think in transfusion, describing their successes since changing to 1:1. A 1:1 or 1:1.5 ratio is recommended, because part of the coagulopathy that leads to DIC is dilutional in nature (from our crystalloids and colloids).

Found it:

Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. The Journal of Trauma, Injury, Infection and Critical Care 2007;63(4):805-813.

Background: Patients with severetraumatic injuries often present with coagulopathyand require massive transfusion.The risk of death from hemorrhagic
shock increases in this population. Totreat the coagulopathy of trauma, some
have suggested early, aggressive correction using a 1:1 ratio

Conclusions: In patients with combat relatedtrauma requiring massive transfusion,a high 1:1.4 plasma to RBC ratiois independently associated with improved survival to hospital discharge, primarily by decreasing death from hemorrhage. For practical purposes, massive transfusion protocols
should utilize a 1:1 ratio of plasma to RBCs for all patients who are hypocoagulable with traumatic injuries.

 

[needadvice]

given the massive amount of blood you gave in a short amount of time, likely transfusion circulatory overload. check a BNP next time to help differentiate.

 

[aredoubleyou]

I may have missed this, but was the fluid pink-tinged at all?

What was the rough ratio of red to yellow transfusion products?
.

I think Red to yellow 1:1.5 if you only count pRBCs, probably 1.5:1 if you add in cell saver units

 

[aredoubleyou]

given the massive amount of blood you gave in a short amount of time, likely transfusion circulatory overload. check a BNP next time to help differentiate.

Dont know anything about TACO, Ill look it up sometime - but based on the name I doubt it. dropped a TEE, showing an underfilled left ventricle, RV not impressive. CVP was intermittently monitored and was not very high. Also, I sent coags and platlets midway thru the case and 2 hours later still had not gotten stat results...not sure I'd believe a BNP over a TEE image anyway??

 

[pushthesux]

given the massive amount of blood you gave in a short amount of time, likely transfusion circulatory overload. check a BNP next time to help differentiate.

The BNP wouldn't even be in my top 10 objective measures of volume status in this kind of patient....am I wrong? This is a trauma situation in a young healthy patient and these patients are rarely volume overloaded...or is this too much of a generalized statement?

 

[Gator05]

Maybe not BNP...but did you think of TEE? Normally I don't think it would matter in young healthy folks, but in face of TRALI there's the concern for right heart issues. If you were hypoxic with a full and well-functioning RV, that's a different matter than a crapped out heart and/or over-resuscitation.

 

[desflurane]

Am I the only one here that finds the decision to extubate riDONKulous? What was the argument for? I guess residency can be a time to learn what NOT to do.

 

[aredoubleyou]

Maybe not BNP...but did you think of TEE? Normally I don't think it would matter in young healthy folks, but in face of TRALI there's the concern for right heart issues. If you were hypoxic with a full and well-functioning RV, that's a different matter than a crapped out heart and/or over-resuscitation.

Dropped a TEE as mentioned above, only significant for moderate hypovolaemia. RV was fine, if heart was bad he would have never made itfor sure.

 

[aredoubleyou]

The BNP wouldn't even be in my top 10 objective measures of volume status in this kind of patient....am I wrong? This is a trauma situation in a young healthy patient and these patients are rarely volume overloaded...or is this too much of a generalized statement?

100% agree. Urine output, TEE and progressive change in cvp probablly far more useful.

 

[needadvice]

did not realize you had an echo or cvp monitoring. as you know low filling pressures would be associated with trali while taco is associated with elevated cvp/wedge pressures and an elevated bnp.


its important to make the distinction, because you would be very hesitant to transfuse further in a trali patient without further workup for antibodies in contrast to taco where you further transfusions wouldnt require further testing.