Transfusion-Related Acute Lung Injury (TRALI)

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Offline Danielle

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Transfusion-Related Acute Lung Injury (TRALI)
« on: March 02, 2006, 07:38:26 AM »
I need to post this here for you guys, because I've had a very horrible experience with this particular transfusion reaction.  I almost died because I wasn't taken care of properly, and ended up on life support because of it.  Please be aware of this transfusion reaction, as it's the 3rd leading cause of death from transfusions.  If you guys have any questions, I'll be happy to answer for you. 

This happened to me in March 2000, and it still haunts me 'til this day.  I have nightmares about it all the time, because I was aware of that ventilator breathing for me and the whole experience was just awful.  It was the most horrifying thing in my life, and I never want any of you to have to go through this.  Please remember the symptoms, and make sure you are aware of the treatment.  Diuretics do not work!  They were pumping me with diuretics and it only made things worse.  My lungs were filled with fluid and blood, and no one knew what to do.  My transfusion wasn't even stopped when it should've been.  It took them 45 minutes to shut it off, because they didn't think anything was wrong when I kept telling them something was wrong.  I couldn't breathe, I was freezing to death, and coughing up blood.  Even after I turned blue and my oxygen saturation (which is supposed to be 100) was at 50, I still didn't get seen by the doctor until 4 and 1/2 hours later!  By the time they got me admitted upstairs, I was practically dead and they had to intubate me.

I never want this to happen to anyone, so please recognize the symptoms and alert someone immediately if you feel anything weird.  And shut the transfusion off if no one else will.  I couldn't do it myself because I couldn't get up.  Everything was done the wrong way, and my life almost ended because of it.  Please be aware of this, and all other transfusions reactions.  This one can be quite deadly.   :sadyup

Also, the transfusion that I reacted to was donated by my good friend.  Supposedly, she had some type of protein in her body from having three children, and my body basically turned on me and attacked my lungs.  This protein can be tested for, but unfortunately the blood bank doesn't have a standard procedure of doing that because it will cost more money.  And we all know how saving money is more important than saving lives, right?  :rolleyes  I don't even want to go there, because my anger will return.

Anyway, I am getting washed packed cells again because of this reaction.  I used to get washed blood when I was in a different hospital, but when I moved to my current hospital, they wouldn't do it because it was too expensive.  *big shock*  So, I've been getting the washed blood ever since, but now the blood bank is fighting with me to end that because they want to get rid of their machine that washes it to (again) save money.   :rolleyes  They are telling me that I'm the only one in the hospital that uses it, so they want to get rid of it.  You know what I say?  TOO BAD!   :mad  We should all be getting washed blood!  Too expensive?!  Aren't we worth it?  :huh   They can fight with me all they want, I'm not going back to unwashed blood and risking my life again.  I had one TRALI, I don't want another.   :hmph

I'm telling you guys, if you want something, please fight for it!  We deserve it!  Don't let anyone treat you like you're worthless, because you're NOT!

Be well, and be aware of everything going on.  Don't rely on the medical staff for everything.  They cannot tell you what you're feeling.  Only you can tell them that.  And if they don't believe you, MAKE them believe you.

I'm going to end my rant here.  Thanks for reading.   :heartred



TRALI: Transfusion Related Acute Lung Injury

Transfusion related acute lung injury (TRALI) is best described as a clinical constellation of signs and symptoms including dyspnea, cyanosis, hypotension, fever and chills along with physical findings of bilateral pulmonary edema. The symptoms typically begin within 1-2 hours of transfusion and usually are present by 4-6 hours. The severity can range from mild to severe but is related to the degree of hypoxia.

The syndrome is associated with significant morbidity and has been reported as the third most common cause of a fatal transfusion reaction. In a series of 36 patients with TRALI, all required oxygen support for a mean of 40 hours.  Mechanical ventilation was required in 72 percent; TRALI was determined to contribute significantly to mortality in 6 percent.

TRALI most often is associated with transfusion of whole blood, packed red blood cells (pRBCs) and fresh frozen plasma (FFP). There are rare reports of TRALI following transfusion of granulocytes, cryoprecipitate, platelet concentrates and apheresis platelets. Infusion of even very small volumes of blood can trigger this reaction. Estimates of frequency have ranged from 0.014 percent to 0.02 percent per unit transfused and from 0.04 percent to 0.16 percent per patient transfused.


Radiographic Findings

The development of bilateral pulmonary infiltrates after transfusion, without evidence of cardiac compromise or acute volume overload, should lead to suspicion of TRALI. The pulmonary infiltrates appear at the time of the reaction and resolve within 96 hours in about 80 percent of affected patients. Arterial blood gas values typically show hypoxemia and respiratory alkalosis paralleling the changes seen on chest x-ray and physical exam. Infiltrates may persist for at least 7 days in the remaining 20 percent. Persistence of infiltrates has been associated with difficulty weaning from mechanical ventilation. The radiographic findings tend to be more remarkable than the physical findings.

Etiology

Classically, the etiology of TRALI has been attributed to the presence of leukocyte antibodies in the plasma of multiparous donors directed against recipient white blood cells (WBCs). Granulocyte or HLA class I antibodies are found in at least one donor in about 70 percent of cases.  In some cases, HLA class II antibodies in donor plasma have been detected against recipient cells.  The exact specificity of the antibody involved and documentation of the presence of the corresponding antigen in the recipient have been determined in only a few cases of TRALI.

TRALI

Clinical Picture:

  • Noncardiogenic pulmonary edema*
  • Dyspnea*, cyanosis*, hypotension*, fever, chills
  • Develops within 1-2 hours of transfusion. Usually present by 4-6 hours
  • Difficult to distinguish from Acute Respiratory Distress Syndrome

Pathogenesis:

  • Sequestration of WBCs in pulmonary microvasculature leads to increased vascular permeability and pulmonary edema


Etiology:

  • Antibodies against granulocyte, HLA class I or class II antigens
  • Biologically active lipids in stored cellular blood compo-nents
  • Pulmonary edema arises from capillary injury rather than volume overload


Treatment:

  • Supportive ventilatory assistance
  • Maintenance of hemodynamic status (e.g., saline infusion)
  • Diuretics are contraindicated


Less often, leukocyte antibodies, directed against donor white blood cells, are identified in the recipient. Interdonor reactions, caused by the interaction in the recipient of leukocyte antibodies from one donor with the leukocytes of another donor have also been reported. Popovsky et al. have hypothesized that donor antibodies more commonly cause TRALI than recipient antibodies because the former are able to react with the entire circulating and marginating pool of WBCs in the recipient.  Antibodies in the recipient have a much smaller pool of donor WBCs in a blood component with which to react.

The pulmonary edema in TRALI is attributed to WBC-antibody interaction, with subsequent sequestration of WBCs in the pulmonary microvasculature, leading to increased vascular permeability and accumulation of fluid and protein in the alveoli.

Another hypothesis of the etiology of TRALI is that biologically active lipids in stored blood components enhance polymorphonuclear cell (PMN) NADPH oxidase activity.  This priming activity, however, is not present in non-cellular blood components or fresh cellular blood components.

Silliman et al. advanced a two-event hypothesis to explain the etiology of TRALI.  The first event consists of a predisposing condition. The second is the infusion of biologically active lipids or antibodies to leukocytes in stored cellular blood components. These researchers demonstrated that there was significantly more PMN-priming activity present in post-transfusion samples from 10 patients who had TRALI reactions compared to their pre-transfusion samples or in pre- and post-transfusion samples from 10 control patients with only febrile or urticarial transfusion reactions. Additionally, all 10 patients with TRALI had a predisposing condition including infection, cytokine administration, recent surgery or massive transfusion. Only 2 of the 10 patients with febrile or urticarial reactions had a similar predisposing condition.

Diagnosis

The diagnosis of TRALI is based primarily upon clinical signs and symptoms, not laboratory findings. It is important to determine that the pulmonary edema is noncardiogenic, because it is treated differently than cardiogenic or volume overload types of pulmonary edema. Noncardiogenic pulmonary edema is clinically distinguished from other forms of pulmonary edema based upon normal to decreased pulmonary capillary wedge pressure, normal pulmonary artery pressure, absence of jugular venous distention, absence of murmurs or gallops, normal cardiac silhouette, absence of pulmonary vascular congestion and no evidence of myocardial infarction by EKG and enzyme testing.

Laboratory confirmation of the clinical diagnosis of TRALI, although important, is performed at a later date. The donors of all components transfused within 6 hours of initiation of the reaction should be screened for the presence of granulocyte and HLA class I antibodies. If a large number of donors are involved, female donors or multiparous female donors can be screened for antibodies first. Then, if those donors are negative for antibody, male donors should be screened. If all of the implicated donors' units are negative, including for HLA class II antibodies4, the patient should be tested for leukocyte antibodies. To prove the diagnosis, the antibody present in the donor (or rarely the recipient) should correspond to an HLA or granulocyte antigen present in the recipient (or donor).

Treatment

Corticosteroids, epinephrine and diuretics traditionally have been used to treat TRALI. However, since the pulmonary edema in TRALI is not related to fluid overload or cardiac dysfunction, but to altered vascular permeability in the lungs with exudation of fluid and protein into the alveoli, it is logical that maintenance of adequate circulating volume is the most beneficial and appropriate therapy.  Ventilatory assistance and circulatory support are the mainstays of treatment of TRALI; because the disease is self-limited, the majority of patients will respond to these therapies alone. The use of corticosteroids remains controversial. Since the pulmonary edema is due to capillary leak syndrome and is not secondary to volume overloaddiuretic use may be detrimental and could lead to hypotension, and decreased cardiac output.

Prevention

Several approaches to the prevention of TRALI have been recommended. Most include limiting the amount of plasma transfused from implicated donors by diverting plasma to recovered plasma and using pRBCs with either washed or frozen-deglycerolized. Popovsky et al. suggested that implicated donors should be told not to donate again.

Given the rarity of TRALI, a more moderate approach probably is more realistic. The blood center that supplied the blood component should be notified. Any remaining blood product should be returned for studies, such as screening for HLA antibodies in the donor. HLA typing of the recipient will assist in determining specificity. Plasma from implicated donors should be diverted for protein fractionation. Transfusion of pRBCs from such donors when preserved in an anticoagulant-preservative solution like AS-2 probably is acceptable due to the small volume of plasma present in this component.

http://www.scbcinfo.org/publications/bulletin_v3_n1.htm



*Pulmonary Edema = Fluid accumulation and swelling in the lungs
*Dyspnea = Difficulty breathing
*Cyanosis = Blue/Purple color of the skin from lack of oxygen
*Hypotension = Low blood pressure


If you guys are unsure of any other medical terms, just let me know and I'll explain. :)
« Last Edit: March 15, 2008, 03:56:14 AM by Danielle »

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Offline §ãJ¡Ð ساجد

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Re: Transfusion-Related Acute Lung Injury (TRALI)
« Reply #1 on: March 02, 2006, 10:30:51 AM »
Get ready for another shocker!

Symptoms like the ones you described are expereinced by everyone all the time here, including yours truly!

The only solution we have here is that the staff stops the transfusion and give an injection by the brand name of "Avil" then again resume the transfusion when the patients feels better.

I've experiencd it too. The injection is a terible experience and makes you feel nauseating and rush to the toilet for vomiting and urination.
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Offline Smurfette

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Re: Transfusion-Related Acute Lung Injury (TRALI)
« Reply #2 on: March 02, 2006, 11:58:21 PM »
Hello All,

Well Danielle what you have described is very good..I have had it as well in 1995 but luckily for me the nurses and doctors seen me straight away and I didnt have to be put on a respirator!!!!

I noticed there was something wrong with me when I started to get a really bad headache and then all of a sudden I started to turn blue....

I was on oxygen though for a week or so and then I fully recovered....I too was victimised of hospital protocol saying that its too expensive to have wash blood...

But now all I get is washed blood with a filter as well and hydrocortisone on top to stop me from reacting like that again...

I know what its all about....


Take Care
 :veil

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Offline Poirot

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Re: Transfusion-Related Acute Lung Injury (TRALI)
« Reply #3 on: March 03, 2006, 01:21:20 PM »
I need to post this here for you guys, because I've had a very horrible experience with this particular transfusion reaction.  I almost died because I wasn't taken care of properly, and ended up on life support because of it.  Please be aware of this transfusion reaction, as it's the 3rd leading cause of death from transfusions.  If you guys have any questions, I'll be happy to answer for you. 
This happened to me in March 2000, and it still haunts me 'til this day.  I have nightmares about it all the time, because I was aware of that ventilator breathing for me and the whole experience was just aweful.  It was the most horrifying thing in my life, and I never want any of you to have to go through this.

That is a truly horrible, horrible experience that you have recounted here. To not be able to breathe, and see yourself turning blue and not have the energy to stop the transfusion ..... wow! that is a LOT of trauma  :(  And, then have the doctor give you the wrong medications .... Gleeps  :quiver

Thanks for sharing the experience/symptoms with us. Although I do get washed packed RBCs from my centre, I am going to look out for these indicators more closely now ....

And, you poor girl, everything does happen to you, does it not?  :console

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Offline Poirot

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Re: Transfusion-Related Acute Lung Injury (TRALI)
« Reply #4 on: March 03, 2006, 01:26:35 PM »
I too was victimised of hospital protocol saying that its too expensive to have wash blood...

I really do not believe this ... if centres in India can provide washed blood to Thal patients, hospitals in USA and Australia think it is too expensive? ??? And, this is with the insurance companies paying for it? A really sorry state of affairs.

There are some "small, private centres" in Bombay that I know does not provide washed RBCs, and does that trick with Avil, that Sajid talked about. But, the hospitals usually do provide washed, packed RBCs.

Guys from other cities in India - what do they provide you?

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Offline §ãJ¡Ð ساجد

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Re: Transfusion-Related Acute Lung Injury (TRALI)
« Reply #5 on: March 03, 2006, 04:10:05 PM »
Hi Danielle,

               Just wanted to let you know that the consistuentes of Avil injection is Pheniramine maleate. I had to close my previous post early as I had to go shopping.

               The injection is quite strange. Although the nurse injects the few mLs slowly directly into the brown rubber part of the I.V line with the syringe. The process is very painfull and the entire arm feels pain as if the veins are on fire! I have had other injections taken in via the rubber part of the line, but they were totally painless! since you're not getting pricked and the injection flows through the cannula.

               Anyway after the injection you feel very weak as if your heart has completely stopped and the ears are no longer working, you fell even more cold and this adds to the chills that we are already having. Lastly you have this urge to puke which most of the small childern do on the spot(I know that there is an emoticon for it; which I am not going to use! ewww  :winkblue). After that you slowly start to feel better after which the transfusion continues!

               I feel it quite often but I don't call the nurse!  :wink just to avoid that dreadful and painful injection. I just stop the transfusion myself by reaching out to that regulator control and wait till I feel better!
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Offline Danielle

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Re: Transfusion-Related Acute Lung Injury (TRALI)
« Reply #6 on: March 04, 2006, 07:33:44 AM »
I feel it quite often but I don't call the nurse!  :wink just to avoid that dreadful and painful injection. I just stop the transfusion myself by reaching out to that regulator control and wait till I feel better!

Sajid, that injection sounds aweful, but please do not keep any of your symptoms from the medical staff!  Honestly, if you were having a TRALI, you wouldn't have been able to restart your blood when you were feeling better.  It would've taken its course without any treatment, so that doesn't really sound like a TRALI to me.  I don't doubt that you've had one, but there is some type of protein reaction with a TRALI, and you need immediate treatment with it.  The blood should not be restarted if you are feeling these symptoms.  Please tell your nurse the next time you feel something weird.  I know that you don't want to get the Avil again, but it may save your life.  Those times that you were given the Avil, you were probably having a TRALI, so I think that medication is definitely better than being on life support.  I'm glad they intervened on time and that you are ok.

We don't use Avil over here.  Not that I know of anyway.  That medication sounds crazy.   :scared

Thank you for the information.  I'm not happy to hear that this is going on in other places, but it's good to know of different treatments (ie, Avil) that are being used.  :)

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Offline Danielle

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Re: Transfusion-Related Acute Lung Injury (TRALI)
« Reply #7 on: March 04, 2006, 07:35:28 AM »
Hello All,
Well Danielle what you have described is very good..I have had it as well in 1995 but luckily for me the nurses and doctors seen me straight away and I didnt have to be put on a respirator!!!!
I noticed there was something wrong with me when I started to get a really bad headache and then all of a sudden I started to turn blue....
I was on oxygen though for a week or so and then I fully recovered....I too was victimised of hospital protocol saying that its too expensive to have wash blood...
But now all I get is washed blood with a filter as well and hydrocortisone on top to stop me from reacting like that again...
I know what its all about....
Take Care
 :veil

Smurfette, I'm so glad that you were taken care of on time!  That's the most important thing with a TRALI.  I wish they would've intervened on time with me.  Maybe I would've have had to experience that horrible situation.  The whole thing was a horror. :(

I'm so glad you're ok. :)

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Offline Danielle

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Re: Transfusion-Related Acute Lung Injury (TRALI)
« Reply #8 on: March 04, 2006, 07:49:11 AM »
That is a truly horrible, horrible experience that you have recounted here. To not be able to breathe, and see yourself turning blue and not have the energy to stop the transfusion ..... wow! that is a LOT of trauma  :(  And, then have the doctor give you the wrong medications .... Gleeps  :quiver
Thanks for sharing the experience/symptoms with us. Although I do get washed packed RBCs from my centre, I am going to look out for these indicators more closely now ....
And, you poor girl, everything does happen to you, does it not?  :console

Poirot, you have no idea what they put me through.  I haven't even told you guys most of it.  That was only a small piece. :(  One of the most horrible things that I went through with that TRALI, is that when they sedated me to intubate me, they didn't sedate me enough, and they gave me this medication to paralyze me, so I would relax and wouldn't pull the tube from my throat.  So, I was paralyzed and awake, and felt everything they were doing to me.  I felt them intubate me, tape my eyes closed like I was dead (so they wouldn't dry out), put the urinary catheter in me, and then heard everyone talking around me, as if I was in my coffin and no one knew I was awake.  I was trying to move my fingers or blink, but I couldn't.  I couldn't move a muscle, and I felt that damn machine breathing for me.  I couldn't tell them I was in pain, I couldn't say anything at all.  Thank God, my best friend, who is like my sister, felt that something was wrong.  Her and I have been like twins for over 12 years.  We finish each other's sentences, and know each other inside and out.  If she wasn't there, and told the nurse that she felt something was wrong, they would've never known I was awake.  My best friend made them take the tape off my eyes, and they realized I was awake after that.   :mad

It was the most horrifying experience I have ever had in my entire life.  I felt like I was buried alive and couldn't tell anyone that I was aware of anything.  I felt the tube in my throat gagging me, but I couldn't use my muscles to cough or swallow.  They eventually unparalyzed me, and I was able to write them notes on pieces of paper.  The first thing I said was "DO NOT PARALYZE ME EVER AGAIN!"  and they made me promise I wouldn't pull the tube from my throat, and I promised them.

Again, this is only a piece of the story.  I went through an extremely horrifying experience, and I never want anyone to have to go through what I did, because I have nightmares about it all the time.  I almost didn't get to see my newborn niece, who was born the day before I had that TRALI.  These doctors and nurses need to learn how to react quicker, and to take their patient's word when they say that something is wrong.  We know better than they do when it comes to this stuff.

I have to relive this experience each day when I look in the mirror.  The nurses who were taking care of me when I was on the respirator didn't see the tube slipping from my throat and the rubber piece on my mouth that was holding the tube in, pulled all the skin off my lip.  So, now I have a scar above my lip that reminds me each and every day of what they put me through.  :sigh

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Re: Transfusion-Related Acute Lung Injury (TRALI)
« Reply #9 on: March 04, 2006, 08:27:02 AM »
This is indeed horrifying! You truly are a brave soldier :thumbsup We all are glad that you are with us. Don't get dis-hearted that you suffered all that. God tests His good people in different ways and rewards the one who are successful! May God bless you with all the rewards throughout your life. Amen!
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Offline Andy Battaglia

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Re: Transfusion-Related Acute Lung Injury (TRALI)
« Reply #10 on: March 04, 2006, 08:35:44 AM »
Danielle,

Your experience is like something from a horror movie. You'd think they'd have the sense to make sure you were unconcious before proceeding. An experience like that can be very emotionally scarring. I'm glad you survived all of these things that have happened to you over the years. And I'm glad you're willing to share your experience. Everyone needs to know the signs of a TRALI and I would also say that I know from my own experience that talking about it does help in dealing with it. We've got a great group of people here and the support offered each other is a wonderful thing.

I am always amazed at the strength and will that thals have and I greatly respect it. And Danielle, you're an inspiration. In spite of everything you still have a great atttiude.  :thumbsup
Andy

All we are saying is give thals a chance.

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Offline Danielle

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Re: Transfusion-Related Acute Lung Injury (TRALI)
« Reply #11 on: March 04, 2006, 08:50:01 AM »
Thank you, Sajid and Andy.  I'm very happy to still be alive and be here with you guys.  What has happened to me in my life has scarred me in many ways, but I have always told myself that I would not let it beat me.  I'm not going to let this disease get to me so easily.  It's testing me each day, and it will have to work a lot harder than it has to win this fight, because I'm not going down without a battle.  None of us should.

Each time something bad happens to me, I use it to my advantage.  Mostly, I use it to help others, so maybe they won't have to be put through what I have.  I also use it as a means to gain more knowledge.  People ask me all the time why I haven't sued for each time something horrible happened to me, at the hands of these medical professionals.  My answer ... what will that do?  Will it remove the scars from what happened to me?  No.  Will it erase the fact that it happened at all?  No.  It will only drain me of more energy, and create enemies.

What I will do, though ... is warn every single person I come in contact with, that may end up in the same situations that I have been in.  That's all I can do.   :dunno

I love you guys, and I'm so glad I have this group to share my feelings and to help others as well.  I have been though a lot in my 29 years, and I'm sure you'll be hearing about more of my mishaps in the future, and you may even find yourselves saying "oh geez, not her again with another crazy story" ... but maybe it will help someone else in the long-run.  The last thing I'd ever want to do is upset anyone, or bring anyone down.  I just want to create some kind of awareness.  That's all.   :sadyup

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Offline Smurfette

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Re: Transfusion-Related Acute Lung Injury (TRALI)
« Reply #12 on: March 04, 2006, 11:21:52 AM »
Well Danielle,

I think that most of us have been through alot in their time...I have been through quiet abit myself in my 37yrs...Have you ever been given someone elses blood group....

Well it happened to me in 96.... I was given A+ blood instead of O+.... Yes it does happen!!!!

Well I can tell you I wasnt very well at all when that all happened....

It was given to me by accident, that shouldnt have happened....My blood bag was next to the other one and while the nurses did check them together they didnt separate them...so the nurse just pick up one without checking it and hung it....Untill I started to feel quiet sick and got up to check if that unit was mine and i yelled saying " why am I having someone else's blood.." they all froze and panicked....

To cut a long story short, I recovered, sued the hospital and sacked the nurse that gave me the blood cause i didnt have faith in her at all after that...I am still weary of going to hospital these days...but we have a good nurse that looks after us and I am at ease....

But I wouldnt want to go through anything like that again in my life...

Take care all
 :veil

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Offline Poirot

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Re: Transfusion-Related Acute Lung Injury (TRALI)
« Reply #13 on: March 04, 2006, 01:04:21 PM »
Poirot, you have no idea what they put me through.  ...
It was the most horrifying experience I have ever had in my entire life.  I felt like I was buried alive and couldn't tell anyone that I was aware of anything. 

Jeeez, that is really straight out of a horror movie, as Andy says. And, the worst part of it is that it was due to the incompetence of the doctors and nurses who are there to help!!! Un-f***ing-believable.  :mad

You should have sued the hell out of them  .... made their malpractice insurance costs go up. It's alright educating the rest of us  :hug, but some of these people do not deserve to be doctors and need be to be run out of business  :mad

Really glad that you made it through all that crap and are stronger for it.

Salute.

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Offline Poirot

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Re: Transfusion-Related Acute Lung Injury (TRALI)
« Reply #14 on: March 04, 2006, 01:13:53 PM »
Just wanted to let you know that the consistuentes of Avil injection is Pheniramine maleate.

They do use Avil a lot in India, too. But, you should not be getting such a terrible reaction from it. While the injection is the stronger form, you do get it in a tablet form, too.

As far as I know, Avil is some kind of an anti-allergic/immuno-suppresant drug, not related to TRALI, at all. It suppresses the febrile (fever-like) reactions that you get because your body's immune system reacts to the antibodies/proteins/gunk that you are getting in the transfused blood. This usually happens if you are not getting washed blood, sometimes even with washed blood.

But, here's the deal: you should not need to use Avil in more than 1 out of 50 transfusions, maybe. If you do, then there's some problem with the "washing" process.  You should check this out - its not good if you are getting a febrile reaction every time you take a tx.

Cheers


 

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