Case Report Nama : Ny. Sumirah Umur : 63 th BB : 50 kg RM : 12.23.41.34 Diagnosa pre op : Struma difusa non toksika PS ASA : 2 (Geriatri, special condition airway sulit) OP : Sub total Thyroidectomy k/p Sternotomi Ass Post Op : Sub total Thyroidectomy + Sternotomi + TRALI
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Case Report
Nama : Ny. Sumirah Umur : 63 th BB : 50 kg RM : 12.23.41.34 Diagnosa pre op : Struma difusa non toksika PS ASA : 2 (Geriatri, special condition airway sulit) OP : Sub total Thyroidectomy k/p Sternotomi Ass Post Op : Sub total Thyroidectomy + Sternotomi + TRALI
Opasitas berdensitas massa berbentuk bulat, batas tegas, tepi reguler di R Colli D yg terproyeksi setinggi VC5-VTh 7 sisi kanan yang menyebabkan pendesakan trakea ke sisi kanan dan penyempitan lumen trakea bagian distal tanpa gambaran bulging soft tissue mass di R thoracalis dpt mrpk massa R Colli D s/d Retrosternal
CT Scan thorak + kontras11/3/13
Heterougenous enhancing solid lobulated mass di thyroid lobus kanan, kiri, dan istmus yg meluas ke retrosternal mengisi mediastinum anterior dan posterior terutama posterior hemithorak kanan kiri ( dominan kanan) disertai encasement trachea yg menyebabkan penyempitan lumen trachea dan pembesaran KGB pretrachea mengesan struma multinudusa kemungkinan dengan degenerasi maligna
FNAB 28/3/13
Massa di R colli anterior - Nodular Colloid Goiter
Konsul kardio4/4/13Irama sinus 70 x/mnt, axis N CRI klas 1
Komorbid :1. Geriatri2. Special condition airway sulit
Konsultasi
Dr. Maulydia SpAn- Melaporkan pasien dengan PS ASA 2- ACC dikerjakan dg GA Intubasi, dengan
mempersiapkan ETT dg berbagai ukuran untuk mengantisipasi besarnya lumen trakea yg mengalami penyempitan, persiapan difficult intubation, LD sebelum intubasi, Intubasi sleep non apneu.
GBPT OK 51216/4/13
Jam 10.00 Persiapan alat dan obat GA IV line terpasang berjalan lancar, pasang prekordial
Jam induksi : 10.00 – ( 17.30) insisi I ( SubTotal thyroidectomy ) : 10.30 insisi II ( Sternotomy ) : 14.00 HemodinamikTD S/D : 34-135/ 15-90 mmHgHR : 61-130 x/mntSpO2 : 88-98 %Perdarahan : ± 7000 cc
Durante Op
Perdarahan yang merembes dari tumor bed yang tdk dpt berhenti, ditambah dengan sternotomi yang dilakukan dmn kontrol perdarahan pada tumor bed yang masih belum optimal merupakan kontribusi terbesar perdarahan durante op dan gejolak hemodinamik pada operasi tersebut.
Durante Op
Pemakaian inotropik (dopamin, noradrenalin )Pada saat sternotomi hampir selesai, muncul
– Clinical presentation (“classic”, severe form)• Acute respiratory distress• Pulmonary edema• Hypoxemia• Hypotension• Transfusion usually within 6 hours (majority of cases during
transfusion or within 2 hours of transfusion)
Comparison TRALI TACO
Blood Pressure Hypotension Hypertension
Onset Up to six hrs post transfusion
Usually occurs during or immediately after a transfusion
Chest X-Ray Bilateral pulmonary infiltrates, normal heart
Bilateral pulmonary infiltrates, enlarged heart
Lab tests BNPTNI
<250pg/ml Normal
>250 pg/ml Elevated
temp Normal to elevated Normal
PAWP ≤ 18 higher
Respons to fluid improves worsen
TRALI• Clinical criteria
– Insidious, acute onset of pulmonary insufficiency - Profound hypoxemia PaO2/FiO2 < 300 mmHg Hg regardless of PEEP or O2 saturation of < 90% on room air
– CXR b/l fluffy infiltrates c/w pulmonary edema– Cardiac PA wedge pressure 18 mmHg– No clinical evidence of LA HTN
TRALI: Clinical Presentation
Diffuse Bilateral Pulmonary Infiltrates
TRALI• Syndrome of TRALI (Weber KE et. al., Transfusion Med
Acute Lung InjuryEndothelial DamageDestruction of Alveolar Vasculature Capillary LeakFlooding of Air-Space with protein rich fluid Pulmonary Edema
FIRST: Underlying Inflammatory Condition
Second: Transfusion
How can we prevent TRALI?
• We have evidence that antibodies are responsible for TRALI in a primed host
• How can we identify a primed host?• Fresher product for the primed host?
How can we prevent TRALI?
• TRALI reduction strategies have focused on donors with antibodies and specifically plasma containing products
– Secondary – Measures taken to identify the cause of a reaction that has occurred and prevent it from happening again
– Primary – Preventive measures taken to eliminate the risk before it happens in the first place
How can we prevent TRALI• Secondary…defer implicated donors
– Donors associated with a reported TRALI are investigated for anti HLA and anti neutrophil antibody and deferred if positive
– Pilot 2001 – 2006, SOP 2006• Primary…avoid donors with anti HLA or anti neutrophil
antibody• what have blood suppliers done and what has the effect
been– Donor loss– Reduction of TRALI
Which donors develop WBC antibodies?
• WBC alloimmunization may occur following previous exposure to WBCs through pregnancy or transfusion – 332 female plateletpheresis donors – 17% had detectable anti-HLA antibody– Frequency of HLA antibodies increased with pregnancy:
0 pregnancies: 7.8%1-2 pregnancies: 14.6% 3 or more: 26.3%
Densmore et al. Transfusion 1999;39:103-6
Primary Prevention
• 2003 – UK changed component production policy moving to predominantly male plasma for transfusion
2003 2004 2005
TRALI 36 23 23
Highly likely/probable
22 13 6
Chapman et al. Vox Sang 2006;91(Suppl 3):227
SHOT data• 10 years hemovigilance in UK and impact of preferential
use of male donor plasma• Risk of highly likely/probable TRALI due to FFP decreased
– 15.5 per million units 1999-2004– 3.2 per million units issued 2005-2006 (p= 0.0079)
• Risk of highly likely/probable TRALI due to platelets decreased– 14 per million to 5.8 per million
– Chapman.Transfusion 2009;49:440-452
TRALI reduction measures CBS-predominantly male plasma
• CBS moved to predominantly male plasma for transfusion Oct 2008
• Female plasma diverted fractionation
TRALI Reduction Measures – Platelet Apheresis
• On July 20, 2009 CBS started asking all female platelet donors if they’d ever been pregnant
• Any responding positively redirected to whole blood
Donor Loss YTD
• June 2009 there were 2394 female apheresis platelet donors
• By Nov 2009 only 300 active female apheresis platelet donors
• 32% of the remaining donors converted to whole blood or plasma (approx 765 donors)
• Net loss of approx 1329 donors
Summary Primary Prevention
• Transfuse blood or blood components only if absolutely necessary
• Donor screening for leukocyte antibodies• Avoidance of multiparous female FFP donors• Use of fresh cellular components – as biologically
active lipids accumulate in blood products with storage, fresh cellular components may reduce the risk by preventing exposure of recipient neutrophils to neutrophil-priming agents
Summary Primary Prevention
• Use of solvent detergent plasma – the pooling process decreases the titre of responsible antibodies