Abstract
Overall, there are several components that we believe are critical for the successful investigation of a suspected case of TRALI. One is verbal communication with the hospital transfusion service and the clinicians taking care of the patient, the importance of which can not be overstated. Data that may be missed or understated on a form are often made clear when questions are asked directly to the clinician. Additionally, communication with the clinical staff improves TRALI education and awareness and streamlines the reporting of future suspected TRALI cases. In short, verbal communication with the hospital transfusion service and clinical staff facilitates a timely and thorough investigation. It also ensures the capture of vital information that assists in the clinical diagnosis and donor management of suspected TRALI cases. Equally important is a clinical classification that is consistent with what other institutions are using to document cases of TRALI. To better understand TRALI, larger case numbers need to be analyzed and studied, and only through consistent reporting and classification can this be accomplished. We currently rely on the working definition recommended by the Canadian consensus conference panel for TRALI and possible TRALI. We have made some modifications to the Canadian consensus conference panel for our classifications, but these modifications are for the purposes of donor management only. As long as complete documentation is maintained, the use of these modifications should not affect our ability to share data with other institutions that do not use similar modifications. Despite our best efforts to establish a consistent and effective way to manage suspected TRALI cases, the management of donors associated with TRALI remains a difficult task given that TRALI remains an incompletely understood reaction. Contributing to the problem is the inconsistent recognition and reporting of TRALI that continues to occur from the bedside to the collecting facility, an issue that ultimately hampers the blood centers' ability to recognize and prevent potential TRALI reactions. There is great promise that reporting of suspected TRALI events will improve significantly once the AABB's efforts to establish a US hemovigilance system come to fruition. We expect that these efforts will have similar success to programs already established internationally. A US hemovigilance system will make great strides in improving data collection and may provide new insight into additional risk factors for TRALI in donors. The approach described has been in place for United Blood Services since 2006 and thus far has been effective at providing a consistent framework to our TRALI investigations. Over the past several years, we have investigated approximately 30 to 40 suspected cases of TRALI per year. In 2007, we have had 10 TRALI investigations to date, of which 2 were classified as TRALI or likely to be TRALI. Since implementation of our new approach, donor testing has been reduced from previous years; this is a result of more selective donor testing under the newly designed algorithm. In the past, only donors with antibody to HNA-3a (5b) were deferred. Now, with the criteria for donor deferral expanded, implementation of this protocol has resulted in the deferral of more donors. Our approach represents only one of many potential ways to handle donors associated with TRALI. To what degree a donor is truly at risk for causing TRALI is not well known and thus accounts for the variability in possible strategies. Nevertheless, our current approach represents what we believe to be an effective and judicious strategy for deferring those donors at highest risk of causing severe or fatal TRALI based on our current understanding of TRALI. As we learn more about TRALI through basic science and improved data collection and reporting, we expect our management of suspected TRALI cases to continue to evolve.