Intraoperative transfusion-related acute lung injury in a child during calvarial vault remodeling

Transfusion-related acute lung injury (TRALI) is currently recognized by the US Food and Drug Administration as the number one cause of mortality related to blood transfusion. Although various pathophysiologic mechanisms have been proposed, it is thought to be related to the presence of anti-HLA antibodies or bioactive lipid components in the donor blood product, which results in activation of recipient leukocytes and the resultant pulmonary damage from the release of bioactive substances including cytokines. As TRALI manifests as acute lung injury with signs and symptoms consistent with acute respiratory distress syndrome, it is frequently underdiagnosed, as the acute lung injury may be attributed to other factors. Transfusion-related acute lung injury is an important clinical entity for anesthesia providers to recognize and diagnose accurately, as many transfusions occur in the surgical patient. We present a case report of a pediatric patient who developed intraoperative TRALI during calvarial vault remodeling to treat craniosynostosis. The history, pathophysiology, and treatment of TRALI are discussed. Potential preventive measures are reviewed.