Wednesday, September 12, 2007


You are wandering the hills of downtown San Francisco when suddenly Sean Connery in a Hummer closely chased by Nicolas Cage in a Ferrari pass by, causing a massive motor vehicle accident, even involving a trolley.

You're a first responder for one of the victims, a young man who is bleeding profusely from his legs. You accompany him to the ER and when the doctor finds out you're a medical student, he invites you into the OR. In the OR, they have to transfuse a significant amount of whole blood. The surgery proceeds without complications, but near the end of the two hour surgery, the patient becomes hypoxic, tachycardic, hypotensive, and febrile. You see elevated peak airway pressures and frothy pink airway secretions around the endotracheal tube. You draw some blood and a cell count shows eosinophilia and neutropenia. JVP is not elevated. B-type natriuretic peptide is <100 pg/ml.

You look over at the anesthesiologist who says, "Oh, the hypothesized etiology of this disorder is anti-granulocyte antibodies and/or granulocyte priming."

Challenge: This incident can be described with a specific acronym. What is it?

Related Questions:
1. At the end of the surgery, what happened? What general condition do the peak airway pressure and secretions suggest?
2. Why was the JVP and BNP important?
3. This could have been a deleted scene from what 1996 movie?


Alex said...

google medicine saves the day

1. bronchospasm? pulmonary edema?
2. not CHF

Anonymous said...

1. craig
2. is such
3. a nerd


Craig said...


This disorder is called Transfusion Related Acute Lung Injury or TRALI. It is pronounced trolley; I apologize for the pun. It has only recently (within the last few decades) been recognized as a consequence of blood product transfusion, but there are several UCSF doctors interested in it. It occurs within 6 hours (usually 1-2 hours) of transfusion of whole blood, platelets, packed RBCs, and FFP (but is not limited to those) and causes acute lung injury which can progress to ARDS. Mortality for recognized TRALI is around 5-8%, but treatment is supportive.

The presentation is pulmonary edema, which is described in this case. It is important to distinguish TRALI from TACO or transfusion-associated circulatory overload. This is evidenced by the lack of a JVP and the low BNP. The movie is The Rock.

Sources: Wikipedia, UpToDate.