TRALIとTACOの鑑別診断

輸血後の急性肺水腫に対するアプローチのフローチャートである。
出典
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1: Pulmonary edema after transfusion: how to differentiate transfusion-associated circulatory overload from transfusion-related acute lung injury.
著者: Ognjen Gajic, Michael A Gropper, Rolf D Hubmayr
雑誌名: Crit Care Med. 2006 May;34(5 Suppl):S109-13. doi: 10.1097/01.CCM.0000214311.56231.23.
Abstract/Text: OBJECTIVE: Pulmonary edema is an under-recognized and potentially serious complication of blood transfusion. Distinct mechanisms include adverse immune reactions and circulatory overload. The former is associated with increased pulmonary vascular permeability and is commonly referred to as transfusion-related acute lung injury (TRALI). The latter causes hydrostatic pulmonary edema and is commonly referred to as transfusion-associated circulatory overload (TACO). In this review article we searched the National Library of Medicine PubMed database as well as references of retrieved articles and summarized the methods for differentiating between hydrostatic and permeability pulmonary edema.
RESULTS: The clinical and radiologic manifestations of TACO and TRALI are similar. Although echocardiography and B-type natriuretic peptide measurements may aid in the differential diagnosis between hydrostatic and permeability pulmonary edema, invasive techniques such as right heart catheterization and the sampling of alveolar fluid protein are sometimes necessary. The diagnostic differentiation is especially difficult in critically ill patients will multiple comorbidities so that the cause of edema may only be determined post hoc based on the clinical course and response to therapy. Guided by available evidence, we present an algorithm for establishing the pretest probability of TRALI as opposed to TACO. The decision to test donor and recipient blood for immunocompatibility may be made on this basis.
CONCLUSIONS: The distinction between hydrostatic (TACO) and permeability (TRALI) pulmonary edema after transfusion is difficult, in part because the two conditions may coexist. Knowledge of strengths and limitations of different diagnostic techniques is necessary before initiation of complex TRALI workup.
Crit Care Med. 2006 May;34(5 Suppl):S109-13. doi: 10.1097/01.CCM.00002...

アナフィラキシーの治療手順

アナフィラキシーが疑われたときの治療手順である

TRALIの胸部X線写真およびCT画像

TRALIの典型的な胸部X線写真（a）および胸部CT画像（b）である。
出典
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1: Radiographic manifestations of transfusion-related acute lung injury.
著者: Carolina Carcano, Ndubuisi Okafor, Felipe Martinez, Jose Ramirez, Jeffrey Kanne, Jacobo Kirsch
雑誌名: Clin Imaging. 2013 Nov-Dec;37(6):1020-3. doi: 10.1016/j.clinimag.2013.06.008. Epub 2013 Aug 15.
Abstract/Text: OBJECTIVE: The purpose of this article is to describe the clinical symptoms and illustrate the radiological manifestations of transfusion-related acute lung injury (TRALI) as the condition develops. We mention those findings that aid the discrimination from transfusion-associated cardiac overload. We will also point some of the characteristics that increase the risk of TRALI.
CONCLUSION: TRALI generally occurs within 1 to 2 h of the start of a blood transfusion. Though the radiographic features of TRALI are nonspecific, the diagnosis is established using clinical and radiological parameters. The diagnosis warrants a high index of suspicion as well as knowledge of its risk factors. There are no specific treatments; the best chance of survival in TRALI is with early diagnosis and prevention.

© 2013 Elsevier Inc. All rights reserved.
Clin Imaging. 2013 Nov-Dec;37(6):1020-3. doi: 10.1016/j.clinimag.2013....

APACHE IIスコア

APACHE IIスコア＝A＋B＋Cの合計
a：Total Acute Physiology Score（APS）（12の生理機能パラメーターの合計点数）
＃ ：通常はFiO2＝1.0の場合のPaCO2とPaO2を求めて右の計算式で求める：A－aDO2＝713－PaCO2－PaO2
FiO2＜1.0の場合は右の簡略式を用いると便利である：A－aDO2＝{FiO2×713－（PaCO2/0.8）}－PaO2
＊ ：Glasgow Coma scale＝a＋b＋c
挿管および処置による鎮静によってスコアの判定が難しい場合は、その要因がない場合を想定しスコアを判定する。
b:年齢ポイント
c:慢性併存病態ポイント
  1. 重篤な臓器（肝、循環器、呼吸器、腎）不全あるいは免疫能低下がある場合
    a．非手術あるいは緊急手術患者：5ポイント
    b．予定手術患者：2ポイント
出典
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1: APACHE II: a severity of disease classification system.
著者: W A Knaus, E A Draper, D P Wagner, J E Zimmerman
雑誌名: Crit Care Med. 1985 Oct;13(10):818-29.
Abstract/Text: This paper presents the form and validation results of APACHE II, a severity of disease classification system. APACHE II uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status to provide a general measure of severity of disease. An increasing score (range 0 to 71) was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals. This relationship was also found for many common diseases. When APACHE II scores are combined with an accurate description of disease, they can prognostically stratify acutely ill patients and assist investigators comparing the success of new or differing forms of therapy. This scoring index can be used to evaluate the use of hospital resources and compare the efficacy of intensive care in different hospitals or over time.
Crit Care Med. 1985 Oct;13(10):818-29.

SOFA（sequential organ failure assessment）スコア

  1. 重要臓器の障害度を数値化した指数である。呼吸器、凝固系、肝機能、心血管系、中枢神経系、腎機能の6項目について、臓器障害の程度を0から4点の5段階で評価する。スコアが5を超えると死亡率は20％といわれている。
出典
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1: Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on "sepsis-related problems" of the European Society of Intensive Care Medicine.
著者: J L Vincent, A de Mendonça, F Cantraine, R Moreno, J Takala, P M Suter, C L Sprung, F Colardyn, S Blecher
雑誌名: Crit Care Med. 1998 Nov;26(11):1793-800.
Abstract/Text: OBJECTIVE: To evaluate the use of the Sequential Organ Failure Assessment (SOFA) score in assessing the incidence and severity of organ dysfunction in critically ill patients.
DESIGN: Prospective, multicenter study.
SETTING: Forty intensive care units (ICUs) in 16 countries.
PATIENTS: Patients admitted to the ICU in May 1995 (n = 1,449), excluding patients who underwent uncomplicated elective surgery with an ICU length of stay <48 hrs.
INTERVENTIONS: None.
MEASUREMENTS AND MAIN RESULTS: The main outcome measures included incidence of dysfunction/failure of different organs and the relationship of this dysfunction with outcome. In this cohort of patients, the median length of ICU stay was 5 days, and the ICU mortality rate was 22%. Multiple organ dysfunction and high SOFA scores for any individual organ were associated with increased mortality. The presence of infection on admission (28.7% of patients) was associated with higher SOFA scores for each organ. The evaluation of a subgroup of 544 patients who stayed in the ICU for at least 1 wk showed that survivors and nonsurvivors followed a different course. This subgroup had greater respiratory, cardiovascular, and neurologic scores than the other patients. In this subgroup, the total SOFA score increased in 44% of the nonsurvivors but in only 20% of the survivors (p < .001). Conversely, the total SOFA score decreased in 33% of the survivors compared with 21% of the nonsurvivors (p < .001).
CONCLUSIONS: The SOFA score is a simple, but effective method to describe organ dysfunction/failure in critically ill patients. Regular, repeated scoring enables patient condition and disease development to be monitored and better understood. The SOFA score may enable comparison between patients that would benefit clinical trials.
Crit Care Med. 1998 Nov;26(11):1793-800.

TRALIとTACOの鑑別診断

輸血後の急性肺水腫に対するアプローチのフローチャートである。
出典
imgimg
1: Pulmonary edema after transfusion: how to differentiate transfusion-associated circulatory overload from transfusion-related acute lung injury.
著者: Ognjen Gajic, Michael A Gropper, Rolf D Hubmayr
雑誌名: Crit Care Med. 2006 May;34(5 Suppl):S109-13. doi: 10.1097/01.CCM.0000214311.56231.23.
Abstract/Text: OBJECTIVE: Pulmonary edema is an under-recognized and potentially serious complication of blood transfusion. Distinct mechanisms include adverse immune reactions and circulatory overload. The former is associated with increased pulmonary vascular permeability and is commonly referred to as transfusion-related acute lung injury (TRALI). The latter causes hydrostatic pulmonary edema and is commonly referred to as transfusion-associated circulatory overload (TACO). In this review article we searched the National Library of Medicine PubMed database as well as references of retrieved articles and summarized the methods for differentiating between hydrostatic and permeability pulmonary edema.
RESULTS: The clinical and radiologic manifestations of TACO and TRALI are similar. Although echocardiography and B-type natriuretic peptide measurements may aid in the differential diagnosis between hydrostatic and permeability pulmonary edema, invasive techniques such as right heart catheterization and the sampling of alveolar fluid protein are sometimes necessary. The diagnostic differentiation is especially difficult in critically ill patients will multiple comorbidities so that the cause of edema may only be determined post hoc based on the clinical course and response to therapy. Guided by available evidence, we present an algorithm for establishing the pretest probability of TRALI as opposed to TACO. The decision to test donor and recipient blood for immunocompatibility may be made on this basis.
CONCLUSIONS: The distinction between hydrostatic (TACO) and permeability (TRALI) pulmonary edema after transfusion is difficult, in part because the two conditions may coexist. Knowledge of strengths and limitations of different diagnostic techniques is necessary before initiation of complex TRALI workup.
Crit Care Med. 2006 May;34(5 Suppl):S109-13. doi: 10.1097/01.CCM.00002...

アナフィラキシーの治療手順

アナフィラキシーが疑われたときの治療手順である