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LETTER TO EDITOR
Year : 2016  |  Volume : 64  |  Issue : 4  |  Page : 795-796

Fresh frozen plasma for plasma exchange - How safe is it?


Department of Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India

Date of Web Publication5-Jul-2016

Correspondence Address:
Smita Vimala
Department of Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.185357

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How to cite this article:
Vimala S, Muthachen NR, Lionel KR. Fresh frozen plasma for plasma exchange - How safe is it?. Neurol India 2016;64:795-6

How to cite this URL:
Vimala S, Muthachen NR, Lionel KR. Fresh frozen plasma for plasma exchange - How safe is it?. Neurol India [serial online] 2016 [cited 2019 Aug 19];64:795-6. Available from: http://www.neurologyindia.com/text.asp?2016/64/4/795/185357


Sir,

Transfusion-associated acute lung injury (TRALI) is a rare but potentially fatal complication of transfusion of blood products. We report a case where transfusion of fresh frozen plasma (FFP) following plasma exchange (PE) for a patient with myasthenia gravis led to TRALI.

A 22-year-old female patient diagnosed to be having myasthenia gravis was admitted to the Intensive Care Unit (ICU) in crisis following a respiratory infection. She had bulbar weakness and respiratory distress for which she was intubated and ventilated. As her muscle weakness did not improve with anticholinergic medications, large volume PE was initiated. After the third cycle of PE, her albumin level was low (2.5 g/dl), and FFP was administered to correct it. Within 2 h of infusion of FFP, she developed desaturation and a chest X-ray showed diffuse bilateral infiltrates [Figure 1]. Her lung compliance was as low as 9 ml/cm of H2O and PaO2 was 58 mm of Hg with 100% O2. An echocardiogram showed normal cardiac contractility and no signs of fluid overload. A diagnosis of TRALI was made and pressure control ventilation was started with a positive end-expiratory pressure of 15 cm of H2O, titrated to a SpO2 >92%. As her condition continued to worsen, prone ventilation was initiated. Her course in the ICU was stormy with refractory acute respiratory distress syndrome, sepsis, derangement of liver enzymes, and coagulopathy, following which she made a slow recovery to normalcy.
Figure 1: Chest X-ray showing bilateral infiltrates

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Myasthenic crisis is a medical emergency and severe cases might require PE to tide over the crisis.[1] There is no consensus on the ideal fluid for replacement in PE and most centers use crystalloids, FFP, or human albumin.[2] PE is well tolerated but can produce hypoalbuminemia. Though the use of FFP is not advocated in the correction of hypoalbuminemia, it is still used in many centers. TRALI is mostly implicated with transfusion of platelet concentrates and packed cells but can be associated with any product containing plasma.[3] TRALI is an immune-mediated reaction which is best explained by a “two event” mechanism.”[4] In our patient, the presence of mechanical ventilation must have acted as the first event and the transfusion of FFP triggering the immune reaction acted as the second event.

To conclude, TRALI being a life-threatening situation, the use of FFP in patients ventilated for neurological conditions, may need to be reconsidered. Using recombinant human albumin for the correction of hypoalbuminemia in ventilated patients undergoing PE would overcome this problem.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Cortese I, Chaudhry V, So YT, Cantor F, Cornblath DR, Rae-Grant A. Evidence-based guideline update: Plasmapheresis in neurologic disorders: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2011;76:294-300.  Back to cited text no. 1
    
2.
Korach JM, Berger P, Giraud C, Le Perff-Desman C, Chillet P. Role of replacement fluids in the immediate complications of plasma exchange. French Registry Cooperative Group. Intensive Care Med 1998;24:452-8.  Back to cited text no. 2
    
3.
Silliman CC, Boshkov LK, Mehdizadehkashi Z, Elzi DJ, Dickey WO, Podlosky L, et al. Transfusion-related acute lung injury: Epidemiology and a prospective analysis of etiologic factors. Blood 2003;101:454-62.  Back to cited text no. 3
    
4.
Silliman CC. The two-event model of transfusion-related acute lung injury. Crit Care Med 2006;34 5 Suppl: S124-31.  Back to cited text no. 4
    


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1 Plasma
Reactions Weekly. 2016; 1619(1): 151
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