Case presentation
A 79-year-old man (height, 169 cm; weight 79 kg) was scheduled for total cystectomy and ileal conduit diversion for bladder cancer. The patient had a history of acute myeloid leukemia and achieved remission by chemotherapy 9 years earlier. He was diagnosed with a thoracic aortic aneurysm and myocardial infarction, and underwent total arch replacement and coronary artery bypass grafting 3 years earlier. His blood pressure, heart rate, and peripheral blood oxygen saturation (SpO2) while breathing room air were 110/70 mmHg, 90 bpm, and 98%, respectively. On chest X-ray, the cardiothoracic ratio (CTR) was 58% with normal lung fields (Figure 1a). Transthoracic echocardiography showed normal cardiac function with left ventricular ejection fraction (LVEF) of 50%. The complete blood cell count showed anemia and thrombocytopenia (RBC 2.83 x 106/μL, hemoglobin 8.9 g/dL, hematocrit 26.7%, and platelets 1.0 x 105/μL). He was scheduled to receive intraoperative platelet transfusion.
For anesthesia induction, he received intravenous midazolam 7 mg and remifentanil 0.2 μg/kg/min, and endotracheal intubation was carried out with rocuronium 50 mg as a muscle relaxant. Anesthesia status was maintained using 4% desflurane and remifentanil 0.1 - 0.2 μg/kg/min. When his blood pressure dropped, ephedrine and/or phenylephrine was administered as needed. Standard intraoperative monitoring and invasive blood pressure measurement were carried out. Platelet transfusion was initiated at the beginning of the surgery, and the blood oxygenation level of the patient gradually decreased 40 minutes after the transfusion, with SpO2 of 92-95% at fraction of inspired oxygen (FiO2) of 0.5, and a large amount of foamy sputum was suctioned from the endotracheal tube. The patient became hypotensive, and noradrenaline administration was initiated. The patient was transfused with packed red blood cells (560 mL), platelets (400 mL), and 5% albumin (1000 mL). The total amount of fluid infusion was 5100 mL; total blood loss was 1552 mL, and total urine volume was 100 mL. Total operation time was 3 h 59 min, and total anesthesia time was 5 h 18 min. The postoperative chest X-ray showed bilateral pulmonary edema (Figure 1b). The patient showed a poor oxygenation level with a PaO2/FiO2 (P/F) of 70.1 and was transferred to the intensive care unit (ICU) under sedation and mechanical ventilation. After transfer to the ICU, bleeding from the drainage tube continued, and anemia progressed. Therefore, he was scheduled for emergency hemostasis in the operating room 1 hour after admission to the ICU.
Anesthesia was maintained using desflurane and remifentanil, and continuous administration of sivelestat was added. Steroid was also administered to correct increased vascular permeability. During the operation, foamy secretions were continuously produced from the endotracheal tube and removed using a bronchofiberscope and suction tube. A recruitment maneuver was also manually carried out whenever necessary. TRALI was suspected from the clinical course. After surgical hemostasis, blood gas analysis at FiO2 1.0 showed pH 7.06, PaCO2 96.1 mmHg, PaO2 67.9 mmHg, and HCO3- 26.1 mmol/L, indicating severe hypoxemia and hypercapnia. VV-ECMO support was then started.
His chest X-ray at the beginning of VV-ECMO support showed infiltration in the entire lung field (Figure 1c). He received continuous treatment with steroid and sivelestat. After VV-ECMO support was started, hypoxemia and hypercapnia improved markedly. Under VV-ECMO support, mechanical ventilation with driving pressure at 10 cmH2O, PEEP at 10 cmH2O, and FiO2 at 0.4 was provided. His lung condition improved gradually, and foamy secretions decreased from postoperative day (POD) 2. The chest X-ray image improved markedly. His further clinical course was good, and he was weaned off VV-ECMO on POD6 and mechanical ventilation on POD7. He was then discharged from the ICU. Antibody testing of donor serum was performed for TRALI diagnosis, and the anti-HLA Class II antibody was positive, and a positive cross reaction to the patient’s white blood cells was confirmed.