From the Guidelines
For a patient with Transfusion-Related Acute Lung Injury (TRALI) following a blood transfusion, I recommend ordering arterial blood gases (ABGs), complete blood count (CBC), comprehensive metabolic panel (CMP), coagulation studies (PT/INR, PTT), type and screen, chest X-ray, and blood cultures. These tests are crucial in assessing the severity of TRALI and guiding supportive care. ABGs help evaluate oxygenation status and acid-base balance, while CBC and CMP assess baseline hematologic parameters and organ function, respectively. Coagulation studies rule out concurrent coagulopathy, and type and screen is essential if additional blood products are needed. A chest X-ray shows bilateral infiltrates characteristic of TRALI, differentiating it from other causes of acute respiratory distress. Blood cultures are obtained to rule out transfusion-associated sepsis. According to the most recent guidelines 1, patient monitoring is essential to identify and manage adverse reactions, with respiratory rate, pulse, blood pressure, and temperature being crucial observations. The association of anaesthetists guidelines also highlights the importance of ascertaining whether a patient has received a transfusion at any other hospital within a three-month period. Key laboratory tests should include a CBC count with differential leukocyte count and platelet count; measurement of serum levels of creatinine and blood urea nitrogen; and measurement of electrolytes, hepatic transaminase enzymes, and total bilirubin, as recommended by the clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer 1. However, it is essential to prioritize the most recent and highest quality study, which in this case is the 2025 association of anaesthetists guidelines 1. Some key points to consider when treating a patient with TRALI include:
- Monitoring respiratory rate, pulse, blood pressure, and temperature throughout transfusion
- Assessing for risk factors of transfusion-associated circulatory overload (TACO), such as older age, comorbidities, and low body weight
- Obtaining blood cultures to rule out transfusion-associated sepsis
- Ordering a chest X-ray to show bilateral infiltrates characteristic of TRALI
- Evaluating organ function, particularly renal and hepatic, through CMP and coagulation studies.
From the Research
Laboratory Tests for TRALI Diagnosis
When treating a patient with Transfusion-Related Acute Lung Injury (TRALI) after blood transfusion, the following laboratory tests can be ordered:
- Chest X-ray to check for lung injury and non-cardiogenic pulmonary edema 2, 3
- Arterial blood gas (ABG) to assess oxygenation and ventilation 4, 2
- Complete Blood Count (CBC) to evaluate for any changes in blood cell counts 5
- Electrolyte panel to check for any electrolyte imbalances 4
- Liver function tests to assess for any liver damage 4
- Coagulation studies to evaluate for any coagulopathy 4
- Leukocyte antibody testing of implicated donors to prevent further antibody-mediated cases 2, 6
Diagnostic Criteria
The diagnosis of TRALI is based on the presence of acute respiratory distress and non-cardiogenic lung edema within 6 hours of transfusion 2, 3. The American-European Consensus Conference (AECC) has developed diagnostic criteria for TRALI, which include:
- Acute respiratory distress within 6 hours of transfusion
- Non-cardiogenic pulmonary edema
- No other explanation for the acute respiratory distress 4
Differential Diagnosis
It is essential to differentiate TRALI from other causes of acute lung injury, such as: