What is the management and treatment of Transfusion-Related Acute Lung Injury (TRALI)?

Management and Treatment of Transfusion-Related Acute Lung Injury (TRALI)

The management of TRALI primarily consists of stopping the transfusion immediately and providing supportive critical care measures, as there is no specific therapy other than respiratory and hemodynamic support.

Definition and Clinical Presentation

TRALI is a serious transfusion complication characterized by:

• Noncardiogenic pulmonary edema resulting from immune reactivity of leukocyte antibodies
• Onset typically within 1-2 hours after transfusion (by definition within 6 hours)
• Peak symptoms within 6 hours of transfusion
• Clinical manifestations include:
  • Hypoxemia
  • Fever
  • Dyspnea
  • Bilateral pulmonary infiltrates on chest imaging
  • Possible fluid in the endotracheal tube in intubated patients

Immediate Management Algorithm

1. Stop the transfusion immediately when TRALI is suspected
2. Notify the blood bank to quarantine any remaining components from the same donor
3. Provide respiratory support based on severity:
   • Supplemental oxygen for mild cases
   • Non-invasive ventilation for moderate cases
   • Mechanical ventilation for severe respiratory failure
4. Monitor and maintain hemodynamics:
   • Fluid management (avoid overload)
   • Vasopressors if needed for hypotension
   • Close monitoring of volume status and urine output

Specific Supportive Care

• Respiratory management:

  • Maintain adequate oxygenation (target SpO2 > 90%)
  • Consider PEEP to recruit alveoli if mechanically ventilated
  • Lung-protective ventilation strategies if intubated

• Hemodynamic support:

  • Judicious fluid management (avoid aggressive fluid resuscitation)
  • Vasopressors for persistent hypotension
  • Invasive hemodynamic monitoring in severe cases

• Medication considerations:

  • Diuretics should be avoided unless there is evidence of fluid overload 1
  • Glucocorticoids are controversial and not routinely recommended 2

Important Distinctions and Pitfalls

• Do not confuse with volume overload: TRALI is noncardiogenic pulmonary edema, distinct from transfusion-associated circulatory overload (TACO)
• Avoid unnecessary additional transfusions: Each transfusion carries risk of further reactions
• Recognize high-risk products: Fresh frozen plasma carries the highest risk of TRALI, followed by platelets, then packed red blood cells 3
• Report all suspected cases: Reporting to the blood bank is essential to prevent future reactions by deferring implicated donors 4

Expected Clinical Course

Most patients with TRALI show clinical improvement within the first few hours of supportive care and typically resolve completely within 96 hours 1, 5. However, TRALI remains one of the top three most common causes of transfusion-related deaths 1.

Prevention Strategies

• Use male-only plasma when possible (lower risk of anti-HLA antibodies)
• Implement appropriate blood product utilization to avoid unnecessary transfusions
• Consider pathogen-inactivated plasma products when available
• Screen donors with history of pregnancy for anti-leukocyte antibodies

Special Considerations

• Patients requiring mechanical ventilation may need more prolonged support
• Monitor for secondary complications (ventilator-associated pneumonia, etc.)
• Consider transfer to a higher level of care facility if management capabilities are limited

TRALI is a serious but manageable complication when recognized promptly and treated appropriately with supportive care measures.