What is the treatment for Transfusion-Related Acute Lung Injury (TRALI)?

Treatment of Transfusion-Related Acute Lung Injury (TRALI)

The cornerstone of TRALI management is immediate cessation of transfusion followed by supportive respiratory care with supplemental oxygen and mechanical ventilation if needed, while avoiding diuretics unless there is clear evidence of concurrent fluid overload. 1

Immediate Management

1. Stop the transfusion immediately when TRALI is suspected 1

2. Provide respiratory support:

   • Begin with supplemental oxygen to maintain SpO2 > 90% 1
   • Escalate to mechanical ventilation if needed for respiratory failure 1, 2
   • When mechanical ventilation is required, use lung-protective strategies:
     • Avoid high tidal volumes and elevated airway pressures
     • Apply PEEP to recruit alveoli 1, 3

3. Hemodynamic support:

   • Practice judicious fluid management (avoid aggressive fluid resuscitation) 1
   • Use vasopressors for persistent hypotension 1
   • Consider invasive hemodynamic monitoring in severe cases 1

4. Medication considerations:

   • Avoid diuretics unless there is clear evidence of concurrent fluid overload 1
   • Corticosteroids are controversial and not definitively supported by current evidence 3, 4

Monitoring and Additional Care

• Monitor vital signs closely, comparing to pre-transfusion baseline 1
• Obtain chest imaging to confirm bilateral infiltrates 1
• Assess cardiac function to rule out cardiogenic causes 1
• Check BNP/NT-proBNP levels (typically normal or only mildly elevated in TRALI) 1
• Monitor for secondary complications in ventilated patients (e.g., ventilator-associated pneumonia) 1

Reporting and Prevention

• Report all suspected TRALI cases to the blood center for investigation 4
• This allows identification of implicated donors and implementation of preventive measures 4
• Blood centers may exclude donors with anti-HLA antibodies from future donations 5

Expected Clinical Course

• Most patients show clinical improvement within the first few hours of supportive care 2
• Complete resolution typically occurs within 96 hours 2, 3
• Patients requiring mechanical ventilation may need more prolonged support 1

Common Pitfalls and Caveats

1. Misdiagnosis: TRALI must be differentiated from Transfusion-Associated Circulatory Overload (TACO)

   • TRALI: normal BP or hypotension, normal cardiac function, normal/mildly elevated BNP
   • TACO: hypertension, evidence of cardiac strain, significantly elevated BNP 1

2. Delayed recognition: TRALI occurs within 6 hours of transfusion, typically within 1-2 hours 1

3. Inappropriate treatment: Using diuretics can worsen hypotension in TRALI 1

4. Failure to report: Reporting is essential for preventing future cases through donor deferral 4

Despite being a leading cause of transfusion-related mortality, TRALI remains underdiagnosed and underreported 6. Prompt recognition, appropriate supportive care, and reporting are essential for improving outcomes and preventing future cases.