TACO and TRALI: Presentations, Symptoms, and Treatments
Both Transfusion-Associated Circulatory Overload (TACO) and Transfusion-Related Acute Lung Injury (TRALI) present with respiratory distress within hours of transfusion, but TACO is characterized by fluid overload with cardiovascular changes while TRALI is a non-cardiogenic pulmonary edema requiring immediate cessation of transfusion and supportive care. 1
Transfusion-Associated Circulatory Overload (TACO)
Presentation and Symptoms
- TACO is now the most common cause of transfusion-related mortality and major morbidity 1
- Occurs during or up to 12 hours after transfusion 1
- Key clinical features include:
Risk Factors
- Older patients (age >70 years) 1
- Non-bleeding patients 1
- Comorbidities: heart failure, renal failure, hypoalbuminemia 1
- Low body weight 1
- Rapid transfusion 1
- Positive fluid balance 2
Treatment
- Immediate cessation of transfusion 1
- Diuretic therapy 1, 3
- Supplemental oxygen 3
- Phlebotomy in severe cases 3
- Slow transfusion rates for future transfusions 1
- Body weight-based dosing of blood products 1
Transfusion-Related Acute Lung Injury (TRALI)
Presentation and Symptoms
- Non-cardiogenic pulmonary edema resulting from immune reactivity 1
- Signs and symptoms appear 1-2 hours after transfusion and reach maximum intensity within 6 hours 1
- Key clinical features include:
Risk Factors
- No specific patient profile has been identified as high risk 3
- Associated with all blood components, but most commonly with plasma-containing products 3
- Caused by donor antibodies (usually HLA or granulocyte-specific) interacting with recipient antigens 1
Treatment
- Immediate cessation of transfusion 1
- Critical care supportive measures 1
- Oxygen therapy 2
- Mechanical ventilation if necessary 2
- No specific therapy beyond supportive care 1
- Most patients recover within 96 hours 1, 3
Distinguishing Between TACO and TRALI
Key Differences
- TACO is cardiogenic (hydrostatic) pulmonary edema 2, 4
- TRALI is non-cardiogenic (permeability) pulmonary edema 2, 4
- TACO typically presents with hypertension, while TRALI does not 1, 2
- Elevated BNP levels suggest TACO rather than TRALI 1, 2
- TRALI more commonly presents with fever 1
Monitoring for Transfusion Reactions
- Monitor respiratory rate throughout transfusion (early indicator of serious reactions) 1
- Record vital signs before transfusion, 15 minutes after starting, and within 60 minutes of completion 1
- Check for signs and symptoms periodically during transfusion 1
- Assess urine output and color 1
- Monitor peak airway pressure in ventilated patients 1
Prevention Strategies
TACO Prevention
- Assess need for transfusion carefully 1
- Use body weight-based dosing of blood products 1
- Transfuse slowly in high-risk patients 1
- Monitor vital signs and fluid balance closely 1
- Consider prophylactic diuretics in high-risk patients 1
TRALI Prevention
- Blood banks have implemented measures to reduce TRALI risk 1
- Screening of donors for leukocyte antibodies 2
- Using male-only plasma donors has reduced TRALI incidence 5
Important Considerations
- Both conditions can be life-threatening and require prompt recognition 2
- Distinguishing between TACO and TRALI can be challenging but is crucial for appropriate management 4
- Some patients may present with features of both conditions simultaneously 5
- Bacterial contamination of blood products can present with similar symptoms (fever, respiratory distress) and should be considered in the differential diagnosis 1