Management and Treatment of Transfusion-Related Acute Lung Injury (TRALI)
The management of TRALI primarily involves immediate cessation of transfusion, supportive respiratory care, and avoidance of diuretics, as TRALI is a form of non-cardiogenic pulmonary edema requiring oxygen therapy and possibly mechanical ventilation in severe cases. 1, 2
Definition and Diagnosis
- TRALI presents as acute lung injury within 6 hours of transfusion with key clinical features including hypoxemia, respiratory distress, dyspnea, and bilateral pulmonary infiltrates without evidence of circulatory overload 1, 3
- TRALI must be differentiated from Transfusion-Associated Circulatory Overload (TACO), which presents with similar respiratory symptoms but includes cardiovascular changes and evidence of fluid overload 4
- Diagnosis requires excluding other causes of acute lung injury such as sepsis, cardiogenic pulmonary edema, and bacterial infection 3
- All suspected cases of TRALI should be promptly reported to the local blood bank as it is a leading cause of transfusion-associated morbidity and mortality 5
Immediate Management
- Immediately stop the transfusion when TRALI is suspected 1, 2
- Provide oxygen therapy; nasal oxygen may be sufficient in mild cases 2
- For severe cases, implement mechanical ventilation and invasive hemodynamic monitoring 2, 6
- Avoid diuretics, which are ineffective for TRALI and may worsen the condition 1, 2
- Monitor vital signs closely, including respiratory rate, pulse, blood pressure, and temperature 4
- In ventilated patients, monitor peak airway pressure 4
Supportive Care
- Provide critical care supportive measures focusing on respiratory support 1
- Most patients show clinical improvement within the first few hours and resolve completely within 96 hours 6
- The administration of glucocorticoids is controversial with insufficient evidence to support routine use 2
- Maintain appropriate fluid balance without overhydration 4
Prevention Strategies
- Blood banks have implemented measures to reduce TRALI risk, including:
- Screening donors for leukocyte antibodies 1
- Using male-only plasma donors or female donors without history of pregnancy 2
- Since 2009 in Germany, using only plasma from female donors without prior pregnancy history or negative testing for antibodies against HLA I, II or HNA has eliminated TRALI-related deaths 2
- Fresh frozen plasma (FFP) and platelet concentrates are the blood components most frequently implicated in TRALI 1
- Careful assessment of the need for transfusion, especially in high-risk patients, is essential 4
Risk Factors
- TRALI has two primary mechanisms: immune-mediated (caused by donor antibodies) and non-immune-mediated (caused by biologically active lipids in stored blood products) 2, 3
- Neutrophils play a central role in mediating the early immune response and lung vascular injury 3
- Both donor and recipient factors contribute to TRALI risk 7
Clinical Course and Prognosis
- Most cases of TRALI show clinical improvement within the first few hours 6
- Complete resolution typically occurs within 96 hours with appropriate supportive care 6
- TRALI remains a significant clinical problem despite preventive measures reducing overall fatalities 3