Management of Transfusion-Related Acute Lung Injury (TRALI)
Immediate Actions
Stop the transfusion immediately when TRALI is suspected—this is the single most critical intervention that can prevent progression to severe morbidity or mortality. 1, 2
- Maintain IV access with normal saline for medication administration and fluid resuscitation 2
- Report the suspected case promptly to the local blood bank, as TRALI is a leading cause of transfusion-associated morbidity and mortality and remains underdiagnosed and underreported 1, 2
- Double-check all documentation for administration errors, particularly patient identification and blood component compatibility 2
Diagnostic Recognition
TRALI presents with specific clinical features that distinguish it from other transfusion reactions:
- Timing: Acute lung injury occurs within 6 hours of transfusion, with signs and symptoms typically appearing 1-2 hours after transfusion 1, 3
- Respiratory features: Hypoxemia, respiratory distress, dyspnea, acute shortness of breath, and fluid in the endotracheal tube 1, 2
- Radiographic findings: Bilateral pulmonary infiltrates on chest imaging 1, 3
- Key distinguishing feature: Absence of evidence of circulatory overload (unlike TACO, which presents with cardiovascular changes, tachycardia, hypertension, and fluid overload) 1, 2
Monitoring Requirements
Monitor the following parameters closely:
- Vital signs every 5-15 minutes: respiratory rate, pulse, blood pressure, temperature, and oxygen saturation 1, 2
- In ventilated patients: peak airway pressure 1, 4
- Urine output and color 4
Treatment Approach
Provide critical care supportive measures focusing on respiratory support—this is the cornerstone of TRALI management. 1, 2
Respiratory Support Algorithm:
- Mild cases: Nasal oxygen administration may be sufficient 3
- Severe cases: Mechanical ventilation is required, with most patients showing clinical improvement within the first few hours and complete resolution within 96 hours 3, 5
- Invasive hemodynamic monitoring may be necessary in severe cases 3
Fluid Management:
- Maintain appropriate fluid balance without overhydration 1
- Critical pitfall: Avoid diuretics—they are ineffective for TRALI and may worsen the condition 1, 2, 3
- This is a key distinction from TACO, where diuretic therapy is recommended 2
Controversial Interventions:
- Glucocorticoid administration remains controversial with no clear evidence supporting routine use 3
Pathophysiology Understanding
TRALI occurs through two mechanisms that inform management:
- Immune-mediated TRALI: Donor leukocyte antibodies (HLA class I, class II, or granulocyte-specific antibodies) interact with recipient neutrophils, causing granulocytes in lung capillaries to release oxygen radicals and enzymes that damage endothelial cells and cause pulmonary edema 2, 3
- Non-immune-mediated TRALI: Biologically active lipids from storage of platelet and red blood cell concentrates activate neutrophilic granulocytes 3
Blood Products Most Commonly Implicated
Fresh frozen plasma (FFP) and platelet concentrates are the blood components most frequently implicated in TRALI 1, 2, 3
Clinical Course and Prognosis
- Most cases show clinical improvement in the first few hours 5
- Complete resolution typically occurs within 96 hours (4 days) 5
- Mortality is not uncommon, making early recognition and appropriate management critical 6
Prevention Strategies Implemented by Blood Banks
Blood banks have implemented several measures that have dramatically reduced TRALI incidence:
- Screening donors for leukocyte antibodies 1, 2
- Using male-only plasma donors (implemented in the UK in 2003 and Germany in 2009, resulting in no TRALI-related deaths since implementation) 2, 3
- Excluding plasma from female donors with history of pregnancy, as multiparous women develop leukocyte antibodies when exposed to fetal antigens 2
- Testing female apheresis platelet donors for HLA antibodies 1