What are the management strategies for Transfusion-Related Acute Lung Injury (TRALI), Transfusion-Associated Circulatory Overload (TACO), and Febrile Non-Hemolytic Transfusion Reaction (FNHTR)?

Management of TRALI, TACO, and FNHTR

Immediate Action for All Three Conditions

Stop the transfusion immediately at the first sign of any suspected transfusion reaction—this single intervention is the most critical step that can prevent progression to severe morbidity or mortality. 1

• Maintain IV access with normal saline for medication administration and fluid resuscitation 1
• Monitor vital signs every 5-15 minutes including heart rate, blood pressure, temperature, respiratory rate, and oxygen saturation 1
• Contact the transfusion laboratory immediately to report the reaction and initiate investigation 1
• Double-check all documentation for administration errors, particularly patient identification and blood component compatibility 1

Distinguishing Between TRALI, TACO, and FNHTR

TRALI (Transfusion-Related Acute Lung Injury)

• Presents with acute hypoxemia and non-cardiogenic pulmonary edema within 1-6 hours of transfusion 1, 2
• Key features: hypoxemia, fever, dyspnea, bilateral pulmonary infiltrates, fluid in endotracheal tube 1
• Avoid diuretics—they are ineffective and may worsen the condition 1, 2
• Most commonly caused by fresh frozen plasma (FFP) and platelet concentrates due to donor leukocyte antibodies 1

TACO (Transfusion-Associated Circulatory Overload)

• Presents with respiratory distress during or within 12 hours of transfusion with cardiogenic pulmonary edema 3, 1
• Key features: acute respiratory compromise, pulmonary edema, cardiovascular changes (elevated blood pressure, tachycardia), evidence of fluid overload 1
• High-risk patients: age >70 years, heart failure, renal failure, hypoalbuminemia 1
• Treatment requires diuretic therapy (opposite of TRALI management) 1

FNHTR (Febrile Non-Hemolytic Transfusion Reaction)

• Isolated fever (temperature rise ≥1°C) without hemodynamic instability 4
• Occurs in 1.1-2.15% of transfusions with leukoreduction 3
• Critical pitfall: Never assume fever is "just FNHTR"—bacterial contamination from platelets can present with isolated fever within 6 hours and is potentially fatal 4

Specific Management Algorithms

For TRALI Management

1. Immediately stop transfusion 2
2. Provide critical care supportive measures focusing on respiratory support (oxygen therapy, mechanical ventilation if needed) 1, 2
3. Do NOT give diuretics 1, 2
4. Maintain appropriate fluid balance without overhydration 2
5. Monitor peak airway pressure in ventilated patients 2
6. Report to blood bank—TRALI is underdiagnosed despite being a leading cause of transfusion-related mortality 1

For TACO Management

1. Immediately stop transfusion 1
2. Administer diuretic therapy 1
3. Provide oxygen support as needed 1
4. For future transfusions: use slow transfusion rates, body weight-based dosing, monitor vital signs and fluid balance closely 1
5. Assess cardiovascular status and manage positive fluid balance 5

For FNHTR Management (After Ruling Out Serious Reactions)

1. Stop transfusion and assess for other signs of serious transfusion reaction 4
2. Check for hypotension, tachycardia, respiratory symptoms, or hemodynamic instability that would indicate hemolytic reaction or bacterial contamination 4
3. If fever occurs within 6 hours after platelet transfusion, obtain blood cultures immediately before antibiotics for suspected bacterial contamination 4
4. If isolated fever without concerning features: symptomatic treatment with acetaminophen 650-1000 mg orally or IV 4
5. Send blood component bag with administration set back to transfusion laboratory 4
6. Collect post-reaction blood samples for repeat crossmatch, direct antiglobulin test (Coombs), complete blood count 4

Critical Diagnostic Workup

For Any Suspected Transfusion Reaction

• Send blood component bag with administration set to transfusion laboratory 4
• Post-reaction blood samples: repeat crossmatch, direct antiglobulin test (Coombs), complete blood count 4
• Visual inspection of plasma for hemolysis 4
• Urine analysis for hemoglobinuria 4
• Blood cultures if bacterial contamination suspected (especially with platelets) 4

Distinguishing TRALI from TACO

• TRALI: Non-cardiogenic pulmonary edema, normal or low blood pressure, no response to diuretics 1, 2
• TACO: Cardiogenic pulmonary edema, elevated blood pressure, positive fluid balance, responds to diuretics 1, 5
• Both present with respiratory distress and bilateral pulmonary infiltrates, making clinical distinction challenging 6, 5

Prevention Strategies

TRALI Prevention

• Blood banks use male-only plasma donors (multiparous women have higher frequency of anti-HLA antibodies) 1, 2
• Screen donors for leukocyte antibodies 1, 2
• FFP and platelet concentrates are highest risk products 1

TACO Prevention

• Assess transfusion need carefully in high-risk patients (elderly, heart failure, renal failure) 1
• Use body weight-based dosing of blood products 1
• Transfuse single units in non-hemorrhaging patients and reassess before additional units 1
• Monitor vital signs and fluid balance closely 1

FNHTR Prevention

• Prestorage leukoreduction reduces incidence from 2.15% to 1.1% 3

Common Pitfalls to Avoid

• Never continue transfusion despite "just fever"—general anesthesia and critical illness can mask early signs of serious reactions 4
• Never give diuretics for TRALI (they are ineffective and may worsen the condition) 1, 2
• Never assume isolated fever is benign—bacterial contamination from platelets presents with fever alone and is potentially fatal 4
• Never restart transfusion before laboratory clearance, even if symptoms improve 4
• Never delay blood cultures if bacterial contamination suspected—obtain before antibiotics 4