Management of Transfusion-Related Acute Lung Injury (TRALI)
Immediately stop the transfusion when TRALI is suspected and provide supportive respiratory care—diuretics should be avoided as they are ineffective and potentially harmful. 1, 2
Immediate Actions
When TRALI is suspected (acute respiratory distress, hypoxemia, bilateral pulmonary infiltrates within 6 hours of transfusion):
- Stop the transfusion immediately and maintain IV access with normal saline 1, 2
- Monitor vital signs every 5-15 minutes including respiratory rate, pulse, blood pressure, temperature, and oxygen saturation 1, 2
- In mechanically ventilated patients, monitor peak airway pressure 1
- Do not administer diuretics—this is a critical pitfall as TRALI involves non-cardiogenic pulmonary edema, not fluid overload, and diuretics are ineffective and may worsen the condition 1, 2
Respiratory Support
The cornerstone of TRALI management is supportive respiratory care:
- Provide supplemental oxygen to maintain adequate oxygenation 2, 3
- For severe cases requiring mechanical ventilation, use lung-protective ventilation strategies: avoid high tidal volumes and elevated airway pressures to prevent ventilator-induced lung injury 3
- Apply positive end-expiratory pressure (PEEP) to prevent low-volume shear stress injury 3
- Most patients show clinical improvement within the first few hours and resolve completely within 96 hours 4, 5
Fluid Management
- Maintain appropriate fluid balance without overhydration 1
- Use conservative fluid practices while avoiding hypotension 3
- Invasive hemodynamic monitoring may be required in severe cases 5
Pharmacologic Considerations
- Glucocorticoids are not recommended—the literature is insufficient to support their use in TRALI 3, 5
- Statins are similarly not supported by current evidence 3
Reporting and Documentation
- Report all suspected TRALI cases to the local blood bank immediately—TRALI is underdiagnosed and underreported despite being a leading cause of transfusion-associated morbidity and mortality 6, 1, 2
- Notify the patient's general practitioner to remove them from the donor pool 2
- Contact the transfusion laboratory to initiate investigation 2
Differential Diagnosis
Distinguish TRALI from Transfusion-Associated Circulatory Overload (TACO):
- TRALI: Non-cardiogenic pulmonary edema, no cardiovascular changes, no evidence of fluid overload, occurs 1-6 hours post-transfusion 1, 2
- TACO: Cardiogenic pulmonary edema with cardiovascular changes, evidence of fluid overload, responds to diuretics 2
Prevention Strategies for Future Transfusions
Blood banks have implemented donor screening measures: