Management of Transfusion-Related Acute Lung Injury (TRALI)
Immediately stop the transfusion at the first sign of suspected TRALI and provide supportive respiratory care—do NOT give diuretics as they are ineffective and may worsen the condition. 1, 2
Immediate Recognition and Actions
Stop Transfusion and Maintain Access
- Discontinue the transfusion immediately when TRALI is suspected—this is the single most critical intervention to prevent progression 1, 2
- Maintain IV access with normal saline for medication administration and potential fluid resuscitation 2
- Contact the transfusion laboratory immediately to report the reaction and initiate investigation 2
Clinical Presentation to Recognize
TRALI typically presents within 1-6 hours of transfusion with: 1, 2
- Acute respiratory distress and dyspnea
- Hypoxemia (often severe)
- Bilateral pulmonary infiltrates on chest X-ray
- Fever (common)
- Fluid in the endotracheal tube if intubated
- Absence of cardiovascular changes or fluid overload (key differentiator from TACO)
Critical Management Principles
What TO DO
Provide aggressive respiratory support: 1, 2, 3
- Administer supplemental oxygen therapy immediately
- Prepare for mechanical ventilation if respiratory distress is severe—approximately 53% of cases require intubation 4
- Monitor peak airway pressures in ventilated patients 1
- Most patients show clinical improvement within the first few hours and resolve completely within 96 hours 3
Monitor vital signs intensively: 1, 2
- Check every 5-15 minutes: respiratory rate, pulse, blood pressure, temperature, oxygen saturation
- Watch for shock (occurs in 33% of cases) 4
Maintain appropriate fluid balance: 1
- Avoid overhydration but ensure adequate perfusion
- This is non-cardiogenic pulmonary edema, so fluid management differs from heart failure
What NOT TO DO
Avoid diuretics—they are ineffective for TRALI and may worsen the patient's condition 1, 2. This is a critical pitfall as TRALI mimics cardiogenic pulmonary edema on imaging, but the pathophysiology is completely different (neutrophil-mediated capillary leak rather than hydrostatic pressure).
Mandatory Reporting and Investigation
Report every suspected case to the local blood bank immediately 5, 1, 2. TRALI is underdiagnosed and underreported despite being a leading cause of transfusion-associated mortality. 5, 6
Why Reporting Matters
- Allows identification of implicated donors who have leukocyte antibodies 7
- Enables exclusion of these donors from future blood donation 7, 6
- Protects future transfusion recipients from the same donor 7
- Serological testing can identify anti-HLA or anti-neutrophil antibodies in donor plasma that reacted with the patient's granulocytes 7
Prognosis and Expected Course
Most patients improve within 12-96 hours with supportive care alone 7, 3. The prognosis is substantially better than other causes of acute lung injury, though mortality can occur (approximately 24% in severe cases requiring ICU admission). 4, 8
Mechanical ventilation, when needed, typically lasts 1-4 days 4. Clinical improvement often begins within the first few hours of stopping the transfusion and initiating oxygen therapy. 3
Prevention Context
While management focuses on supportive care, understanding prevention helps contextualize the condition: Fresh frozen plasma (FFP) and platelet concentrates are the blood products most frequently implicated in TRALI 1, 2. Blood banks now screen donors for leukocyte antibodies and preferentially use male-only plasma donors to reduce risk. 1, 2