Management of Transfusion-Related Acute Lung Injury (TRALI)

Stop the transfusion immediately and provide supportive respiratory care—diuretics are contraindicated and may worsen outcomes. 1, 2

Immediate Actions

Upon suspicion of TRALI, execute the following steps in order:

Immediately discontinue the transfusion at the first sign of respiratory distress, hypoxemia, or bilateral pulmonary infiltrates occurring within 6 hours of transfusion 1, 2
Maintain IV access with normal saline for medication administration and potential fluid resuscitation 2
Report the case to the blood bank immediately—TRALI is severely underdiagnosed and underreported despite being a leading cause of transfusion-related mortality 1, 2
Monitor vital signs every 5-15 minutes including respiratory rate, pulse, blood pressure, temperature, and oxygen saturation 3
In mechanically ventilated patients, monitor peak airway pressures 1, 2

Oxygen therapy is the cornerstone of TRALI management:

Administer high-flow oxygen (high FiO2) immediately to address hypoxemia 3
For severe cases requiring mechanical ventilation, use lung-protective strategies including low tidal volumes and positive end-expiratory pressure (PEEP) 2
Most cases show clinical improvement within the first few hours and resolve completely within 96 hours 4
Nasal oxygen administration may be sufficient in mild cases, but severe cases require mechanical ventilation and invasive hemodynamic monitoring 5

The single most important management distinction from other transfusion reactions:

Avoid diuretics entirely—they are ineffective for TRALI and may worsen the condition by causing hypovolemia 1, 2, 5
Maintain conservative fluid practices, avoiding both hypotension and overhydration 2
This contrasts sharply with TACO (Transfusion-Associated Circulatory Overload), where diuretics are the primary treatment 3

TRALI presents with non-cardiogenic pulmonary edema, while TACO presents with cardiogenic overload:

TRALI: hypoxemia, respiratory distress, bilateral pulmonary infiltrates, no evidence of circulatory overload, typically 1-2 hours post-transfusion 1, 2
TACO: acute respiratory compromise with cardiovascular changes, pulmonary edema, evidence of fluid overload, occurs during or up to 12 hours after transfusion 3
The distinction is critical because diuretics are contraindicated in TRALI but are the primary treatment for TACO 3, 2

Provide critical care supportive measures focusing on respiratory support 1
Maintain adequate blood pressure for organ perfusion (MAP >65-70 mmHg) with IV fluids if needed 3
Have vasopressors, intubation equipment, and resuscitation medications readily available 3
Send baseline labs including complete blood count, PT, aPTT, fibrinogen, and direct antiglobulin test (DAT) 3

Glucocorticoid administration remains controversial with no clear evidence supporting routine use 5
No specific TRALI therapies currently exist beyond supportive care 6

Blood banks have implemented donor screening strategies that have dramatically reduced TRALI incidence:

Preferential use of male-only plasma donors, as fresh frozen plasma and platelet concentrates are most frequently implicated 1, 2
Screening donors for leukocyte antibodies (HLA class I, II, and granulocyte-specific antibodies) 1, 2
Since Germany implemented plasma from only male donors or antibody-negative female donors in 2009, no TRALI-related deaths have been registered 5

Do not administer diuretics—this is the most critical error that can worsen patient outcomes 1, 2, 5
Do not delay reporting to the blood bank—this prevents investigation and future prevention 1, 2
Do not confuse TRALI with TACO—the treatments are opposite regarding fluid management 3, 2