What is the immediate management for a patient suspected of having Transfusion-Related Acute Lung Injury (TRALI)?

Immediate Management of Suspected TRALI

Stop the transfusion immediately and provide supportive respiratory care with supplemental oxygen, while avoiding diuretics which are ineffective and potentially harmful in TRALI. 1, 2

Initial Actions

Immediately discontinue the transfusion at the first suspicion of TRALI and maintain IV access with normal saline for medication administration and potential fluid resuscitation. 1, 2 This is the single most critical intervention that can prevent progression to severe morbidity or mortality. 3

Notify the blood bank immediately to report the suspected case, as TRALI is significantly underdiagnosed and underreported despite being a leading cause of transfusion-related mortality. 1, 2 This notification allows for investigation of the implicated blood product and donor screening. 1

Respiratory Support

Administer high-flow supplemental oxygen as the cornerstone of TRALI treatment. 3, 2 The severity of respiratory compromise will dictate the level of support needed:

• For mild to moderate cases, provide oxygen supplementation via nasal cannula or face mask 4
• For severe cases requiring mechanical ventilation, implement lung-protective ventilation strategies including low tidal volumes (6 mL/kg predicted body weight) and positive end-expiratory pressure (PEEP) to prevent ventilator-induced lung injury 2, 4
• Monitor peak airway pressures in ventilated patients 1, 2

Most TRALI cases show clinical improvement within the first few hours and resolve completely within 96 hours. 5

Monitoring

Monitor vital signs closely every 5-15 minutes, including:

• Respiratory rate 1
• Pulse and blood pressure 1
• Temperature 1
• Oxygen saturation 3

Fluid Management

Avoid diuretics entirely - this is a critical distinction from transfusion-associated circulatory overload (TACO). 1, 2 Diuretics are ineffective for TRALI and may worsen the condition by causing hypovolemia. 2

Maintain conservative fluid practices while avoiding both hypotension and overhydration. 2, 4 The goal is adequate organ perfusion (MAP >65-70 mmHg) without volume overload. 3

Diagnostic Workup

Send baseline laboratory studies immediately:

• Complete blood count 3
• PT, aPTT, Clauss fibrinogen 3
• Direct antiglobulin test (DAT) 3
• Repeat cross-match 3

Double-check all documentation for administration errors, particularly patient identification and blood component compatibility. 3

Key Diagnostic Features

TRALI presents with:

• Acute onset within 6 hours of transfusion (typically 1-2 hours) 1, 2
• Hypoxemia and respiratory distress 1, 2
• Bilateral pulmonary infiltrates on chest X-ray 2, 5
• Absence of circulatory overload (distinguishing it from TACO) 1, 2
• Non-cardiogenic pulmonary edema 3, 2

Common Pitfalls

The most critical error is administering diuretics, which are appropriate for TACO but contraindicated in TRALI. 1, 2 TRALI results from immune-mediated non-cardiogenic pulmonary edema, not fluid overload, making diuretics not only ineffective but potentially harmful. 2

Another common pitfall is failure to report suspected cases to the blood bank, perpetuating underdiagnosis of this leading cause of transfusion-related mortality. 1, 2

Prognosis

While TRALI can be severe enough to require mechanical ventilation (occurring in approximately 53% of cases), most patients respond well to supportive care. 4, 5 However, mortality can reach 24-40% in severe cases, particularly in critically ill patients. 4, 6