Treatment of Transfusion-Related Acute Lung Injury (TRALI)
Immediately stop the transfusion and provide supportive respiratory care with supplemental oxygen—diuretics are contraindicated and will worsen the condition. 1
Immediate Actions
Stop the transfusion immediately upon suspicion of TRALI and maintain intravenous access with normal saline for medication administration and potential fluid resuscitation. 1 This is the single most critical intervention that can prevent progression to severe morbidity or mortality. 2
Notify the blood bank immediately, as TRALI remains underdiagnosed and underreported despite being a leading cause of transfusion-related mortality. 1, 3 This notification removes implicated donors from the pool and prevents future reactions in other patients. 2
Respiratory Support
Provide supplemental oxygen as the cornerstone of treatment. 1 The severity of respiratory support should be escalated based on clinical response:
- Mild cases: High-flow oxygen via nasal cannula or face mask may be sufficient 4, 5
- Severe cases: Mechanical ventilation is required, utilizing lung-protective strategies including low tidal volumes and positive end-expiratory pressure (PEEP) 1
- Monitor peak airway pressures in ventilated patients 1, 3
Most patients show clinical improvement within the first few hours, with complete resolution typically occurring within 72-96 hours. 4, 6
Critical Fluid Management Principle
Avoid diuretics—they are ineffective for TRALI and may worsen the condition by causing hypovolemia. 1, 3, 5 This is a critical distinction from Transfusion-Associated Circulatory Overload (TACO), where diuretics are the primary treatment. 2
Maintain conservative fluid practices, avoiding both hypotension and overhydration. 1 Adequate blood pressure for organ perfusion (MAP >65-70 mmHg) should be maintained with IV fluids as needed. 2
Monitoring Requirements
Monitor vital signs closely every 5-15 minutes, including: 2
- Heart rate
- Blood pressure
- Temperature
- Respiratory rate
- Oxygen saturation
Diagnostic Differentiation
TRALI presents with non-cardiogenic pulmonary edema, hypoxemia, respiratory distress, dyspnea, and bilateral pulmonary infiltrates within 6 hours after transfusion (typically 1-2 hours). 1, 3 Unlike TACO, TRALI does not exhibit evidence of circulatory overload such as elevated jugular venous pressure, peripheral edema, or cardiovascular changes. 1, 2
Supportive Care and Prognosis
Provide critical care supportive measures focusing on respiratory and cardiovascular support. 3, 4 In severe cases requiring mechanical ventilation, invasive hemodynamic monitoring may be necessary. 5
The prognosis is generally favorable when TRALI is recognized early—most patients (81%) experience rapid and complete recovery. 7 Patients who tolerate the initial reaction typically make full recovery within 72-96 hours, making early identification and emergent management essential. 4, 6
Common Pitfalls to Avoid
- Do not administer diuretics, which are appropriate for TACO but contraindicated in TRALI 1, 5
- Do not delay stopping the transfusion while waiting to confirm the reaction type 2
- Do not overlook reporting to the blood bank, as this prevents future reactions 1, 3
The use of glucocorticoids remains controversial with no clear evidence supporting their routine use. 5