What is the management of Transfusion-Related Acute Lung Injury (TRALI) after Blood Transfusion (BT)?

Management of Transfusion-Related Acute Lung Injury (TRALI)

Stop the transfusion immediately and provide aggressive respiratory support with 100% oxygen—do NOT give diuretics, as TRALI is non-cardiogenic pulmonary edema requiring critical care supportive measures, not volume removal. 1, 2

Immediate Actions (First 5 Minutes)

• Discontinue the transfusion immediately and maintain IV access with normal saline for medication administration and potential fluid resuscitation 1, 3
• Administer 100% high-flow oxygen to address the severe hypoxemia that characterizes TRALI 1, 3
• Call for help immediately and prepare for potential intubation and mechanical ventilation, as many patients will require mechanical ventilatory support 1
• Maintain blood pressure with IV fluid resuscitation using normal saline or lactated Ringer's solution to support organ perfusion (MAP >65-70 mmHg) 1, 3
• Monitor vital signs every 5-15 minutes, including heart rate, blood pressure, temperature, respiratory rate, and oxygen saturation 3

Critical Diagnostic Distinction

The presence of hypotension (not hypertension) is the key feature that distinguishes TRALI from Transfusion-Associated Circulatory Overload (TACO). 1, 3

• TRALI presents with hypoxemia, dyspnea, hypotension, and bilateral pulmonary infiltrates within 1-6 hours of transfusion 4, 1, 2
• TACO presents with hypertension, cardiovascular changes suggesting fluid overload, and responds to diuretics 1, 3
• Never administer diuretics for TRALI—they are ineffective and potentially harmful, as this is non-cardiogenic pulmonary edema requiring supportive care, not volume removal 1, 2, 3

Respiratory Support Algorithm

• Provide supplemental oxygen immediately with target SpO2 >90% 1, 3
• Prepare for intubation if the patient shows signs of respiratory failure: inability to maintain oxygenation on high-flow oxygen, altered mental status, or respiratory exhaustion 1
• In mechanically ventilated patients, monitor peak airway pressure as it will be elevated 4, 2
• Most patients require mechanical ventilation for 2-4 days, with clinical improvement typically beginning within the first few hours and complete resolution within 96 hours 5, 6, 7

Laboratory Workup

• Send post-reaction blood samples immediately for complete blood count, direct antiglobulin test (Coombs test), repeat crossmatch, PT, aPTT, and fibrinogen to exclude hemolytic reaction 1, 3
• Visual inspection of plasma for hemolysis should be performed 3
• These tests help exclude other transfusion reactions that may present similarly 1, 3

Mandatory Reporting

• Report the reaction to the blood bank immediately—this is critical to remove the implicated donor from the pool and prevent future TRALI reactions in other patients 1, 2, 3
• TRALI is the leading cause of transfusion-related mortality but remains underdiagnosed and underreported 4, 1, 8, 9
• The blood bank will test the donor serum for HLA class I, class II, or granulocyte-specific antibodies, which are found in 65-89% of TRALI cases 1, 7

Ongoing Management

• Continue observation for at least 24 hours, as TRALI can evolve over the first 6-12 hours post-transfusion 1
• Provide critical care supportive measures focusing on respiratory support and maintaining adequate perfusion 4, 2
• Maintain appropriate fluid balance without overhydration, as excessive fluids can worsen pulmonary edema 2
• Avoid additional transfusions unless absolutely necessary for life-threatening hemorrhage 2

Pathophysiology and Prognosis

• TRALI is caused by donor leukocyte antibodies (HLA class I, class II, or granulocyte-specific) interacting with recipient neutrophils, causing granulocyte aggregation and complement activation in lung capillaries 4, 1, 9
• Fresh frozen plasma (FFP) and platelet concentrates are the blood products most frequently implicated, as they contain significant plasma volumes 2, 3
• Mortality rate is 5-14%, making TRALI the leading cause of transfusion-related deaths 8, 6
• 80% of patients recover within 96 hours with appropriate respiratory intervention, with no permanent pulmonary sequelae 6, 7

Common Pitfalls to Avoid

• Do not give diuretics—the single most dangerous error is treating TRALI as fluid overload (TACO), as diuretics are ineffective and potentially harmful 1, 2, 3
• Do not delay reporting to the blood bank—early identification of implicated donors prevents future reactions in other patients 1, 2, 8
• Do not confuse fever with infection—fever is a common feature of TRALI and does not necessarily indicate bacterial contamination 4