Transfusion-Related Acute Lung Injury (TRALI)
The most likely diagnosis is Transfusion-Related Acute Lung Injury (TRALI), not fluid overload, and the critical error was administering diuretics—which are ineffective and potentially harmful in TRALI. 1, 2
Why This Is TRALI, Not TACO
The clinical presentation definitively points to TRALI based on three key features:
- Hypotension (BP 105/62) is the diagnostic hallmark that distinguishes TRALI from transfusion-associated circulatory overload (TACO), which would present with hypertension and cardiovascular changes suggesting fluid overload 1, 2
- Fever (39.1°C) accompanying respiratory distress is a common symptom of TRALI and indicates immune-mediated lung injury rather than simple volume overload 1, 2
- Lack of response to diuretics confirms this is non-cardiogenic pulmonary edema; TACO would improve with diuretic therapy, whereas TRALI does not respond because the mechanism is capillary leak, not volume overload 1, 3
Pathophysiology and Timing
TRALI characteristically presents with non-cardiogenic pulmonary edema within 1-2 hours after transfusion, with the hallmark triad of hypoxemia, dyspnea, and hypotension. 1 The mechanism involves donor leukocyte antibodies (HLA class I, class II, or granulocyte-specific antibodies) interacting with recipient neutrophils, causing acute respiratory distress and cardiovascular instability. 1, 2
The patient's symptoms developed during or shortly after transfusion and persisted despite stopping the transfusion and administering diuretics, which is consistent with the typical TRALI timeline of onset within 6 hours of transfusion. 2, 4, 3
Immediate Management Required NOW
Stop all further transfusions immediately and do NOT give more diuretics. 1, 2 The correct management includes:
- Administer 100% oxygen to address the severe hypoxemia (current O2 sat 94% on 35% venturi mask is inadequate) 1, 2
- Prepare for intubation and mechanical ventilation given the persistent dyspnea and marginal oxygenation 1
- Maintain blood pressure with IV fluid resuscitation using normal saline or lactated Ringer's solution, not diuretics 1
- Call for critical care support immediately as TRALI is a leading cause of transfusion-related mortality despite being underdiagnosed 1
Critical Pitfall Already Made
The administration of diuretics was based on the incorrect assumption that this was fluid overload (TACO). 1 TRALI requires supportive care with oxygen therapy and critical care measures, not volume removal. 1, 3 Diuresis is not indicated in TRALI and can worsen hypotension. 3
Post-Stabilization Actions
- Report the reaction to the blood bank immediately to remove the implicated donor from the pool, as required by the FDA 1
- Continue observation for at least 24 hours, as TRALI can evolve over the first 6-12 hours post-transfusion 1
- Send post-reaction blood samples for complete blood count, direct antiglobulin test, repeat crossmatch, PT, aPTT, and fibrinogen to exclude hemolytic reaction 1
Expected Recovery
When managed with immediate supportive care, most patients with TRALI recover within 96 hours of symptom onset. 1 The prognosis is substantially better than most causes of acute lung injury when recognized and treated appropriately. 5