What is the treatment for Acute Lung Injury (ALI) using blood transfusion?

From the Guidelines

Transfusion-related acute lung injury (TRALI) treatment should focus on immediate cessation of the transfusion, supportive care with oxygen therapy, and mechanical ventilation with lung-protective strategies, as outlined in recent guidelines such as those from the American College of Chest Physicians 1. The primary goal in managing TRALI is to support the patient's respiratory and cardiovascular systems while avoiding further lung injury. This approach is crucial given the significant risks associated with red blood cell transfusions, including TRALI, transfusion-associated circulatory overload, and immunomodulating effects that may increase the risk of nosocomial infections, as highlighted in a 2024 clinical practice guideline 1. Key components of TRALI treatment include:

• Immediate cessation of the transfusion if TRALI is suspected
• Oxygen therapy to maintain adequate oxygenation
• Mechanical ventilation with lung-protective strategies, such as tidal volumes of 6 ml/kg ideal body weight and plateau pressures <30 cmH2O
• Conservative fluid management to avoid worsening pulmonary edema
• Hemodynamic support with vasopressors like norepinephrine, starting at 0.05-0.1 mcg/kg/min, for hypotension It's also important to note that prevention strategies, such as using leukoreduced blood products and avoiding transfusions from female donors with previous pregnancies when possible, can help reduce the risk of TRALI, as discussed in the context of optimizing RBC transfusion strategies 1.

From the Research

Acute Lung Injury Transfusion Treatment

• Acute lung injury (ALI) is a syndrome of injurious pulmonary inflammation resulting in deranged respiratory physiology, with various potential therapeutic targets 2.
• Two main pharmacological treatment strategies for ALI have arisen: the attempted inhibition of excessive inflammation or the manipulation of the resulting physiological derangement causing respiratory failure 2.
• An emerging approach is the use of cell-based therapy, which seeks to convert the inflammatory process from an injurious process to a reparative one 2.

Transfusion-Related Acute Lung Injury (TRALI)

• TRALI is a well-known complication following the transfusion of blood products, characterized by the abrupt onset of respiratory failure within hours of the transfusion 3.
• The classic TRALI syndrome is usually caused by anti-leukocyte antibodies, resolves rapidly, and has a low mortality, while the "delayed TRALI syndrome" is common, occurring in up to 25% of critically ill patients receiving a blood transfusion, and is associated with a mortality of up to 40% 3.
• The management of both the classic and delayed TRALI syndromes is essentially supportive, and the risk and benefits of all blood products should be assessed before transfusion 3.

Red Blood Cell Transfusion Practices in Acute Lung Injury

• Red blood cell (RBC) transfusions are commonly used in patients with acute lung injury (ALI), with 47% of patients receiving an RBC transfusion in the ICU without evidence of active hemorrhage or acute cardiac ischemia 4.
• The mean nadir hemoglobin concentration on the day of first transfusion was 7.7 g/dL, and transfused patients received a mean of 5 RBC units from ALI diagnosis to ICU discharge 4.
• Patient factors, such as prehospital use of iron or erythropoietin and platelet transfusion in the ICU, were independently associated with lower pretransfusion hemoglobin concentrations 4.

Prevention and Treatment of TRALI

• Current treatment for TRALI remains largely supportive, and effective measures for decreasing the incidence of TRALI include the use of predominantly male plasma and apheresis platelets 5.
• Greater understanding of the blood component and patient risk factors for TRALI will hopefully lead to novel treatment and preventive strategies for reducing the risk of this life-threatening syndrome 5.
• Anesthesiologists should consider TRALI in the perioperative setting, identify at-risk patients, recognize early signs of TRALI, and have established strategies for its prevention and treatment 6.