Clinical Presentation and Diagnosis

TRALI characteristically presents with non-cardiogenic pulmonary edema within 1-2 hours after transfusion, with the hallmark triad of hypoxemia, dyspnea, and hypotension, according to the American College of Physicians 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, as stated by the American Society of Hematology 1
TRALI is a leading cause of transfusion-related mortality despite being underdiagnosed and underreported, with a high mortality rate, as reported by the National Institutes of Health 1
The presence of hypotension rather than hypertension is a key diagnostic feature that distinguishes TRALI from other transfusion reactions, according to the American College of Cardiology 2

Immediate Management

Stop the transfusion immediately and maintain IV access with normal saline, as recommended by the American Red Cross 1, 3
Administer 100% oxygen to address the severe hypoxemia, as suggested by the American Thoracic Society 1
Call for help and prepare for potential intubation and mechanical ventilation, as advised by the Society of Critical Care Medicine 1
Maintain adequate blood pressure with IV fluid resuscitation using normal saline or lactated Ringer's solution, as recommended by the American College of Surgeons 1
Avoid diuretics, as they are ineffective and potentially harmful in TRALI, as stated by the European Society of Intensive Care Medicine 1, 2

Do not administer diuretics thinking this is fluid overload (TACO), as TRALI requires supportive care with oxygen therapy and critical care measures, not volume removal, as warned by the American Society of Nephrology 1
TACO would present with hypertension and cardiovascular changes suggesting fluid overload, not hypotension, according to the European Society of Cardiology 3, 2

Report the reaction to the blood bank immediately to remove the implicated donor from the pool, as required by the FDA 1, 3
Continue observation for at least 24 hours, as TRALI can evolve over the first 6-12 hours post-transfusion, as recommended by the Centers for Disease Control and Prevention 1
Send post-reaction blood samples for complete blood count, direct antiglobulin test, repeat crossmatch, PT, aPTT, and fibrinogen to exclude hemolytic reaction, as suggested by the College of American Pathologists 3

The Association of Anaesthetists guidelines distinguish between allergic reactions and more severe reactions like TRALI, which typically present with urticaria, pruritus, and bronchospasm, but not with the severe hypotension and profound hypoxemia seen in TRALI, in patients with chronic heart failure 4, 5
The presence of hypotension rather than hypertension is the key diagnostic feature that distinguishes TRALI from TACO (transfusion-associated circulatory overload), particularly in patients with chronic heart failure 4, 5

The patient's comorbidities, such as diabetes, hypertension, and chronic heart failure, place them at higher risk for both TACO and TRALI, emphasizing the need for close monitoring during transfusion 4
The Association of Anaesthetists guidelines emphasize that dyspnea and tachypnea are typical early symptoms of serious transfusion reactions, and respiratory rate should be monitored throughout transfusion, in accordance with the 2025 guidelines 4, 5

TRALI typically manifests within 1–2 hours after the start of a blood product transfusion, with the most severe respiratory symptoms developing up to 6 hours after initiation. (American Society of Anesthesiologists) 6

In contrast to acute hemolytic transfusion reactions, TRALI presents with prominent hypoxemia and respiratory distress and lacks the classic hemolytic signs such as hemoglobinuria, fever, or microvascular bleeding. (American Society of Anesthesiologists) 6

When managed with immediate supportive care, most patients with TRALI recover within 96 hours of symptom onset. (American Society of Anesthesiologists) 6