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This case highlights the successful management of severe TRALI using VV-ECMO support in a post-surgical patient.

May 20, 2026

C48-15 Successful Management of Transfusion-related Acute Lung Injury (TRALI) With Veno-venous Extracorporeal Membrane Oxygenation (VV-ECMO) Support in a Post-surgical Patient

FRF RavatCatholic Medical Center HSH SekharamahantiCatholic Medical Center HPH PatelCatholic Medical Center

Key Points

This case highlights the successful management of severe TRALI using VV-ECMO support in a post-surgical patient.
A 65-year-old male post-surgery presented with severe TRALI symptoms after multiple blood transfusions.
VV-ECMO was initiated after clinical evaluation indicated worsening hypoxemia and respiratory failure.
Supportive care was provided, including optimizing ventilator settings and monitoring blood gases.
Post-initiation of VV-ECMO, the patient's oxygenation improved significantly over 48 hours.
The patient was decannulated and extubated shortly after stabilization of oxygen levels.
Timely recognition and use of VV-ECMO were crucial for recovery from TRALI.

Abstract

Abstract Introduction TRALI is a serious complication marked by acute hypoxemia and non-cardiogenic pulmonary edema, typically occurring within 6 hours (early) to 72 hours (delayed) of transfusion, in the absence of other causes. Approximately 80% of patients recover within 2-3 days; however, the reported mortality rate is 13-18%. This case highlights the use of VV-ECMO in severe TRALI, which can serve as a bridge to recovery by providing gas exchange and minimizing ventilator-induced lung injury. Case A 65-year-old male with type 2 diabetes, CAD, dyslipidemia, and prior left-lower lobectomy was admitted for elective left-upper lobectomy for biopsy-proven adenocarcinoma. He underwent VATS wedge resection with lingulectomy and lymph node sampling. Estimated blood loss was ∼500 mL; he received 1 unit of platelets he received 2 units PRBCs and returned to the OR for washout. He received 3 additional units PRBCs and 1 unit each of platelets, FFP, and cryoprecipitate. He was extubated shortly after. His course was complicated by aspiration pneumonia, treated appropriately, and intra-abdominal sepsis from cecal volvulus. He underwent ileocecectomy with primary anastomosis and received 1 unit each of PRBCs and platelets. Within 12 hours, he developed worsening hypoxia requiring re-intubation. Despite optimal ventilator support, his PaO2/FiO2 ratio dropped to 59, with increasing oxygen and PEEP needs. Imaging showed diffuse bilateral infiltrates, and ABG confirmed persistent respiratory failure. With presumed TRALI and rapidly progressive ARDS, VV-ECMO was initiated via right IJ and femoral cannulation. ECMO enabled immediate improvement in oxygenation and lung-protective ventilation. Within 48 hours, oxygenation steadily improved, allowing for decannulation. He was extubated two days later. Discussion TRALI is a significant cause of transfusion-related morbidity, with an incidence of 1 in 5,000 units transfused and rates up to 36.3 per 100,000 transfusion hospitalizations in older adults. It is often underdiagnosed due to overlap with other acute lung injuries. Diagnosis is clinical, requiring a temporal association with transfusion and the exclusion of other causes, such as transfusion-associated circulatory overload or cardiogenic edema. Management is supportive, involving oxygen and ventilation if needed, but avoiding diuretics as TRALI is non-cardiogenic. Reporting implicated products prevents recurrence. In severe cases, VV-ECMO provides critical gas exchange and lung rest, enabling recovery. Early recognition and timely intervention with ECMO can be lifesaving, as demonstrated in this patient. This abstract is funded by: none

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