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New TRALI definitions as proposed in 2019

Category	Definition
TRALI
TRALI type I	No risk factors for ARDS and all the following criteria are met: Acute onset Hypoxemia (PaO₂/FiO₂ ≤300 mmHg* or SpO₂ <90% on room air) Clear evidence of bilateral pulmonary edema on imaging^¶ No evidence of LAH^Δ or, if LAH is present, it is judged to not be the main contributor to the hypoxemia Onset during or within 6 hours of transfusion^◊ No temporal relationship to an alternative risk factor for ARDS
TRALI type II	Risk factors for ARDS are present (but ARDS has not been diagnosed) or mild ARDS at baseline* but with respiratory status deterioration^§ that is judged to be due to transfusion based on both of the following: Findings as described in categories a and b of TRALI type I Stable respiratory status in the 12 hours before transfusion
Pulmonary edema not fulfilling TRALI criteria
ARDS	Risk factors for ARDS and deterioration not due to the transfusion but as a consequence of the already present ARDS risk factors, based on at least one of the following: Onset of ARDS within 6 hours after transfusion but respiratory status was deteriorating in the 12 hours before transfusion Existing ARDS of any severity that further deteriorates after transfusion, where respiratory status was already deteriorating in the 12 hours before transfusion
TRALI/TACO cannot be distinguished	Used when TRALI cannot be distinguished from TACO or when both conditions occur simultaneously: Clinical findings compatible with TRALI and TACO and/or lack of data to establish whether or not significant LAH is present
Transfusion-associated dyspnea (TAD)	Used when pulmonary edema occurs within 24 hours after the cessation of the transfusion and is clinically suspicious for temporal association with transfusion (already used in many hemovigilance systems)

These revised criteria were proposed in 2019. Refer to UpToDate for additional information about their use in TRALI reporting, evaluation for LAH, and use of the P/F ratio.

TRALI: transfusion-related acute lung injury; ARDS: acute respiratory distress syndrome; PaO₂/FiO₂: ratio of arterial oxygen tension (measured by arterial blood gas in mmHg) to the fraction (percentage) of inspired oxygen (0.21 for room air); SpO₂: peripheral arterial oxygen saturation as measured by pulse oximetry; LAH: left atrial hypertension; TACO: transfusion-associated circulatory overload.
* The normal range for PaO₂/FiO₂ is 300 to 500 mmHg. Mild ARDS is a PaO₂/FiO₂ ratio of 200 to 300 mmHg. If the altitude is higher than 1000 m, the correction factor should be calculated as follows: [(PaO₂/FiO₂) × (barometric pressure/760)].
¶ Chest radiograph, computed tomography (CT), or ultrasound.
Δ Use objective evaluation when LAH is suspected (imaging [eg, echocardiography] or invasive measurement [eg, using a pulmonary artery catheter]).
◊ Onset of pulmonary symptoms (eg, hypoxemia—lower PaO₂/FiO₂ ratio or SpO₂) should be within 6 hours of end of transfusion. The additional findings needed to diagnose TRALI (pulmonary edema on a lung imaging study and determination of lack of substantial LAH) would ideally be available at the same time but could be documented up to 24 hours after TRALI onset.
§ Use PaO₂/FiO₂ ratio deterioration along with other respiratory parameters and clinical judgment to determine progression from mild to moderate or severe ARDS.

Modified from: Vlaar APJ, Toy P, Fung M, et al. A consensus redefinition of transfusion-related acute lung injury. Transfusion 2019; 59(7):2465-2476. https://onlinelibrary.wiley.com/doi/full/10.1111/trf.15311. Copyright © 2019 The Authors. Transfusion published by Wiley Periodicals, Inc. on behalf of AABB. Reproduced with permission of John Wiley & Sons Inc. This image has been provided by or is owned by Wiley. Further permission is needed before it can be downloaded to PowerPoint, printed, shared or emailed. Please contact Wiley's permissions department either via email: permissions@wiley.com or use the RightsLink service by clicking on the 'Request Permission' link accompanying this article on Wiley Online Library (https://onlinelibrary.wiley.com/).

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