Viscous Sputum and Systemic Edema: Key Physical Signs for Transfusion-Related Acute Lung Injury Diagnosis During Anesthesia

Diagnosing transfusion-related acute lung injury (TRALI) under general anesthesia presents unique challenges for anesthesiologists, particularly when sophisticated diagnostic resources are limited. This case demonstrates how two specific physical signs, such as viscous sputum and systemic edema, provide critical diagnostic information without advanced testing equipment. A 74-year-old man undergoing transurethral resection of the prostate (TURP) developed acute hypoxemia and hypotension after blood transfusion. We diagnosed TRALI based on characteristic white, tenacious sputum difficult to suction and generalized erythematous swelling, distinguishing it from cardiogenic edema and concurrent transurethral resection syndrome. After stopping the transfusion and administering methylprednisolone, we transferred the patient to the high-dependency unit for mechanical ventilation. His respiratory status improved progressively, leading to successful extubation on postoperative day 2. Viscous sputum reflects protein-rich exudate from increased pulmonary vascular permeability characteristic of TRALI pathophysiology, while systemic edema patterns indicate inflammatory capillary leak rather than hydrostatic fluid retention. These observable signs enable accurate diagnosis and appropriate management when advanced diagnostics are unavailable. This case enables clinicians to recognize distinctive TRALI features in perioperative settings, differentiate it from cardiogenic edema using physical examination, understand the pathophysiological bases of sputum and edema patterns, and apply these skills in resource-constrained environments.