What should I do if a patient develops fever and chills after receiving packed Red Blood Cells (RBCs)?

Management of Fever and Chills After Packed RBC Transfusion

If a patient develops fever and chills after receiving packed red blood cells, immediately stop the transfusion, maintain the IV line with normal saline, and initiate supportive care while investigating for a transfusion reaction. 1

Initial Assessment and Management

1. Stop the transfusion immediately

   • Maintain IV access with normal saline 1
   • Do not discard the blood bag and tubing (needed for investigation) 1

2. Assess vital signs

   • Monitor temperature, heart rate, blood pressure, respiratory rate
   • Look for signs of severe reaction: hypotension, tachycardia, respiratory distress 1

3. Provide symptomatic treatment

   • For febrile reactions: intravenous paracetamol (acetaminophen) 1
   • For allergic symptoms: antihistamine (diphenhydramine) 1
   • Avoid indiscriminate use of steroids unless anaphylaxis is suspected 1

Diagnostic Evaluation

1. Contact the blood bank/laboratory immediately 1

   • Report the suspected transfusion reaction
   • Send the blood bag, tubing, and new patient blood samples for investigation

2. Obtain blood samples

   • Post-transfusion blood cultures (if bacterial contamination suspected)
   • Repeat blood typing and crossmatching
   • Direct antiglobulin test (DAT)
   • Complete blood count
   • Chemistry panel including renal function

3. Additional testing based on symptoms

   • Urinalysis (for hemoglobinuria if hemolytic reaction suspected)
   • Chest X-ray (if respiratory symptoms present)
   • Coagulation studies (if bleeding or DIC suspected)

Differential Diagnosis

1. Febrile Non-Hemolytic Transfusion Reaction (FNHTR)

   • Most common cause (1.1-2.15% of transfusions) 1
   • Characterized by fever, chills without evidence of hemolysis
   • Usually self-limiting

2. Acute Hemolytic Transfusion Reaction

   • Rare but serious (1:1,250,000 transfusions) 1
   • Can present with fever, chills, back/flank pain, hypotension

3. Bacterial Contamination

   • Rare but potentially fatal
   • Rapid onset of fever, chills, hypotension, shock 1

4. Allergic Reaction

   • Usually presents with urticaria, pruritus, sometimes with fever

5. Transfusion-Related Acute Lung Injury (TRALI)

   • Presents with respiratory distress, hypoxemia, bilateral pulmonary infiltrates

Management Based on Reaction Type

1. For mild febrile reactions (temperature rise <1°C, no other symptoms):

   • Antipyretics (paracetamol/acetaminophen)
   • Close monitoring
   • May resume transfusion at slower rate if symptoms resolve and no evidence of hemolysis 1

2. For moderate reactions (temperature rise >1°C, chills, no hypotension):

   • Antipyretics
   • Do not resume the current transfusion
   • Monitor closely for progression

3. For severe reactions (hypotension, respiratory distress, severe rigors):

   • Aggressive supportive care
   • IV fluids for hypotension
   • Oxygen as needed
   • Consider ICU transfer for monitoring
   • Follow institutional protocols for severe transfusion reactions 1

4. For suspected bacterial contamination:

   • Immediate broad-spectrum antibiotics
   • Aggressive fluid resuscitation
   • Vasopressors if needed for hypotension 1

Prevention of Future Reactions

1. For patients with history of febrile reactions:

   • Pre-medication with antipyretics before future transfusions
   • Consider leukoreduced blood products 1

2. For patients with history of allergic reactions:

   • Pre-medication with antihistamines
   • Consider washed RBCs for severe reactions

Common Pitfalls to Avoid

1. Do not restart the transfusion if a severe reaction is suspected - this could worsen the reaction and increase mortality risk 1

2. Do not administer corticosteroids routinely - they should be reserved for severe allergic reactions or anaphylaxis 1

3. Do not delay notification to the blood bank - prompt investigation is essential to determine the cause and guide management 1

4. Do not confuse transfusion reactions with other causes of fever - in post-surgical or critically ill patients, consider other sources of infection 1

5. Do not discard the blood product or tubing - these are essential for investigation 1

By following this structured approach, you can effectively manage transfusion reactions while minimizing morbidity and mortality risks for your patient.