What are the indications to pause blood transfusion if a patient develops fever (pyrexia)?

From the Guidelines

Blood transfusion should be paused immediately if a patient develops a fever with a temperature of 38°C (100.4°F) or higher during the transfusion, or if there is a rise of 1°C (1.8°F) from baseline temperature, as indicated in the most recent guideline from the AAGBI in 2016 1. This pause is necessary to evaluate for a potential transfusion reaction, particularly a febrile non-hemolytic transfusion reaction (FNHTR) or a more serious hemolytic transfusion reaction. When a fever develops, the following steps should be taken:

• Immediately stop the transfusion
• Maintain IV access with normal saline through a new administration set
• Notify the physician
• Obtain vital signs including temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation
• Assess the patient for other symptoms such as chills, rigors, back pain, flushing, or shortness of breath
• Draw blood samples to check for hemolysis
• Return the blood product and administration set to the blood bank for investigation The transfusion may be cautiously resumed only after a thorough evaluation rules out a serious reaction and the physician determines it is safe to continue, as also suggested by the American Society of Clinical Oncology in 2018 1. This approach is critical because fever can be the first sign of a potentially life-threatening transfusion reaction that requires prompt intervention, with the risk of fatal hemolysis estimated to be 1:1 250 000 or 8 per 10 million RBC units, as reported in the AABB guideline from 2012 1.

From the Research

Indications to Pause Blood Transfusion

If a patient develops fever (pyrexia) during a blood transfusion, the following are indications to pause the transfusion:

• The development of any symptoms that could indicate a transfusion reaction, including fever, should prompt immediate action 2, 3
• The presence of fever may suggest a febrile nonhemolytic transfusion reaction (FNHTR), which is a common type of transfusion reaction 4, 5, 6
• The transfusion should be stopped immediately and the reaction reported to the blood bank, as this can affect the patient's outcome 2

Management of Transfusion Reactions

The initial management of blood transfusion reactions, including those with fever, requires:

• Early identification of the reaction 3
• Immediate interruption of the transfusion 2, 3
• Early consultation of the hematologic and ICU departments 3
• Fluid resuscitation as needed 3

Prevention of Transfusion Reactions

The best way to prevent transfusion reactions is to:

• Avoid unnecessary blood transfusions 3
• Maintain a transfusion-restrictive strategy 3
• Use leukoreduction, which has been shown to minimize FNHTRs 4