What to do if a patient develops a fever before a scheduled blood transfusion?

Management of Fever Before Scheduled Blood Transfusion

When a patient develops a fever before a scheduled blood transfusion, the transfusion should be postponed until the source of fever is identified and treated, as proceeding with transfusion could mask signs of infection or lead to misdiagnosis of transfusion reactions. 1, 2

Initial Assessment

• Perform a thorough clinical evaluation to identify the source of fever, including blood cultures, urine analysis, and chest X-ray if pulmonary symptoms are present 1
• Obtain complete blood count, inflammatory markers (C-reactive protein, ferritin), and other relevant laboratory tests based on clinical presentation 1, 2
• Consider procalcitonin testing as it can help discriminate between infectious and non-infectious causes of fever 1
• Evaluate for silent sources of infection including otitis media, decubitus ulcers, perineal/perianal abscesses, and other occult infections 1

Management Algorithm

1. Postpone the transfusion until fever resolves and source is identified 1, 2
2. Obtain blood cultures immediately after onset of fever or chills 1
   • Use proper technique: fresh venipuncture, skin sterilization with 70% isopropyl alcohol or iodine solution 1
   • Collect adequate volume (20-60 ml) per culture 1
3. Initiate empiric antibiotics if infection is suspected, especially in neutropenic patients 1
   • Broad-spectrum coverage should be started for neutropenic fever 1
4. Investigate for specific causes based on clinical presentation 1
5. Monitor closely for signs of deterioration 2
6. Resume transfusion only after fever resolves and infection is ruled out or appropriately treated 1, 2

Special Considerations

Immunocompromised Patients

• Maintain high index of suspicion for infection regardless of cell count and glucose concentration 1
• Consider additional testing such as viral PCR studies in immunocompromised patients 1
• Use screened, filtered, or leukocyte-reduced blood components for immunocompromised patients to prevent CMV disease 1

Potential Causes of Fever to Consider

• Bacterial infection (most common cause requiring immediate attention) 1
• Post-transfusion mononucleosis syndrome (typically occurs 1 month after transfusion) 1
• Febrile non-hemolytic transfusion reaction (most common transfusion reaction, but occurs during or after transfusion, not before) 3, 4
• Coincidental fever unrelated to planned transfusion 5

Pitfalls to Avoid

• Don't proceed with transfusion despite fever: Fever may mask signs of a transfusion reaction or be misinterpreted as a transfusion reaction 2, 6
• Don't assume fever is always due to infection: Consider non-infectious causes as well 1, 3
• Don't delay blood cultures: Obtain cultures before starting antibiotics whenever possible 1
• Don't forget to notify the blood bank: If transfusion has already started when fever develops, stop immediately and notify the blood bank 2, 6
• Don't neglect to evaluate for silent sources of infection: Careful history and physical examination are essential 1

When to Resume Transfusion

• Resume transfusion only after fever resolves and infection is ruled out or appropriately treated 1, 2
• Consider slower transfusion rates when resuming transfusion 2
• For patients with history of febrile reactions, consider premedication with antipyretics (though this remains controversial) and use of leukocyte-reduced blood products for future transfusions 3, 7

By following this systematic approach, clinicians can ensure patient safety while appropriately managing fever before blood transfusion, ultimately reducing morbidity and mortality associated with transfusion complications.