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 fever resolves and the source is identified. 1

Initial Assessment

• Perform a thorough clinical evaluation to identify the source of fever, including blood cultures, urinalysis, and chest X-ray if pulmonary symptoms are present 1
• Obtain complete blood count, inflammatory markers, and other relevant laboratory tests based on clinical presentation 1
• Consider procalcitonin testing to 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
• Obtain blood cultures immediately after onset of fever, before starting antibiotics whenever possible 1, 2

Management Algorithm

1. Immediately postpone the transfusion 1
2. Collect blood cultures and other relevant specimens 1, 2
3. Investigate for specific causes based on clinical presentation 1
4. Initiate empiric antibiotics if infection is suspected, especially in neutropenic patients 1
5. Resume transfusion only after fever resolves and infection is ruled out or appropriately treated 1

Special Considerations

• Maintain high index of suspicion for infection in immunocompromised patients 1
• Consider additional testing such as viral PCR studies in immunocompromised patients 1
• When resuming transfusion after fever resolution, consider slower transfusion rates 1
• For patients with recurrent transfusion reactions, use leukocyte-reduced blood components 1, 3

Important 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 1, 4
• Don't assume fever is always due to infection - consider non-infectious causes as well 1
• Don't delay blood cultures - obtain cultures before starting antibiotics 1
• Don't forget to notify the blood bank if transfusion has already started when fever develops 1
• Don't overlook that fever during transfusion could be coincidental rather than causative - as demonstrated in case reports where underlying infections were the actual cause 2

Differential Diagnosis

• Bacterial infection (most common cause requiring immediate attention) 1
• Febrile non-hemolytic transfusion reaction (occurs in approximately 1% of transfusions) 5, 6
• Underlying medical condition unrelated to the planned transfusion 2
• Post-transfusion mononucleosis syndrome (typically occurs 1 month after transfusion) 1

Clinical Impact

• Febrile reactions lead to significant clinical activity including diagnostic testing, medication administration, and potential hospital admission 6
• Approximately one-quarter of patients with febrile reactions undergo chest imaging within 48 hours, and 79% have blood cultures drawn 6
• Hospital admission directly attributable to febrile reactions occurs in 15% of outpatients to exclude other causes of fever 6