What should be done if a patient develops a fever during a blood transfusion with no other symptoms?

Fever During Blood Transfusion: Immediate Management

Stop the transfusion immediately, maintain IV access with normal saline, and assess for other signs of a transfusion reaction before determining whether this is a simple febrile non-hemolytic reaction or a more serious complication. 1, 2

Immediate Actions (First 5 Minutes)

• Stop the blood transfusion immediately and keep the IV line open with normal saline at a keep-vein-open rate 1, 2
• Check patient identification and blood component compatibility labels for any clerical errors 2
• Notify the transfusion laboratory/blood bank immediately 2
• Assess vital signs including heart rate, blood pressure, respiratory rate, oxygen saturation, and repeat temperature 1, 2
• Perform focused assessment for additional symptoms that would indicate a serious reaction: 1
  • Hypotension or tachycardia (suggests hemolytic reaction or septic transfusion)
  • Dyspnea, hypoxemia, or respiratory distress (suggests TRALI or TACO)
  • Urticaria or pruritus (suggests allergic reaction)
  • Rigors or severe chills (suggests bacterial contamination or hemolytic reaction)
  • Changes in urine output or hemoglobinuria (suggests hemolytic reaction)

Risk Stratification Based on Clinical Presentation

If fever is isolated (no other symptoms):

• This likely represents a febrile non-hemolytic transfusion reaction (FNHTR), the most common type of transfusion reaction 3
• FNHTR is defined as temperature ≥38°C (or increase >1°C from baseline) during or within 4 hours after transfusion 3
• However, do not assume FNHTR until other serious reactions are excluded 1, 4

If fever occurs with any of the following, treat as a serious transfusion reaction:

• Hypotension, tachycardia, or hemodynamic instability (hemolytic reaction or bacterial contamination) 1
• Respiratory symptoms within 1-6 hours (TRALI is one of the top three causes of transfusion-related deaths) 1
• Fever within 6 hours after receiving platelets (bacterial contamination is a leading cause of death from transfusions) 1

Diagnostic Workup

Mandatory laboratory testing: 2

• Send the blood component bag with administration set back to the transfusion laboratory for analysis
• Collect post-reaction blood samples for:
  • Repeat crossmatch and direct antiglobulin test (Coombs test)
  • Complete blood count
  • Blood cultures if bacterial contamination suspected (especially if fever occurs within 6 hours of platelet transfusion) 1
  • Visual inspection of plasma for hemolysis
  • Urine analysis for hemoglobinuria 1

Consider additional testing based on clinical context: 1

• Procalcitonin levels (≥0.5 ng/mL suggests bacterial infection; helps discriminate infectious from non-infectious causes)
• Coagulation studies if microvascular bleeding present

Management Algorithm

For isolated fever with no other symptoms:

• Administer antipyretics (acetaminophen 650-1000 mg) for symptomatic relief 3
• Continue monitoring vital signs every 15 minutes for the first hour, then every 30 minutes until stable 2
• Do not restart the transfusion until laboratory results confirm no hemolysis or bacterial contamination 2, 4
• Observe patient for at least 4 hours after fever onset, as delayed symptoms may develop 3

For fever with additional concerning symptoms:

• Provide supportive care based on specific reaction type (oxygen, fluid resuscitation, vasopressors if needed) 1
• For suspected bacterial contamination: initiate broad-spectrum antibiotics immediately after blood cultures 1
• For suspected hemolytic reaction: aggressive fluid resuscitation to maintain urine output >100 mL/hour 1
• For respiratory symptoms: provide respiratory support and consider TRALI vs TACO 1

Critical Pitfalls to Avoid

• Never continue the transfusion despite "just fever" - general anesthesia and critical illness can mask early signs of serious reactions 1
• Never assume fever is always FNHTR - bacterial contamination from platelets can present with isolated fever within 6 hours and is potentially fatal 1
• Never restart the transfusion before laboratory clearance - even if symptoms improve, the reaction may worsen with continued exposure 2
• Never delay blood cultures - obtain before antibiotics if bacterial contamination suspected 1
• Never forget to check for silent sources - in critically ill patients, fever may be unrelated to transfusion (decubitus ulcers, occult abscesses, retained foreign bodies) 1

Prevention for Future Transfusions

• Consider leukocyte-reduced blood products for future transfusions, which significantly reduces FNHTR incidence 3
• Prophylactic antipyretics before transfusion remain controversial and are not routinely recommended 3
• For patients with history of multiple FNHTRs, premedication with acetaminophen 30 minutes before transfusion may be considered 3
• Women with reproductive history and patients with multiple prior transfusions are at higher risk for FNHTR 3