What is the management of a febrile non-hemolytic transfusion reaction?

Management of Febrile Non-Hemolytic Transfusion Reaction

Stop the transfusion immediately and maintain IV access with normal saline while assessing for signs of more serious transfusion reactions before confirming this is a simple febrile non-hemolytic reaction. 1, 2

Immediate Actions Upon Fever Detection

• Discontinue the transfusion immediately and keep the IV line open with normal saline 2
• Verify patient identification and blood component compatibility labels for 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 indicate serious reactions (hypotension, tachycardia, respiratory distress, hemodynamic instability) 2

Critical Risk Stratification

Do not assume isolated fever is benign—bacterial contamination from platelets can present with fever alone within 6 hours and is potentially fatal. 2

• Fever with hypotension or tachycardia suggests acute hemolytic reaction or bacterial contamination requiring immediate aggressive management 2
• Respiratory symptoms within 1-6 hours may indicate TRALI, one of the top three causes of transfusion-related deaths 2
• Fever within 6 hours after platelet transfusion is particularly concerning for bacterial contamination 2
• General anesthesia and critical illness can mask early signs of serious reactions 2

Diagnostic Workup

• Send the blood component bag with administration set back to the transfusion laboratory for analysis 2
• Collect post-reaction blood samples for repeat crossmatch and direct antiglobulin test (Coombs test) 2
• Obtain complete blood count 2
• Perform visual inspection of plasma for hemolysis 2
• Check urine analysis for hemoglobinuria 2
• Obtain blood cultures before antibiotics if bacterial contamination is suspected 2

Treatment for Confirmed FNHTR

For isolated fever without concerning features, administer intravenous paracetamol (acetaminophen) only—do not use steroids or antihistamines indiscriminately. 1

• Give acetaminophen 650-1000 mg orally or IV for fever control 2
• Avoid repeated doses of steroids as they may further suppress immunity in immunocompromised patients 1
• Use a personalized approach tailored to symptoms: febrile reactions require only paracetamol, while allergic reactions require only antihistamines 1

Management of Serious Reactions (If Present)

• Provide oxygen, fluid resuscitation, and vasopressors if hemodynamic instability develops 2
• Initiate broad-spectrum antibiotics immediately after blood cultures for suspected bacterial contamination 2
• Maintain urine output >100 mL/hour with aggressive fluid resuscitation for suspected hemolytic reaction 2
• Follow local anaphylaxis protocols if severe reaction or anaphylaxis is suspected 1

Prevention of Future Reactions

• Leukoreduction significantly reduces febrile non-hemolytic reactions and should be used for all blood products 1, 3, 4, 5
• Consider leukocyte-poor red blood cells for patients with recurrent FNHTR 6
• Routine premedication with acetaminophen or diphenhydramine is not recommended as studies show they fail to prevent transfusion reactions and have potential toxicity 7
• Reserve premedication only for patients with documented severe allergic reactions requiring prevention 3

Critical Pitfalls to Avoid

• Never restart the transfusion before laboratory clearance, even if symptoms improve, as the reaction may worsen with continued exposure 2
• Do not continue transfusion despite "just fever"—serious reactions can present subtly in anesthetized or critically ill patients 2
• Avoid assuming premedication prevents serious reactions like TRALI, TACO, or hemolytic reactions 3
• In neutropenic patients, fever may be masked by scheduled NSAIDs/acetaminophen, so maintain high suspicion even with minimal symptoms 2