What is the best approach to manage shivering in an immunocompromised adult over 50 in the Intensive Care Unit (ICU) setting during a blood transfusion?

Management of Shivering During Blood Transfusion in an Immunocompromised ICU Patient Over 50

For shivering during blood transfusion in an immunocompromised ICU patient, immediately stop the transfusion, assess for serious transfusion reactions (particularly febrile non-hemolytic reaction), and administer intravenous meperidine 12.5-50 mg as first-line pharmacologic therapy while ruling out life-threatening complications. 1, 2

Immediate Assessment and Critical Actions

Stop the transfusion immediately and maintain IV access with normal saline to keep the vein open. 1 This is paramount because shivering may represent the initial manifestation of a serious transfusion reaction that could progress to life-threatening complications.

Vital Signs Monitoring

• Measure temperature, pulse, blood pressure, and respiratory rate immediately and every 5-15 minutes. 1
• Document oxygen saturation continuously, as dyspnea and tachypnoea are early symptoms of serious transfusion reactions including TRALI and TACO. 1
• Assess for cardiovascular changes: tachycardia and hypertension suggest febrile reaction, while hypotension suggests anaphylaxis or hemolytic reaction. 1

Differential Diagnosis to Rule Out

Febrile Non-Hemolytic Transfusion Reaction (most common):

• Presents with fever, shivering, tachycardia, and hypertension without hemolysis. 1, 2
• More common with red blood cell units. 1

TACO (most common cause of transfusion-related mortality):

• Look for acute respiratory compromise, pulmonary edema, tachycardia, and hypertension (not hypotension). 1
• High-risk features in your patient: age >50, immunocompromised status, ICU setting. 1

TRALI:

• Presents with fever, hypoxemia, acute respiratory distress within 6 hours of transfusion. 3
• Distinguished by hypotension rather than hypertension. 3

Septic Transfusion Reaction:

• Rigors with shivering, high fever, hypotension, and rapid clinical deterioration. 4
• Requires immediate blood cultures and broad-spectrum antibiotics. 4

Pharmacologic Management of Shivering

First-Line: Meperidine

Administer intravenous meperidine 12.5-50 mg as the preferred agent for shivering control during transfusion reactions. 1, 2, 5

Rationale for meperidine superiority:

• Possesses potent anti-shivering properties mediated through kappa-opioid receptors, not just mu-receptors. 1, 5
• More effective than equianalgesic doses of morphine or fentanyl for shivering control. 5
• Rapidly effective in treating shivering-associated tachycardia and hypertension. 2
• Can reduce oxygen consumption nearly to baseline values. 5

Critical warnings for meperidine use:

• Active metabolite (normeperidine) associated with neurotoxicity, particularly concerning in ICU patients. 1
• Decreases seizure threshold—use with extreme caution in patients with seizure history. 1
• Avoid in renal dysfunction due to metabolite accumulation. 1

Alternative Anti-Shivering Agents (if meperidine contraindicated)

Magnesium sulfate:

• Dose: 2-4 g bolus, then 1 g/h infusion. 1
• Safer profile in renal dysfunction compared to meperidine. 1

Fentanyl (less effective but safer):

• Bolus: 25-100 μg, infusion: 0.5-15 μg/kg/h. 1
• Short duration of action, will not accumulate in kidney/liver dysfunction. 1
• Less effective for shivering than meperidine but provides analgesia. 1

Symptomatic Management Based on Reaction Type

For Febrile Reactions (fever with shivering, no allergic symptoms):

Administer intravenous paracetamol only—do not use steroids or antihistamines indiscriminately. 1 Repeated steroid doses further suppress immunity in immunocompromised patients. 1

For Allergic Reactions (urticaria, pruritus with shivering):

Administer antihistamine only (e.g., chlorphenamine 10 mg IV). 1 Tailor treatment to symptoms rather than empiric premedication. 1

For Suspected Anaphylaxis (bronchospasm, hypotension, cardiovascular compromise):

Administer epinephrine 50 mcg IV (0.5 mL of 1:10,000 solution) immediately, repeat every 5-15 minutes as needed. 6 This takes precedence over all other interventions. 6

Laboratory Evaluation

Immediate blood work:

• Repeat crossmatch and direct antiglobulin test (DAT) to rule out hemolytic reaction. 4
• Complete blood count to assess for hemolysis. 4
• Blood cultures from patient and blood bag if septic reaction suspected. 4
• Coagulation studies if DIC suspected. 4

Notify transfusion laboratory immediately and return the blood component bag with administration set for analysis. 6, 4

Special Considerations for Immunocompromised Patients

Prevention of Future Reactions

Use irradiated blood products (15 Gy) for all future transfusions to prevent transfusion-associated graft-versus-host disease (TA-GVHD). 7, 8 TA-GVHD has >90% mortality and affects skin, liver, GI tract, and bone marrow. 7, 8

Use leukocyte-reduced blood components to minimize febrile reactions and prevent CMV transmission. 9

Infection Surveillance

Maintain high index of suspicion for concurrent infection as cause of fever/shivering, independent of the transfusion. 9 Obtain blood cultures before attributing symptoms solely to transfusion reaction. 9

Common Pitfalls to Avoid

• Do not restart the transfusion even if symptoms improve—the reaction may worsen with continued exposure. 6, 4
• Do not give diuretics empirically for shivering alone—they are contraindicated in anaphylaxis and ineffective in TRALI. 6, 3
• Do not use steroids/antihistamines indiscriminately without first determining if the reaction is febrile versus allergic. 1
• Do not assume shivering is benign—it increases oxygen consumption up to 500%, potentially catastrophic in patients with limited cardiopulmonary reserve. 2
• Do not delay assessment for TACO in elderly ICU patients—it is now the leading cause of transfusion-related mortality. 1

Post-Event Management

Continue monitoring for at least 24 hours after severe reactions, as delayed complications may occur. 6, 4 Document the reaction in the patient's medical record and report to the hemovigilance system. 4

For future transfusions: Consider slower transfusion rates, premedication based on confirmed reaction type, and use of washed blood products if allergic reaction confirmed. 9, 6