What is the management for a patient who develops hyperthermia after starting a packed Red Blood Cells (RBCs) transfusion?

Management of Fever (39°C) After Starting Packed RBC Transfusion

Stop the transfusion immediately and maintain IV access with normal saline—this is the single most critical intervention that can prevent progression to severe morbidity or mortality. 1, 2, 3

Immediate Actions (First 5 Minutes)

• Stop the transfusion immediately without waiting to confirm the reaction type, as fever can signal life-threatening complications including acute hemolytic reaction, bacterial contamination, or TRALI 1, 2, 3
• Maintain IV access with normal saline for medication administration and potential fluid resuscitation 2, 4
• Notify the transfusion laboratory/blood bank immediately to report the reaction and initiate investigation 1, 2, 3
• Double-check all documentation for clerical errors, particularly patient identification and blood component compatibility labels, as administration errors are a preventable cause of serious reactions 2, 3

Rapid Clinical Assessment (Next 5-10 Minutes)

Assess vital signs every 5-15 minutes including heart rate, blood pressure, respiratory rate, oxygen saturation, and repeat temperature 1, 2, 4

Risk Stratification Based on Associated Symptoms:

High-Risk Features (Treat as Medical Emergency):

• Fever + hypotension or tachycardia suggests acute hemolytic reaction or bacterial contamination—both potentially fatal 1, 2
• Fever + respiratory distress (dyspnea, hypoxemia, tachypnea) within 1-6 hours suggests TRALI, one of the top three causes of transfusion-related deaths 2, 3
• Fever + oliguria or dark urine indicates hemolytic reaction with renal involvement 2
• Fever within 6 hours after platelet transfusion is particularly concerning for bacterial contamination, a leading cause of transfusion mortality 2, 3

Lower-Risk Presentation:

• Isolated fever without hemodynamic instability or respiratory symptoms may represent febrile non-hemolytic transfusion reaction (FNHTR), but this is a diagnosis of exclusion only after ruling out serious complications 2, 5

Immediate Diagnostic Workup

Send the following immediately:

• Return the blood component bag with administration set to the transfusion laboratory for analysis 2, 3
• Post-reaction blood samples: complete blood count, direct antiglobulin test (Coombs test), repeat crossmatch, PT, aPTT, fibrinogen 2, 3
• Visual inspection of plasma for hemolysis and urine analysis for hemoglobinuria 2, 3
• Blood cultures (from patient AND from the blood bag) if bacterial contamination is suspected, particularly with platelets or if fever occurred within 6 hours 2, 4

Treatment Algorithm Based on Clinical Presentation

If Fever + Hemodynamic Instability (Hypotension/Tachycardia):

• Initiate aggressive fluid resuscitation with normal saline bolus 1000-2000 mL to maintain MAP >65-70 mmHg 2, 3
• Obtain blood cultures immediately (before antibiotics) from patient and blood bag 2, 4
• Administer broad-spectrum antibiotics immediately after cultures if bacterial contamination suspected 1, 4
• Maintain urine output >100 mL/hour with aggressive hydration if hemolytic reaction suspected 2
• Prepare vasopressors if hypotension persists despite fluid resuscitation 2

If Fever + Respiratory Distress:

• Administer high-flow oxygen (high FiO2) immediately 3
• Assess for TRALI vs TACO: TRALI presents with non-cardiogenic pulmonary edema 1-2 hours post-transfusion with hypoxemia and fever; TACO presents with fluid overload signs and cardiovascular changes 3
• Critical distinction: For TRALI, provide oxygen and critical care support but avoid diuretics (they are ineffective); for TACO, administer diuretics 3
• Obtain chest X-ray and arterial blood gases 4
• Prepare for potential intubation if respiratory failure develops 2

If Isolated Fever Without Other Concerning Features:

• Continue close monitoring every 5-15 minutes for development of additional symptoms 2, 4
• Administer acetaminophen 650-1000 mg orally or IV for symptomatic fever control 2
• Do NOT restart transfusion before laboratory clearance, even if symptoms improve, as the reaction may worsen with continued exposure 2
• Await laboratory results before determining if this is simple FNHTR 2, 5

Critical Pitfalls to Avoid

• Never continue the transfusion despite "just fever"—general anesthesia and critical illness can mask early signs of serious reactions 2
• Never assume fever is always FNHTR—bacterial contamination from platelets can present with isolated fever within 6 hours and is potentially fatal 2
• Never restart the transfusion before laboratory clearance, even if symptoms improve 2
• Never give diuretics for TRALI—they are ineffective and delay appropriate supportive care 3
• Never delay blood cultures if bacterial contamination is suspected—obtain them before starting antibiotics 2, 4

Documentation and Follow-Up

• Document all findings in the patient record with 100% traceability (legal requirement) 3
• Report to blood bank as serious reactions like TRALI are underdiagnosed and underreported despite being a leading cause of transfusion-related mortality 3
• Consider leukocyte-reduced or washed blood products for future transfusions if allergic reaction confirmed 4, 6