What are the immediate steps to take when a patient develops a fever during a blood transfusion?

Immediate Management of Fever During Blood Transfusion

Stop the Transfusion Immediately

Stop the blood 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

Do not continue the transfusion despite "just fever," as general anesthesia and critical illness can mask early signs of serious reactions. 1 Even isolated fever can represent life-threatening complications such as bacterial contamination or acute hemolytic reaction. 1, 2

Immediate Assessment and Stabilization

Vital Signs Monitoring

• Monitor vital signs every 5-15 minutes: heart rate, blood pressure, respiratory rate, oxygen saturation, and repeat temperature 1, 2
• Maintain mean arterial pressure >65-70 mmHg with IV fluid resuscitation 2
• Administer high-flow oxygen to address potential hypoxemia 3

Critical Risk Stratification

Fever with any of the following indicates a serious, potentially fatal transfusion reaction requiring immediate escalation:

• Hypotension or tachycardia: Suggests hemolytic reaction or bacterial contamination 1
• Respiratory symptoms within 1-6 hours: Potential TRALI, one of the top three causes of transfusion-related deaths 1, 3
• Fever within 6 hours after platelet transfusion: Bacterial contamination is a leading cause of transfusion-related mortality 1
• Pain at IV site, difficulty breathing: Acute hemolytic transfusion reaction (medical emergency) 2
• Oliguria or dark urine: Hemolytic reaction with renal involvement 1

Immediate Notifications and Documentation

• Notify the transfusion laboratory/blood bank immediately 1
• Check patient identification and blood component compatibility labels for clerical errors 1
• Prepare for potential escalation with vasopressors, intubation equipment, and resuscitation medications readily available 3

Diagnostic Workup

Send to Laboratory Immediately

• Return the blood component bag with administration set to the transfusion laboratory for analysis 1
• Collect post-reaction blood samples for:
  • Repeat crossmatch and direct antiglobulin test (Coombs test) 1, 3
  • Complete blood count 1, 3
  • PT, aPTT, Clauss fibrinogen 3
  • Visual inspection of plasma for hemolysis 1
  • Blood cultures if bacterial contamination suspected (obtain BEFORE antibiotics) 1
• Urine analysis for hemoglobinuria 1

Specific Management Based on Clinical Presentation

Suspected Bacterial Contamination (Fever ± Hypotension)

• Initiate broad-spectrum antibiotics immediately after blood cultures 1
• Critical pitfall: Fever within 6 hours after platelets may indicate bacterial contamination—do not assume this is always febrile non-hemolytic transfusion reaction (FNHTR) 1

Suspected Hemolytic Reaction (Fever + Hypotension + Dark Urine/Oliguria)

• Aggressive fluid resuscitation to maintain urine output >100 mL/hour 1
• The clinical triad of pain at IV site, difficulty breathing, and fever within 10 minutes is most consistent with acute hemolytic reaction 2
• Risk of acute hemolytic transfusion reaction is approximately 1:70,000 per unit 2

Suspected TRALI (Fever + Respiratory Distress Within 1-6 Hours)

• Provide critical care supportive measures and oxygen therapy 3
• Avoid diuretics—they are ineffective for TRALI and may worsen outcomes 3
• TRALI presents with non-cardiogenic pulmonary edema, hypoxemia, dyspnea, and fluid in the endotracheal tube 3

Suspected TACO (Fever + Respiratory Distress + Fluid Overload)

• Administer diuretic therapy 3
• TACO is now the most common cause of transfusion-related mortality, occurring during or up to 12 hours after transfusion 3
• Higher risk in patients >70 years, with heart failure, renal failure, or hypoalbuminemia 3

Isolated Fever Without Other Concerning Features (Likely FNHTR)

• Symptomatic treatment with acetaminophen 650-1000 mg orally or IV for fever control 1
• For adults ≥50 kg: acetaminophen 1,000 mg IV every 6 hours or 650 mg every 4 hours (maximum 4,000 mg/day) 4
• For adults <50 kg: acetaminophen 15 mg/kg IV every 6 hours or 12.5 mg/kg every 4 hours (maximum 75 mg/kg/day) 4
• FNHTR has an incidence of 1.1-2.15% and presents with isolated fever and chills without IV site pain, respiratory distress, or hemodynamic instability 2

Critical Pitfalls to Avoid

• Never restart the transfusion before laboratory clearance, even if symptoms improve—the reaction may worsen with continued exposure 1
• Do not assume fever is always FNHTR—bacterial contamination from platelets can present with isolated fever and is potentially fatal 1
• In neutropenic patients, fever may be masked by scheduled NSAIDs/acetaminophen, so maintain high suspicion for infection even with minimal symptoms 1
• Check for silent sources of fever in critically ill patients—not all fever during transfusion is causally related to the transfusion 1, 5

Documentation and Follow-up

• Document all findings and interventions in the patient record—100% traceability is a legal requirement 3
• Report to the blood bank, as serious reactions like TRALI are underdiagnosed and underreported despite being a leading cause of transfusion-related mortality 3
• Notify the patient's general practitioner, as this may affect future transfusions and donor pool management 3