What is the management of fever during blood transfusion in a patient?

Management of Fever During Blood Transfusion

Immediate Actions: Stop the Transfusion

Stop the transfusion immediately at the first sign of fever—this is the single most critical intervention that can prevent progression to severe morbidity or mortality. 1

• Maintain IV access with normal saline for medication administration and potential fluid resuscitation 1
• Do not wait to confirm the reaction type before stopping—the first 10 minutes of infusion are critical, and immediate reactions typically occur within the first minute 2
• Notify the transfusion laboratory/blood bank immediately to report the reaction and initiate investigation 1

Rapid Assessment: Rule Out Life-Threatening Complications

Check vital signs every 5-15 minutes:

• Heart rate, blood pressure, respiratory rate, oxygen saturation, and repeat temperature 1, 2
• Tachycardia >110 beats/min, hypotension, or respiratory distress require immediate escalation 2

Perform focused assessment for serious reactions:

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

Critical pitfall to avoid:

• Never assume "just fever" is benign—general anesthesia and critical illness can mask early signs of serious reactions 1
• Never assume fever is always febrile non-hemolytic transfusion reaction (FNHTR), as bacterial contamination from platelets can present with isolated fever and is potentially fatal 1

Verify Patient and Product Identification

• Double-check patient identification and blood component compatibility labels for any clerical errors 1
• Use four core identifiers on wristband when available 2
• Visually inspect the blood component bag for leakage, discoloration, clots, or clumps 2

Diagnostic Workup

Send immediately to transfusion laboratory:

• Return the blood component bag with administration set to the laboratory for analysis 1

Collect post-reaction blood samples:

• Complete blood count 1, 2
• Direct antiglobulin test (Coombs test) for hemolysis 1, 2
• Repeat crossmatch 1, 2
• PT, aPTT, fibrinogen (Clauss method) 2
• Visual inspection of plasma for hemolysis 1

If bacterial contamination suspected:

• Obtain blood cultures immediately BEFORE starting antibiotics—use proper technique and collect adequate volume 3
• Blood cultures should be drawn from the patient, not just the blood product 4

Additional testing:

• Urine analysis for hemoglobinuria if hemolytic reaction suspected 1
• Procalcitonin testing can help discriminate between infectious and non-infectious causes of fever 3

Management Based on Clinical Presentation

For isolated fever without hemodynamic instability:

• Administer acetaminophen 650-1000 mg orally or IV for symptomatic fever control 1
  • For adults ≥50 kg: 1000 mg IV every 6 hours or 650 mg every 4 hours (maximum 4000 mg/day) 5
  • For adults <50 kg: 15 mg/kg IV every 6 hours (maximum 75 mg/kg/day) 5
• Maintain high index of suspicion—this may still represent early bacterial contamination 1

For fever with hypotension or hemodynamic instability:

• Administer high-flow oxygen (high FiO2) to address potential hypoxemia 2
• Maintain adequate blood pressure for organ perfusion (MAP >65-70 mmHg) with IV fluid bolus 1000-2000 mL normal saline 2
• Prepare vasopressors, intubation equipment, and resuscitation medications 2
• Initiate broad-spectrum antibiotics immediately AFTER blood cultures if bacterial contamination suspected 1

For suspected hemolytic reaction (fever + dark urine/oliguria):

• Aggressive fluid resuscitation to maintain urine output >100 mL/hour 1
• Monitor for disseminated intravascular coagulation with serial coagulation studies 2

For suspected TRALI (fever + respiratory distress within 1-6 hours):

• Provide critical care supportive measures and oxygen therapy 2
• Avoid diuretics—they are ineffective for TRALI and may worsen outcomes 2
• Fresh frozen plasma (FFP) and apheresis platelets are the products most frequently implicated in TRALI 2

For suspected TACO (fever + fluid overload signs):

• Immediate cessation of transfusion 2
• Administer diuretic therapy 2
• Older patients (>70 years), those with heart failure, renal failure, and hypoalbuminemia are at highest risk 2

Special Considerations

In neutropenic or immunocompromised patients:

• Fever may be masked by scheduled NSAIDs/acetaminophen, so maintain high suspicion for infection even with minimal symptoms 1
• Maintain high index of suspicion for infection regardless of cell count 3
• Consider viral PCR studies and additional testing 3
• Evaluate for silent sources of infection: otitis media, decubitus ulcers, perineal/perianal abscesses 3

In patients with pre-existing fever:

• The transfusion should have been postponed until fever resolved and source was identified 3
• If transfusion was already started, the new fever during transfusion must be treated as a potential transfusion reaction, not assumed to be continuation of pre-existing fever 3

Critical Pitfalls to Avoid

• Never continue the transfusion despite "just fever"—serious reactions can present initially with isolated fever 1
• Never restart the transfusion before laboratory clearance, even if symptoms improve—the reaction may worsen with continued exposure 1
• Never assume fever is coincidental—while concurrent infections can occur, every fever during transfusion must be investigated as a potential transfusion reaction 4
• Never delay blood cultures—obtain cultures before starting antibiotics whenever possible 3
• Never forget to check for silent sources of infection in critically ill patients—careful history and physical examination are essential 3

Documentation and Reporting

• Document all findings in the patient record—100% traceability is a legal requirement 2
• Report to the blood bank as TRALI and other serious reactions are underdiagnosed and underreported despite being leading causes of transfusion-related mortality 2
• Notify the patient's general practitioner as this may remove them from the donor pool 2
• Inform patients they received blood products before discharge 2

When to Resume Transfusion

• Resume transfusion only after fever resolves, infection is ruled out or appropriately treated, and laboratory clearance is obtained 3
• Consider slower transfusion rates when resuming 3
• If recurrent febrile reactions occur, use leukocyte-poor red blood cells (LP RBCs) prepared by inverted centrifugation technique for subsequent transfusions 6