During an ongoing blood transfusion, the patient’s temperature increased from 36 °C to 37.7 °C; how should I manage this?

Management of Temperature Rise During Blood 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, regardless of whether this represents a simple febrile reaction or a life-threatening complication. 1

Immediate Actions (First 5 Minutes)

• Halt the blood transfusion immediately without waiting to determine the reaction type, as continuing the transfusion despite "just fever" can mask early signs of serious reactions, particularly in critically ill patients 1
• Keep the IV line open with normal saline to maintain vascular access for medication administration and fluid resuscitation 1, 2
• Notify the transfusion laboratory/blood bank immediately to report the reaction and initiate mandatory investigation—this is a legal requirement 1, 3
• Assess vital signs comprehensively: heart rate, blood pressure, respiratory rate, oxygen saturation, and repeat temperature measurement 1

Critical Risk Stratification

Your patient's temperature rise from 36°C to 37.7°C (1.7°C increase) requires urgent evaluation for serious complications:

High-Risk Features Requiring Aggressive Management

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

Perform Focused Assessment for Additional Symptoms

• Check for hypotension (systolic <90 mmHg)—suggests hemolytic reaction, septic transfusion, anaphylaxis, or TRALI 3
• Assess for tachycardia (>110 bpm)—one of the most common early warning signs across all reaction types 3
• Look for respiratory distress—dyspnea, hypoxemia, or increased work of breathing 1, 2
• Examine for rash or urticaria—signals allergic reaction 3
• Ask about back pain or chest pain—critical warning signs of acute hemolytic reaction 3

Immediate Diagnostic Workup

Send Blood Component Back to Laboratory

• Return the blood bag with administration set to the transfusion laboratory for analysis 1
• Double-check patient identification and blood component compatibility labels for clerical errors 1

Collect Post-Reaction Blood Samples

• Complete blood count 1
• Direct antiglobulin test (Coombs test) and repeat crossmatch 1, 3
• Visual inspection of plasma for hemolysis 1
• Urine analysis for hemoglobinuria 1
• Blood cultures if bacterial contamination suspected (especially if platelets were transfused) 1
• PT, aPTT, fibrinogen 3

Management Algorithm Based on Clinical Presentation

If Fever ALONE (No Other Symptoms)

While isolated fever may represent a febrile non-hemolytic transfusion reaction (occurring in ~1.1% of transfusions), do not assume this diagnosis until serious reactions are excluded 1, 3:

• Continue monitoring vital signs every 5-15 minutes 3
• Administer acetaminophen 650-1000 mg orally or IV for symptomatic fever control 1
• Await laboratory clearance before considering restarting transfusion, even if symptoms improve 1

If Fever + Hypotension/Tachycardia

Treat as serious transfusion reaction—likely hemolytic reaction or bacterial contamination 1:

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

If Fever + Respiratory Symptoms

Suspect TRALI or TACO—both are leading causes of transfusion-related mortality 3, 2:

• Administer high-flow oxygen (100% FiO2) to address hypoxemia 3, 2
• Call for help and prepare for potential intubation 2
• Distinguish TRALI from TACO: hypotension suggests TRALI; hypertension and fluid overload signs suggest TACO 3, 2
• For TACO: administer diuretics 3
• For TRALI: avoid diuretics (ineffective); provide supportive care and oxygen therapy 3, 2

Critical Pitfalls to Avoid

• Never continue the transfusion despite "just fever"—general anesthesia and critical illness can mask early signs of serious reactions 1
• Never assume fever is always febrile non-hemolytic reaction—bacterial contamination from platelets can present with isolated fever and is potentially fatal 1
• Never restart the transfusion before laboratory clearance, even if symptoms improve, as the reaction may worsen with continued exposure 1
• Never delay blood cultures if bacterial contamination is suspected—obtain them before starting antibiotics 1
• Never use dextrose solutions or lactated Ringer's to maintain IV access—use only normal saline 4

Documentation and Follow-Up

• Document all findings in the patient record—100% traceability is a legal requirement 3
• Continue observation for at least 24 hours, as reactions can evolve over the first 6-12 hours post-transfusion 2
• Inform the patient they received blood products and experienced a reaction 3