Immediate Management of Fever During Blood Transfusion in AML Patient
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
Initial Actions (First 5 Minutes)
Stop the transfusion but keep the IV line open with normal saline for medication administration and potential fluid resuscitation. 1, 2 Do not disconnect the blood bag; it must be returned to the laboratory with the administration set intact for investigation. 2
Administer high-flow oxygen (100% FiO2) immediately to address potential hypoxemia, as fever during transfusion can signal life-threatening complications including acute hemolytic reaction, bacterial contamination, TRALI, or TACO. 1, 2
Call for medical assistance and assemble a resuscitation team, as fever—especially when reaching 38.8°C during transfusion—may indicate bacterial contamination, which is a leading cause of transfusion-related death. 1, 2
Rapid Assessment
Monitor vital signs every 5-15 minutes: heart rate, blood pressure, temperature, respiratory rate, and oxygen saturation. 1, 2 The patient's current stable vital signs (aside from fever) do not exclude serious reactions, as they can evolve rapidly.
Assess for additional warning signs that indicate specific reaction types:
- Hypotension, rigors, or back pain suggest acute hemolytic reaction or bacterial contamination 1, 2
- Dyspnea, hypoxemia, or respiratory distress indicate TRALI or TACO 1, 3
- Rash or urticaria point to allergic reaction 1, 2
Verify patient identification and blood component compatibility immediately—double-check all documentation for clerical errors, as ABO incompatibility causes the most dangerous transfusion reactions. 1, 2
Immediate Laboratory Workup
Send stat labs to the transfusion laboratory:
- Complete blood count 1, 2
- Direct antiglobulin test (Coombs test) and repeat crossmatch 1, 2
- PT, aPTT, Clauss fibrinogen 1, 2
- Visual inspection of plasma for hemolysis 1, 2
- Blood cultures from the patient AND from the blood bag if bacterial contamination is suspected 1, 2
- Urinalysis for hemoglobinuria 2
Mandatory Reporting
Contact the transfusion laboratory/blood bank immediately to report the reaction and initiate investigation—this is a statutory requirement that has been in place for three decades and is critical for patient safety. 1, 2 The implicated blood component must be withdrawn from circulation to prevent future occurrences. 2
Empiric Antibiotic Coverage
In febrile neutropenic AML patients, initiate broad-spectrum antibiotics immediately if not already on them. Cefepime 2g IV every 8 hours is indicated for empiric therapy of febrile neutropenia in AML patients, particularly those at high risk with underlying hematologic malignancy. 4 The fever may represent concurrent infection rather than (or in addition to) a transfusion reaction, and AML patients with neutropenia are at extreme risk for severe infection. 5
Hemodynamic Support
Maintain adequate blood pressure (MAP >65-70 mmHg) with IV normal saline boluses if hypotension develops. 1, 2 Prepare vasopressors, intubation equipment, and resuscitation medications at bedside. 1
Position the patient appropriately: Trendelenburg for hypotension, upright for respiratory distress, recovery position if consciousness is impaired. 2
Critical Pitfalls to Avoid
Never restart the transfusion, even if symptoms improve—reactions may worsen with continued exposure. 2
Do not give diuretics empirically—they are contraindicated in anaphylaxis, hypovolemic states, and TRALI, and may worsen outcomes. 2, 3
Do not assume this is simply a febrile non-hemolytic reaction (which occurs in only 1.1% of transfusions with leukoreduced blood 1) until life-threatening causes are excluded. Fever during transfusion, especially with platelet components, may indicate bacterial contamination—a leading cause of transfusion-related death. 1
Do not delay antibiotic administration in this neutropenic AML patient—the fever may represent sepsis independent of the transfusion, and infectious complications are a major cause of mortality in AML patients with prolonged neutropenia. 5
Ongoing Management
Continue observation for at least 24 hours, as transfusion reactions can evolve over the first 6-12 hours post-transfusion. 3 Transfer to intensive care if respiratory compromise, hemodynamic instability, or evidence of hemolysis develops. 3
Maintain hemoglobin above 8 g/dL once the reaction is investigated and resolved, as this is the accepted threshold in thrombocytopenic AML patients, though the patient's current Hgb of 63 g/L (6.3 g/dL) indicates severe anemia requiring transfusion support. 5 Future transfusions should use leukocyte-depleted components and may require premedication depending on the final diagnosis of this reaction. 5