Investigation - Febrile Non-Hemolytic Transfusion Reactions

Transfusion services should have clear policies indicating the investigations required for suspected FNHTR and whether or not transfusions can be restarted. Because of the risk of hemolytic reactions with RBC and bacterial contamination of platelets, (and particularly since the introduction of universal prestorage leukoreduction and the resulting decrease in the frequency of FNHTR), extreme caution should be used if restarting transfusion.
In all cases, restarting transfusion should be

• exceptional rather than routine
• only with specific MD orders
• accompanied by close patient surveillance for the remainder of transfusion

An example of an immediate investigation shows steps that could be used to investigate any immediate transfusion reaction.

Because fever may occur in immediate and delayed hemolytic transfusion reactions and transfusion of a bacterially contaminated blood component, these complications must be excluded.

Clinical judgement should also be exercised based on all of the patient's symptoms, clinical condition, and prior history of transfusion reactions. For further discussion, see "Controversies in Transfusion Medicine: Should a Febrile Transfusion Response occasion the return of the blood component to the blood bank?" (pro and con by Widmann and Oberman, respectively) in Further Reading.

Suspected FNHTR to RBC Components

Since FNHTRs are diagnosed by exclusion, some laboratories tentatively diagnose reactions to RBC components as FNHTR if the symptoms are limited to those typical of mild to moderately severe FNHTR (fever, chills, discomfort, etc.) and there is no serologic or clerical evidence of a hemolytic transfusion reaction.

In the presence of universal prestorage leukoreduction, others prefer that donor RBC implicated in suspected FNHTR be cultured to rule out bacterial sepsis.

Suspected FNHTR to Platelet Components

Some laboratories follow the above policy with the addition, in the presence of more severe symptoms, that the platelets are returned to the laboratory for Gram stain and culture.

Because platelet components are stored at room temperature for up to five days, they have a higher incidence of septic transfusion reactions.