Neutropenic Fevers and Transfusion reactions

[kimblain]

I have had some feedback recently from the nursing staff who generally work with our outpatient oncology patients that if they have a patient who has a rise in temperature during the transfusion that the physician says to keep transfusing as it is most likely due to a neutropenic fever. However; I am concerned that they may be missing something else without doing the Transfusion reaction work-up. Does anyone have a procedure that addresses this situation?

[Bill]

I went through this discussion several years ago with an oncologist and our pathologist. My question to both MD's, "What indicator do we use to report a suspected transfusion reaction, if not rise in temp? After much thinking and discussion, we all concluded that we had to work up the rise in temp as a suspected transfusion reaction. Good luck!

[Deny Morlino]

We handle it the same way as Bill. Be conservative, do the workup.

[SMILLER]

I agree with the others. The rise in temp in this situation may indeed have nothing to do with a trasfusion reaction, but you certainly cannot say for sure that it does not! For minor temp increases, a quick DAT that comes out negative is usually enough here to allow the transfusion to continue with a Drs. permission.

But if there is any indication of a real reaction to the transfusion (eg big increase in temp, pos DAT, whatever) the transfusion CANNOT be started, no matter what the Dr. wants to do. If there is a hassle on this (it has happened) we get ahold of our pathologist ASAP and have them talk it out.

Scott

Scott

[David Saikin]

I agree - do the workup.

[Abdulhameed Al-Attas]

I also agree..to stop the Transfusion and do workup.

[tkakin]

We recently had a patient that is as you described. Everything we gave him he had a fever and we worked it up for every product he received, 5 so far

Teresa

[L106]

Most of our oncology physicians frequently order their frequently-transfused patients to receive benedryl prior to blood transfusions. I understand the ligitimate concerns expressed in the previous posts that this could mask a transfusion reaction. However, I must say that to my knowledge (or maybe I should say "to the best of my recollection" since it's election time here in the USA) I am not aware that we have ever missed a significant transfusion reaction in my many years at this facility. (And we do transfuse a lot of patients that we see frequently.)

Donna

[Mabel Adams]

If you have no way of telling a neutropenic fever from a TRX fever then eventually you will come upon the bullet in the 1000-chambered gun if you don't at least pause the transfusion and do the workup to rule out a serious incompatibility (i.e. provide some evidence that this is not a fever due to incompatibility). Remember the Challenger explosion? Because the early launches had gone okay they concluded that the problems they had observed with the O rings could never cause a problem. Until the time that they did and everyone died.

Scenario: neutropenic patient premedicated with benedryl is sleepy during transfusion. First sign of incompatible unit is rise in Temp but it is ignored due to believing it is just the usual fever spike. Give tylenol. More of the unit is transfused. Patient now more awake and complaining of pain at infusion site and sense of dread but nurse just thinks she's anxious and readjusts IV. Gives more of unit. Now patient has violent chills and complains of back pain as well. Nurse finally decides it is serious and stops the unit for a workup only to find it is incompatible--let's say an anti-Cw in a patient that has always had a neg Ab screen. The patient got 100 cc more of the unit than if it has been stopped initially. How do you word your QA and transfusion reaction write-ups? What if you had to defend it in a court of law? If the last 2 thoughts give you (and the MDs involved) serious qualms, then you probably don't want to go there. How often is it okay to cause a patient harm by continuing to give incompatible blood? There are actions that are defensible in this business but I don't think this is one of them. Just because the most common cause of these patient's fever is neutropenia, that doesn't make the rare cause, transfusion reaction, either impossible or less harmful.

[L106]

I hear you, Mabel, and all of your comments are valid. Rest assured, I am not advocating the physicians' choice of action........just relating my observations.

Donna

[Mabel Adams]

Sorry if I came on too strong. I was just trying to present my thought processes, not judge anyone's actions.

[L106]

Oh, there wasn't a problem, Mabel.....Just another one of those little frustrations when things aren't "done by the book."

[JulieSt]

I'd also want to check that it wasn't a transfusion reaction because as others have said you want to make sure its not a 'real' event.

1 observation for you - in the UK all our products are leuco-reduced and have been since 1998 ( I think!). Previously we experienced this type of report frequently (all of which we'd do some investigation on but rarely found anything)- at once once or twice weekly. Since leuco reduction - we still some reports of this type of reaction but significantly less then previously ( probably get one report every 6-8 weeks now).

[Kim D]

Do you allow the transfusion to be stopped and restart if work up checks out ok?

[Deny Morlino]

Sometimes depending upon initial symptoms.

[aafrin]

At our hospital we stop transfusion and do work-up even if temperature rises by 1 degree.