Nursing care
Chills and back pain during a blood transfusion: what the nurse does first
Written and reviewed by Olivia Parker, BSN, RN, CMSRN · 4 min read · Updated October 2026
Short answer
Stop the transfusion immediately and stay with the client. Chills, fever, flushing and low back or flank pain during a transfusion can signal an acute haemolytic reaction. Keep the vein open with normal saline through new tubing, check vital signs and airway, then notify the provider and blood bank. Slowing the rate still lets the suspect blood reach the client.
First action: stop the blood, not slow it
The first action is to stop the transfusion. Chills, fever, facial flushing and pain in the lower back or flank that start during or soon after a transfusion are listed features of an acute haemolytic reaction, where the client's antibodies destroy the donor red cells. Every further millilitre adds to the reaction, so the priority is removing the cause.
This is a safety and circulation priority rather than a comfort one. A haemolytic reaction can progress to shock, with a rapid pulse, cold skin and falling blood pressure, and it threatens kidney blood flow. At the moment the symptoms appear, the nurse cannot tell a mild febrile reaction from a severe haemolytic one at the bedside, so the response starts the same way: stop the unit.
Keep the vein open and assess airway, breathing and circulation
Once the blood is stopped, keep the intravenous access open with normal saline. Standard teaching is to disconnect the blood tubing at the hub and attach new saline tubing, so the client does not receive the blood still sitting in the old line. The open line matters because supportive treatment for a haemolytic reaction centres on fluids to protect blood pressure and kidney perfusion.
Next, stay with the client and assess. Check the airway and breathing for wheeze, stridor or new breathlessness, then the blood pressure, pulse, temperature and oxygen saturation, and compare them with the pre-transfusion baseline. Dyspnoea can point to an allergic reaction, circulatory overload or lung injury, which changes what the provider orders next.
What can wait and what can be delegated
Notifying the provider and the blood bank comes straight after the client is safe, not before the blood is stopped. Return the blood bag and attached tubing to the blood bank, and collect blood and urine samples as the local transfusion protocol directs. Dark or red urine suggests haemoglobin in the urine and should be reported.
Some tasks suit other staff. An assistant can fetch saline and new tubing, call for help, or take the bag and samples to the lab under facility policy. Assessing the client, interpreting changes and deciding whether to escalate stay with the registered nurse. Documentation of the reaction, the time the transfusion stopped and the client's response comes after care is under way.
Worked scenario: back pain fifteen minutes in
Hypothetical practice question: a client receiving packed red blood cells reports chills and a dull ache in the lower back about fifteen minutes into the unit. The temperature has risen from baseline. Which action should the nurse take first? Options: slow the infusion rate; give the prescribed antipyretic; stop the transfusion; call the provider.
Stopping the transfusion is correct because it removes the cause of a possible haemolytic reaction. Slowing the rate is tempting because it feels cautious, but suspect blood is still running. The antipyretic treats a symptom and may mask a rising temperature. Calling the provider is necessary, yet it follows the action that directly protects the client.
Why the other tempting answers fall short
Questions on this topic often offer actions that are reasonable later. Flushing the blood tubing with saline pushes the remaining blood into the vein, which is why new tubing is the usual teaching. Restarting the same unit once symptoms settle is not appropriate for a suspected haemolytic reaction; the unit goes back to the blood bank for testing.
Not every reaction is haemolytic. Febrile non-haemolytic reactions also cause chills, and mild allergic reactions with itching or hives may let a transfusion resume on the provider's order. The exam point is that the nurse does not make that call alone: stop, support, report, and let the provider and blood bank decide what happens to the unit.
Sources and further reading
Complications of Transfusion, MSD Manual Professional Edition. Signs of acute haemolytic reaction including chills and lumbar pain, stopping the transfusion, keeping the IV open with saline, returning the bag, febrile and allergic reaction contrasts.
Hemolytic transfusion reaction, MedlinePlus. Symptoms such as back and flank pain, chills, fever and dark urine during or after transfusion, and stopping the transfusion right away.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our med-surg practice questions are the closest set to what this page covers.
One question from the med-surg set
A client with chronic obstructive pulmonary disease has an oxygen saturation of 88% on 2 L/min via nasal cannula and is alert with no distress. What should the nurse do first?
Rationale
In COPD a saturation of 88–92% is the therapeutic target, not an emergency, and this client is alert with no distress. The first action is the independent nursing intervention that is least invasive and most likely to help: sit them up and reassess. Turning the oxygen up to 6 L/min risks blunting the hypoxic drive, and calling rapid response or drawing an ABG escalates ahead of an assessment you have not finished.
Answer: B
Common questions
Why use new tubing instead of the existing blood line?
The existing line still contains donor blood. Running saline through it would push that blood into the client. Standard teaching is to disconnect at the hub and attach new saline tubing so the vein stays open for fluids and medicines without giving more of the suspect product. Follow the local transfusion protocol for the exact steps.
Can a febrile reaction and a haemolytic reaction look the same at first?
Yes. Both can begin with chills and a rise in temperature, and back pain can occur in either. That overlap is why the first steps are the same: stop the transfusion, keep the vein open with saline, assess, and report. Laboratory testing of the client's samples and the returned unit helps the team tell them apart.
What should the nurse send back to the blood bank?
Return the blood bag and the attached administration set, with the required paperwork, so the blood bank can recheck compatibility. The client's blood and urine samples are collected as the facility protocol directs. Report dark or red urine, because it can indicate haemoglobin released from destroyed red cells.
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