In addition to stopping the transfusion and resuscitating the patient, broad-spectrum antibiotics such as vancomycin and cefepime should be started, and blood cultures should be drawn to determine the infecting organism. The patient is most likely experiencing sepsis as a result of transfusion-transmitted bacterial infection. Clinical criteria for a possible septic transfusion reaction include any of the following within 5 hours of completion of a transfusion: temperature greater than 39.0 °C (102.2 °F) or temperature two degrees higher than pretransfusion, rigors, pulse rate greater than 120/min or more than 40/min higher than pretransfusion, or a decrease or increase in blood pressure of greater than 30 mm Hg. Transfusion-transmitted bacterial infection remains an important cause of transfusion-related morbidity and mortality with rates of all septic reactions and fatal septic reactions reaching 1:74,807 and 1:498,711 per distributed platelet component. The majority of infections are due to staphylococcal species, although gram-negative organisms are also implicated. The blood product bag should be sealed and sent to the microbiology laboratory for culture.
Acetaminophen, diphenhydramine, and meperidine may be used as symptomatic treatment of a febrile nonhemolytic transfusion reaction. However, febrile nonhemolytic transfusion reactions are not typically associated with hypotension.
Epinephrine should only be used to treat anaphylaxis, which is less likely than sepsis in this patient. Anaphylaxis is associated with hypotension and respiratory distress, but this patient has no dermatologic (pruritus, urticaria, angioedema), pulmonary (wheezing, cough), or gastrointestinal (nausea, vomiting, abdominal cramping, diarrhea) manifestations suggesting anaphylaxis. Additionally, anaphylaxis is not associated with fever.
Considering the high morbidity and mortality associated with a septic transfusion reaction, stopping the transfusion and volume resuscitation alone are insufficient. This patient needs broad spectrum antibiotics to treat his transfusion-associated infection.