Fifteen minutes after packed red blood cells are started, a client develops fever, chills, hypotension, back pain, dread, and pink urine. Which initial actions are correct? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
Fever, chills, hypotension, back pain, dread, and hemoglobinuria soon after transfusion strongly suggest an acute hemolytic transfusion reaction (Choice 6). Stop the transfusion immediately. Disconnect the blood administration set and maintain the existing vascular access with new tubing and 0.9% sodium chloride according to facility protocol (Choice 5). Notify the provider and transfusion service, send the implicated component and administration set, and obtain required post-reaction samples (Choice 1). Do not slow, restart, or continue the implicated unit while treating symptoms (Choices 2 and 3). This severe systemic presentation is not managed as an uncomplicated febrile or allergic reaction (Choice 4).
Universal First Steps for Any Reaction 1. STOP transfusion 2. Disconnect at catheter hub — do not flush residual blood 3. NEW 0.9% NS line + tubing to maintain access 4. Stay with client; ABCs; vitals 5. Notify provider + blood bank 6. Return unit + tubing; collect post-reaction labs/urine per policy 7. Document
Memory Tip "STOP-Disconnect-NEW saline-Notify-Return"
ScenarioAdult post-op on PRBC, 15 min into transfusion: back pain, chills, dread, T 39, HR 124, BP 88/54, SpO2 92%, pink urine.
Initial Actions1. STOP the transfusion2. Disconnect at catheter hub + new 0.9% NS line + new tubing3. Stay with client; ABCs; continuous vitals4. Notify provider + blood bank5. Return unit + tubing; collect post-reaction blood + urine samples6. Hemodynamic + renal support per orders
Avoid- Slowing and continuing the same unit- Treating as "mild allergic" with diphenhydramine alone- Reusing the existing blood tubing (residual blood)
Acute Hemolytic Transfusion Reaction — Severe, immediate (within minutes) reaction usually due to ABO incompatibility from clerical or identification errors. Recipient antibodies destroy donor red blood cells, causing intravascular hemolysis. Classic features: fever, chills, back/flank pain, sense of dread, hypotension, tachycardia, dyspnea, hemoglobinuria, and risk of DIC and acute kidney injury. Mortality is high without immediate action. Prevention: rigorous two-RN identification at the bedside before initiating transfusion.
Universal First Steps for a Suspected Reaction — STOP the transfusion. Disconnect the blood tubing AT the catheter hub (do not flush residual blood through). Start a NEW 0.9% normal saline line with NEW tubing to maintain venous access. Stay with the client; assess ABCs and full vital signs. Notify the provider AND the blood bank. Return the unit and tubing to the blood bank for investigation. Collect post-reaction blood and urine samples per facility protocol. Document the reaction. Treat shock, fever, allergic, or respiratory features as indicated.