# 臨床情境 紅血球輸注開始 12 分鐘後，病人出現突發寒顫、嚴重下背痛、胸悶、低血壓、心搏過速與深紅色尿液，需要立即處理可能伴隨溶血與休克的嚴重輸血反應。 針對每項發現，辨識其最能支持的輸血反應模式。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=522657&lang=zh-tw  
> language: zh-TW  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## 題目

臨床情境
紅血球輸注開始 12 分鐘後，病人出現突發寒顫、嚴重下背痛、胸悶、低血壓、心搏過速與深紅色尿液，需要立即處理可能伴隨溶血與休克的嚴重輸血反應。

針對每項發現，辨識其最能支持的輸血反應模式。

|  | 急性溶血反應 | TACO | TRALI | 細菌污染 |
| --- | --- | --- | --- | --- |
| 下背痛、血紅素尿和直接抗球蛋白試驗陽性 |  |  |  |  |
| 高血壓、頸靜脈怒張、囉音和體液快速增加 |  |  |  |  |
| 新發低血氧症和雙側浸潤，無循環過載 |  |  |  |  |
| 高燒、嚴重寒顫以及來自個案和殘餘成分的匹配微生物 |  |  |  |  |

## 解析

血紅素尿、背痛和直接抗球蛋白試驗陽性支持急性溶血。高血壓伴頸靜脈怒張支持 TACO，非心源性低血氧症支持 TRALI，以及明顯發燒伴寒顫和匹配的微生物培養支持細菌污染。

## 深入解析

快速解答
區分溶血、循環過載、肺損傷和細菌污染。

為什麼這是正確的
幾種反應都可能導致呼吸困難或低血壓。模式辨識使用完整的群集、時間、體液狀態、實驗室證據和產品調查，而不是單一症狀。

簡單類比或心像
將每次輸注視為受控的臨床系統：驗證產品和通路、辨識變化的線索、停止可預防的暴露、穩定個案並確認反應。

記憶點
產品、通路、相容性、輸注線索、保護措施和重新評估。

NCLEX 決策規則
選擇能預防最直接輸注相關傷害的措施，同時保留血管通路和醫囑診斷證據。

為什麼其他選項是錯誤的
重新啟動可疑產品、繞過安全裝置、強行疏通阻塞的管路或延遲重新評估的選項，可能將可逆的警告轉變為嚴重的傷害。References
1CDC NHSN Hemovigilance Module Surveillance Protocol, January 2026Definitions and clinical patterns for acute hemolytic reaction, TACO, TRALI, and transfusion-transmitted infection
2CDC Clinical Guidance for Bacterial Contamination and Blood SafetyStop a suspected contaminated transfusion, preserve the unit, culture the patient, and investigate the residual component
3FDA-recognized Circular of Information for Blood and Blood ComponentsTransfusion reaction recognition, immediate discontinuation, product investigation, and supportive care

## 臨床情境

臨床情境
紅血球輸注開始 12 分鐘後，病人出現突發寒顫、嚴重下背痛、胸悶、低血壓、心搏過速與深紅色尿液，需要立即處理可能伴隨溶血與休克的嚴重輸血反應。

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