# Clinical context: A 46-year-old client with B-cell precursor acute lymphoblastic leukemia had normal orientation and language before treatment. A continuous blinatumomab infusion through a central line began 18 hours ago. The client now has a temperature of 39.3°C (102.7°F), BP 82/48 mm Hg, HR 122/min, and SpO2 89% on room air. The client is newly confused, cannot name common objects, and has a new hand tremor. There is no rash, wheezing, or lip swelling. The central-line site is clean without redness or drainage. Blood glucose is 104 mg/dL, and pupils are equal and reactive. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617381&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

Clinical context: A 46-year-old client with B-cell precursor acute lymphoblastic leukemia had normal orientation and language before treatment. A continuous blinatumomab infusion through a central line began 18 hours ago. The client now has a temperature of 39.3°C (102.7°F), BP 82/48 mm Hg, HR 122/min, and SpO2 89% on room air. The client is newly confused, cannot name common objects, and has a new hand tremor. There is no rash, wheezing, or lip swelling. The central-line site is clean without redness or drainage. Blood glucose is 104 mg/dL, and pupils are equal and reactive.

Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Central-line-associated septic shock
Anaphylactic infusion reaction
Hypoglycemic encephalopathy
Cytokine release syndrome with neurotoxicity

Actions to take

Select 2
Give prescribed epinephrine 0.5 mg IM
Stop the blinatumomab infusion and notify the provider
Slow the infusion rate and recheck vital signs in 1 hour
Apply oxygen and give the prescribed IV fluid bolus
Remove the central line and send the tip for culture

Parameters to monitor

Select 2
Blood pressure
Serum tryptase level
Capillary blood glucose
Blood and central-line culture results
Naming and handwriting assessment

## Explanation

Fever, hypotension, and hypoxemia within the first day of blinatumomab, together with new aphasia, confusion, and tremor, indicate cytokine release syndrome with neurologic toxicity. The nurse stops the infusion, notifies the provider, and supports oxygenation and circulation while prescribed treatment (such as corticosteroids) is prepared. Blood pressure tracks the CRS response, and naming and handwriting checks track the neurotoxicity.

## In-depth explanation

Quick answer
Cytokine release syndrome with neurotoxicity. Stop the blinatumomab infusion and notify the provider; apply oxygen and give the prescribed fluid bolus. Monitor blood pressure and naming and handwriting ability.

Why this is correct
Blinatumomab activates T cells against CD19-positive cells, and the cytokine surge causes fever, capillary leak hypotension, and hypoxemia, most often in the first days of the first cycle. The same therapy can cause neurotoxicity that shows up first as word-finding and naming trouble, tremor, and confusion. The label directs interrupting the infusion for severe reactions and treating per grade, while the nurse supports airway, breathing, and circulation.

Easy analogy or mental picture
Think of the drug as a match thrown into a room full of fuel (T cells and leukemia cells). The fire spreads to the whole body (fever, low BP) and smoke reaches the brain (aphasia, tremor). First take away the match, then fight the fire.

Memory hook
"Fever + low BP + can't name a pen = CRS plus ICANS." Stop, support, and watch the pen test.

NCLEX decision rule
When a new infusion is followed by a serious systemic reaction, stop the infusion first and support ABCs; choose monitoring that tracks both the circulatory and the neurologic arms of the reaction.

Why the other choices are wrong
Septic shock from the line shares fever and hypotension, but the clean site, onset timing, and focal language loss favor CRS with neurotoxicity; pulling the line and trending line cultures would be appropriate if infection were the leading problem, and cultures can still be sent without delaying the priority actions. Anaphylaxis appears within minutes with rash, wheezing, or swelling, which are absent, so IM epinephrine and tryptase target the wrong reaction. Hypoglycemia can cause confusion and tremor, but glucose is 104 mg/dL, so glucose checks do not measure progress. Slowing the rate continues exposure to the cause while the client is in shock.

References
1DailyMed: Blinatumomab (BLINCYTO) prescribing informationBoxed warning for cytokine release syndrome and neurological toxicities; interrupt or discontinue the infusion and treat per severity

## Clinical scenario

Case update
Fever, hypotension, hypoxemia, aphasia, and tremor 18 hours into a continuous blinatumomab infusion.

## Key concepts

- **Cytokine release syndrome (CRS)** — A systemic inflammatory reaction to T-cell activation that causes fever, hypotension, and hypoxemia.
- **ICANS** — Immune effector cell-associated neurotoxicity syndrome; early signs include word-finding difficulty, handwriting change, tremor, and confusion.
- **Infusion interruption** — Stopping a continuous infusion when a serious adverse reaction develops, pending prescriber decision on treatment and restart.

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