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Difficulty: HardPharmacological and Parenteral Therapies

A client with symptomatic anemia is receiving a transfusion of packed red blood cells (PRBCs) through a peripheral intravenous catheter. Fifteen minutes after the transfusion begins, the client reports acute lower back pain, severe chills, and dyspnea. The nurse observes that the urine in the urinary drainage bag has suddenly turned dark reddish-brown. The nurse immediately stops the blood transfusion. Which of the following is the most critical next action for the nurse to take?

  1. Disconnect the blood administration set at the IV catheter hub and infuse 0.9%0.9\% sodium chloride using entirely new tubing.Answer
  2. B
    Open the normal saline clamp on the existing Y-type blood administration set to flush the remaining blood into the vein.
  3. C
    Prepare to administer intravenous epinephrine and diphenhydramine to reverse the suspected anaphylactic response.
  4. D
    Administer prescribed as-needed oral acetaminophen for the chills and monitor closely for early indicators of shock.

Answer

Disconnect the blood administration set at the IV catheter hub and infuse 0.9%0.9\% sodium chloride using entirely new tubing.
The client is experiencing an acute hemolytic transfusion reaction, characterized by flank pain (kidney ischemia from hemoglobinuria) and dark urine. After immediately stopping the transfusion, the absolute priority is to maintain venous access and preserve renal perfusion to prevent acute kidney injury. This is achieved by disconnecting the blood tubing entirely at the catheter hub and initiating a rapid infusion of normal saline using completely new tubing. This ensures that the remaining incompatible blood in the original IV line is not pushed into the client.

Step-by-Step Solution

1
Analyze the client's symptom cluster.
Lower back pain, chills, dyspnea, and dark reddish-brown urine (hemoglobinuria) occurring within 15 minutes of a blood transfusion strongly indicate an acute hemolytic transfusion reaction (ABO incompatibility).
Accurate identification of the specific type of transfusion reaction dictates the emergency medical management.
2
Determine the immediate physiological priority.
In an acute hemolytic reaction, destroyed red blood cells release massive amounts of hemoglobin, which can obstruct renal tubules and cause acute kidney injury.
Maintaining robust renal perfusion with intravenous fluids is critical to flush out the free hemoglobin and support blood pressure.
3
Select the safest method to administer the required fluids.
The nurse must completely disconnect the blood tubing from the client and attach a brand new IV line primed with normal saline.
If the existing Y-tubing is flushed, the 20 to 30 mL of incompatible blood sitting in the distal tubing will be forced into the client's bloodstream, worsening the systemic reaction.

Key Concept

Management of Acute Hemolytic Transfusion Reactions
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Topics

Pharmacological and Parenteral Therapies

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