護理師正在監測一位正在輸血的病人。下列哪些徵象可能代表病人發生了溶血性輸血反應？（選所有適合的）
A nurse is monitoring a client receiving a blood transfusion. Which of the following findings would indicate a possible hemolytic transfusion reaction? (Select all that apply.)
- AHypotension✓ 正解低血壓
- BLower back pain✓ 正解下背部疼痛
- CFever and chills✓ 正解發燒與畏寒
- DUrticaria and itching蕁麻疹與搔癢
- EHemoglobinuria✓ 正解血紅素尿
急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction）是輸血過程中最嚴重的併發症之一，通常源於 ABO 血型不相容。其病理機轉是受體抗體攻擊供體紅血球，導致細胞大量破碎釋放血紅素。核心臨床表徵包括：1. 腰背部疼痛（Lower back pain），這是由於血紅素複合物在腎小管沉積所致，具有高度特異性；2. 發燒與畏寒，這是免疫反應觸發的全身性發炎；3. 低血壓（Hypotension）甚至休克，因為血管活性物質釋放；4. 血紅素尿（Hemoglobinuria），尿液呈現暗紅色。選項 D 的蕁麻疹與搔癢則是「過敏反應」（Allergic reaction）的典型表現，通常不屬於溶血反應的範圍。護理師一旦懷疑溶血，必須立即停止輸血，更換生理食鹽水維持管路，並通報醫師與血庫。這種臨床判斷力能大幅降低醫療過失風險，確保病人生命安全。
An acute hemolytic transfusion reaction is one of the most serious complications during transfusion, usually caused by ABO incompatibility. Its pathophysiology involves recipient antibodies attacking donor red blood cells, causing massive cellular destruction and release of hemoglobin. Core clinical features include: 1. Lower back pain, due to deposition of hemoglobin complexes in the renal tubules, which is highly specific; 2. Fever and chills, from systemic inflammation triggered by the immune response; 3. Hypotension and even shock, due to release of vasoactive substances; 4. Hemoglobinuria, with dark red urine. Option D (urticaria and itching) represents a typical allergic reaction and does not generally fall within the scope of hemolytic reactions. Once a hemolytic reaction is suspected, the nurse must immediately stop the transfusion, switch to normal saline to maintain the line, and notify the provider and blood bank. This clinical judgment greatly reduces medical error risk and ensures patient safety.
在美國，輸血反應發生時，護理師除了停止輸血，還必須保留血袋、所有管路甚至第一劑尿液樣本送往血庫重新檢驗；台灣臨床亦有相似規範，但美國更強調護理師在發現反應當下即刻進行獨立判斷與處置，而非等待醫師確認後才停止輸血。