一位 55 歲女性在大量創傷後正接受濃縮紅血球 (PRBCs) 的緊急輸血。輸血開始 10 分鐘後,病人出現胸悶、畏寒伴隨發抖,主訴下背部劇烈疼痛、呼吸困難與胸口壓迫感。生命徵象:血壓 85/50 mmHg、心跳 135 次/分、體溫 39.5°C。護理師辨識為急性溶血性輸血反應,應立即執行哪些護理介入?(多選題)
A 55-year-old female is receiving an emergency transfusion of packed red blood cells (PRBCs) following massive trauma. Ten minutes after the infusion begins, she develops chest tightness, chills with shivering, severe lower back pain, dyspnea, and a feeling of chest pressure. Vital signs: BP 85/50 mmHg, HR 135 bpm, temperature 39.5°C (103.1°F). The nurse recognizes this as an acute hemolytic transfusion reaction. Which immediate nursing interventions are required? (Select all that apply.)
- AStop the blood transfusion immediately and disconnect the blood tubing from the client's IV access.立即停止輸血，並將輸血管路從病人的靜脈通路斷開。正確答案
- BFlush the existing blood administration tubing with 50 mL of normal saline to clear residual blood from the line.用 50 mL 生理食鹽水沖洗現有的輸血管路，以清除管路內的殘餘血液。
- CMaintain IV access by replacing the tubing with new tubing primed with 0.9% normal saline.更換為已灌注 0.9% 生理食鹽水的新的管路，以維持靜脈通路。正確答案
- DSlow the transfusion to a keep-vein-open (KVO) rate to see if the back pain subsides.將輸血速率減慢至維持靜脈通路的速率（KVO），以觀察背痛是否緩解。
- ESend the discontinued blood bag, the tubing, and freshly drawn post-reaction blood and urine samples to the blood bank for analysis.將停止輸血的血液袋、管路以及反應後新採集的血液和尿液樣本送交血庫進行分析。正確答案
- A立即停止輸血，並將輸血管路從病人的靜脈通路斷開。
- C更換為已灌注 0.9% 生理食鹽水的新的管路，以維持靜脈通路。
- E將停止輸血的血液袋、管路以及反應後新採集的血液和尿液樣本送交血庫進行分析。
急性溶血性輸血反應 (Acute hemolytic transfusion reaction) 是靜脈輸液與用藥安全中最危急的併發症之一,常因 ABO 血型不相容或強烈抗體反應,使輸入紅血球在循環內被破壞。典型表現為下背部或側腹疼痛、發燒、畏寒、低血壓、心跳加快與胸悶。護理處置原則:第一步,立即停止輸血 (選項 A 正確);減慢速度 (選項 D) 並未阻止不相容血液繼續進入,屬錯誤處置。第二步,維持靜脈通路以利後續急救與輸液,但必須以全新且灌注 0.9% 生理食鹽水的管路取代,而不可沖洗原來的輸血管路 (選項 B),因為原管內仍殘留尚未進入體內的不相容血液,沖洗將把這些血液推入循環,使反應加重。換上新管路灌注生理食鹽水才是正確做法 (選項 C 正確)。第三步,將剩餘血袋、原管路與反應後採集的血液、尿液檢體送回血庫,以利複驗血型、交叉配對與評估溶血程度 (選項 E 正確)。同時需通知醫師、密切監測生命徵象並依醫囑處置低血壓、發燒與可能的腎臟併發症。
- A · 正確答案立即停止輸血，並將輸血管路從病人的靜脈通路斷開。
立即停止輸血是第一優先步驟,可中止不相容血液繼續進入循環,防止溶血反應惡化。
- B用 50 mL 生理食鹽水沖洗現有的輸血管路，以清除管路內的殘餘血液。
沖洗原輸血管路會將管內殘留的不相容血液繼續推入病人體內,加重溶血反應,屬於禁忌行為。
- C · 正確答案更換為已灌注 0.9% 生理食鹽水的新的管路，以維持靜脈通路。
維持靜脈通路對急救與循環支持非常重要;改換已灌注 0.9% 生理食鹽水的全新管路,可避免殘留不相容血液繼續進入病人,同時支援後續給藥與輸液。
- D將輸血速率減慢至維持靜脈通路的速率（KVO），以觀察背痛是否緩解。
將輸血速率減慢至 KVO 仍會讓不相容血液持續進入循環,不適用於急性溶血反應,正確處置應為完全停止輸血。
- E · 正確答案將停止輸血的血液袋、管路以及反應後新採集的血液和尿液樣本送交血庫進行分析。
應將血袋、管路與反應後新採集的血液、尿液檢體送回血庫,以重做血型與交叉配對,並評估溶血程度,供後續調查與處置依據。
「停血、換全新 N/S (生理食鹽水) 點滴管」是世界各國醫院輸血指引的絕對鐵律。在考題選項中故意誘答「沖洗舊管路以保持血管暢通」是最狠毒的陷阱，因為把殘存的一整條管子 (約15-30ml) 毒血推入病患體內，足以造成休克死亡。
English explanation
Options A, C, and E are correct. Option A immediately stops further incompatible blood from entering the circulation and disconnects the blood tubing. Option C preserves intravenous access for emergency treatment by replacing that tubing with new tubing primed with 0.9% normal saline. Option E provides the remaining blood bag, original tubing, and freshly collected post-reaction blood and urine samples for repeat blood typing, crossmatching, and assessment of hemolysis. Option B is not selected because the original tubing contains incompatible blood; flushing it with 50 mL of normal saline would push that blood into the circulation and worsen the reaction. Option D is not selected because slowing the transfusion does not stop incompatible blood from entering. Acute hemolytic transfusion reactions may follow ABO incompatibility or strong antibody responses and can cause lower back or flank pain, fever, chills, hypotension, tachycardia, and chest tightness. The nurse also notifies the physician, closely monitors vital signs, and follows orders for hypotension, fever, and possible kidney complications.
最近修訂：2026-05-11