Neuro:Anxiety, restlessness.
Resp: SOB, dyspnea, tachypnea, bronchospasm.
CV:Chest pain, tachycardia, hypotension.
Skin:Urticaria, pruritus, erythema, burning at infusion site.
GI/GU:Nausea, vomiting, diarrhea, hematuria, oliguria, anuria.
MS: Flank, back, or joint pain.
Metabolic:Fever, chills.
- Stop transfusion and run normal saline to maintain IV access.
Do NOT use lactated Ringer's (LR) solution. It contains calcium and will clot blood in the tubing. - Notify health-care provider and blood bank of reaction STAT.
- Recheck Pt ID and blood labels for possible errors.
- Return unused blood product to blood bank for analysis.
- Prepare to administer fluids and ordered medications:
- Anaphylaxis:Epinephrine, antihistamines, corticosteroids.
- Febrile, nonhemolytic:Acetaminophen; if Pt develops chills, cover with blanket unless temp. >102°F.
- Hemolytic:Furosemide, low-dose dopamine
- Assess urinary catheter for output, color, and clarity of urine. If Pt does not have urinary catheter in place, prepare to insert one for monitoring UO.
- Continue IV fluids to maintain minimum UO of 30 mL/hr.
- Monitor for early detection of any hemodynamic instability (e.g., dysrhythmias, abnormal lab values, CHF).