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Reaksi transfusi1Gejala dan tanda abnormal yang timbul pada saat dan beberapa hari sesudah transfusiPengertianGejala dan tanda:1. Cepat (acute)2. Lambat (delayed) 2RinganSuhu meningkatSakit kepalaAlergi Dll BeratReaksi hemolisisMeninggal Derajat Reaksi Transfusi: 3Faktor darahFaktor transfusiFaktor resipienFaktor penyebab4I. Reaksi hemolitikII.Reaksi non-hemolitikIII.Penularan penyakit1. Faktor darahKlasifikasi Reaksi transfusi56782. Faktor TransfusiOvertransfusionSuhu darah kurang sesuaiEmboli udaraMikroemboliIntoksikasi sitratHemosiderosisTromboflebitis9Multipara atau Multitransfusi (PTP, DHTR)Defisiensi IgA (anafilaksis)Reaksi alergikAIHA 3. Faktor Resipien10Komplikasi Transfusi 11Komplikasi Transfusi 12Reaksi Hemolitik13Faktor darah14Inkompatibilitas ABO15Inkompatibilitas ABO161718Reaksi hemolitik akutTimbul segera (pd 15 mnt pertama, namun dpt terjadi kapan saja ) pd saat transfusi berlangsung Dgn 50 mL darah yg tdk cocok sdh dpt menimbulkan reaksiKrn inkompatibilitas ABOTerjadi akibat clerical error (human error)Tanda dan Gejala Rasa panas sepanjang venaDemam dan menggigil Nyeri pinggang yang khasRasa tertekan pada dadaSesak nafasMual /muntah19Reaksi hemolitik akut (RHA), sambungan

Gejala dan tanda:Hipotensi (bila terjadi prognosis jelek)Sakit kepalaMuka menjadi merahIkterusUrine warna merah (hemoglobinuria)Tidak sadar: nadi kecil tdk teraba, nafas cepatTahap lanjut: GGA, DIC

Insidensi bervariasi :RHA imun fatal, 1: 250.000 600.000RHA imun non fatal, 1:6.000 33.000RHA non imun, jarang20Reaksi hemolitik lambatTerjadi bbrp jam atau bbrp hari (10 14 hari) sesudah transfusiBiasanya pada labu ke 2 atau lebih Pd penderita yg sering mendapat transfusi / pernah melahirkan Dpt terjadi pd pemberian gol O titer anti-A dan anti-B tinggi kpd gol darah lain. Gejala: Spt reaksi transfusi akut + jaundis. Komplikasi: gagal ginjal akut. 21Reaksi transfusi akutReaksi transfusi lambatImunologikNon imunologikImunologik Non imunologikReaksi hemolitik akutKonta minasi bakteri (septik)Reaksi hemolisis lambatKelebihan besiReaksi demam non hemolitikKelebihan cairan (hipervolemik)Alloimunisasi Penularan penyakitReaksi alergi (Mis. urtikaria)Hemolisis non imunReaksi transfusi graft versus hostAnafilaksis Transfusi masif Purpura paska transfusiTransfusion related acute lung injury (TRALI)Komplikasi metabolik: hipotermi, koagulopati hiperkalemia, toksisitas sitratTransfusion related immunomodulationEmboli Refrakter trombositTabel. Klasifikasi Reaksi Transfusi22Klasifikasi ReaksiPenyebab Efek Segera (Akut)a. ImunologikInkompatibilitas RBCAb thdp lekosit donorAb (IgM) thdp IgAAb thdp lekosit resipienAb thdp protein plasmaHemolisis dgn gejalaPanas non-hemolitikAnafilaksis Edema paru non kardialUrtikaria b. Non-imunologikDarah terkontaminasiHipervolume (Kelebihan volume)Darah rusak sblm transfusiEmboli udara, endapan darah, bahan bahan lainTransfusi masifPanas tinggi, syokPayah jantung kongestifHemolisis tanpa gejala-

Hiperkalemia, hiperkalsemia, koagulopatiaTabel. Etiologi Reaksi transfusi hemolitik akut dan lambat23Klasifikasi ReaksiPenyebab Efek Lambat a. ImunologikAnamnestic Ab thdp Ag RBCAb thdp limfositAb thdp trombositHemolisis

Reaksi graft versus hostPurpura post transfusib. Non-imunologikSering transfusi

Penularan penyakitEmboli Infeksi pd tempat tusukan jarumHemosiderosis, hemoragi metabolikHepatitis, malaria, sifilis-Tromboflebitis Tabel. Etiologi Reaksi transfusi hemolitik akut dan lambat24Type Sign and SymptomsUsual Cause TreatmentPreventionIntravascular hemolytic (immune) (acute hemolytic)Hemoglobinemia and Hemoglobin uria, fever, chills, anxiety, shock, DIC, dyspnea, chest pain, flank pain, oliguria, LBP, flushing, bleeding tachycardia, hypote nsion, Cardiovascu lar collapse, deathABO incompati bility (clerical error), complement fixing,antibody causing, antigen antibody incompatibilityStop transfusion; Other hydrate, support, blood pressure & respiration; induce diuresis; treat shock, and DIC, if presentAvoid clerical Errors ; ensure proper sample & recipient identificationTabel. Reaksi transfusi akut25Type Sign and SymptomsUsual Cause TreatmentPreventionExtravascular Hemolytic (immune)Fever, malaise, hiperbilirubinemia, increased urine urobili-nogen, falling hematocritIndirect IgG, non-complement-fixing antibody often associated with delayed hemolysisMonitor Ht, renal & hepatic function, coagulation profile, no acute treatment generally required Avoid clerical Errors ; ensure proper sample & recipient identificationFebrile hypotensionChills (panas dingin) and fever, headache, flushing, anxiety, muscle pain, chest tightness,palpitations, N and VAntibodies to leukocytes or plasma protein; hemolysis; passive cyto kines; infusion; sepsis. Commonly due to patients underlyingConditionStop transfusion; give antipyretic; eg, acetaminophen for rigors use meperidine 25-50 mg IV or IMPre transfusion antipyretic; leukocyte- reduced blood if recurrent

Tabel. Reaksi transfusi akut26Type Sign and SymptomsUsual Cause TreatmentPreventionAllergic (mild to severe)Urticaria (hives), rarely hypotension or anaphylaxis (Broncho spasm, wheezing, dyspnea, tacypnea), Cyanosis Cardiovas cular- tachycardia, hypotension, shock, cardiac arrest, GI, N and V, cramping diarrheaOnset- ImmediateAntibodies to plasma proteins; rarely, antibodies to IgA (developed IgA antibodies from pregnancy or previous transfusion)Stop transfusion; give antihistamine (PO or IM); if severe: epinephrine and /or steroidsPre-transfusion antihistamine; washed RBC components; if recurrent or severe check pre-transfusion IgA levels in patients with a history og anaphylaxis to transfusionHipervolemic Dyspnea, hypertension, pulmonary edema, cardiac arrhytmiasToo rapid and/or excessive blood transfusionInduced diuresis; phlebotomy; support cardio-respiratory system as neededAvoid rapid or excessive transfusionTabel. Reaksi transfusi akut27Table. Reaksi transfusi akutDIC = disseminated intravascular coagulation; IV = intravenous; IM = intramuscular; PO = per oral (by mouth); RBC = red blood cellsType Sign and SymptomsUsual Cause TreatmentPreventionTransfusion related acute lung injuri (TRALI)Dyspnea, fever, pulmonary edema, hypotension, normal pulmonary capillary wedge pressureHLA or leukocyte antibodies; usually donor antibody transfused with plasma in componentsSupport blood pressure and respiration (may require intubation)Leukocyte-reduced RBCs if recipient has the antibody; notify transfusion service to quarantine remaining components from donorBacterial sepsisRigor, chills, fever, shock, vomiting and diarrheaContaminated blood componentStop transfusion; support blood pressure; culture patient and blood unit; give antibiotics; notify blood transfusion serviceCare in blood collection and storage; careful attention to arm preparation for phlebotomy28Common transfusion reactions and transfusion process problems: presentation and managementReaction/eventFebrile non-haemolytic reactionsMinor allergic reactions Transfusion associated circulatory overload (TACO) Incorrect blood component transfused, or wrong dose or rate of transfusionKnown or postulated mechanism(s)HLA antibodies or reaction to inflammatory cytokines in transfused components (or both)Reaction to plasma proteinsRarely, reaction to drug or foodstu ingested by blood donorCirculatory (volume) overloadProduct intended for another patient or did not meet the patients special requirements (for example, required irradiated components)Wrong product, dose, or rate prescribed or administeredManagement and preventionUsually short lived and not serious (although unpleasant for the patient)Symptomatic management with antipyretics/analgesics if prolonged or severe rigorsIn process or prestorage leucocyte reduction of blood components (bedside leucocyte reduction of limited bene.t)Minor reactions usually short livedSymptomatic management with antihistamines if neededIf recurrent and troublesome, pretreatment with antihistamine/steroid may be indicatedInfants, older patients, and those with comorbidities (such as cardiac and renal impairment) are particularly vulnerable to TACOCheck pre-transfusion volume status and monitor fluid balance carefullyTransfuse only one unit at a time and review a.er each unitDiuresis between units if transfusing multiple units, but TACO may occur a.er only a single unit transfusedThese are usually due to: Procedural errors (such as failure to properly identify the intended recipient) Poor communication between members of clinical teams or between clinical teams and the transfusion laboratory Errors in prescription or interpretation of product type, dose, or infusion rateCareful patient identi.cation and attention to detail at blood prescription, pre-transfusion specimen collection, testing, and blood administration stepsElectronic solutions to properly identify the intended recipient and blood componentPresentationFever, chills, rigorsHives and itchingDyspnoea, tachypnoea, pulmonary oedema, tachycardia, and hypertension due to hypervolaemiaVariablemost are no harm events, but do have potential for serious patient harm29Tempat terjadinya hemolisisIntravaskulerEkstravaskuler 30Imunologik Anti-A, anti-B, Anti-AB (jenis IgM)Inkompatibilitas ABO & RhSegeraTanda dan gejalaCemas, muntah, diareDemam, menggigil, nyeri dada dan pinggangCirculatory collapseHemoglobinemia, hemoglobinuria, ikterusPerdarahan tdk terkontrol fatalGagal ginjalAngka kematian 10%Non-ImunologikRBC rusak sblm ditransfusikanHemolisis intravaskuler31Selama transfusiUmumnya krn anti-D (jenis IgG)Reaksi tdk sehebat intravaskulerGejala dan tandaDemam, menggigilKadar Hb turun, sp 10 hari pasca transfusiReaksi jarang fatalTdk diikuti gagal ginjalHemolisis tertunda (lambat)7 hari kemudianDemam, ikterusInsidensi 1:4000Hemolisis ekstravaskuler32Tanda dan gejala pd reaksi transfusi33Reaksi transfusi yg berbahayaTerjadi krn:Inappropriate specification, 33%Salah darah, 20%Transfusi tdk sesuai (inappropriate transfusion), 13%Kesalahan pengujian pre-transfusi, 12%Handling error, 7%34Demam non-hemolitik (Febris), 1: 200Kontaminasi bakteri 1:700TRALI (Transfusion related acute lung injury 1:5000Alergi, 1:33.000Anafilaksis, 1:20.000 50.000Hemolitik akut, 1:250.000 600.000Transfusion associated graft-versus-host diseaseWrong blood is given to patientsDelayed haemolysis Frekuensi Reaksi Transfusi35Table 4 | Some complications of transfusion and their approximate frequency. Data taken from the Serious Hazards of Transfusion scheme17 Transfusion riskFrequency in the UK (units transfused)ABO incompatible red cell transfusion1/180 000Incorrect blood component transfused (excluding ABO incompatible red cell transfusions)1/13 000Serious acute transfusion reaction1/7000Transfusion related acute lung injury1/150 000Transfusion associated circulatory overload1/450 000Transfusion associated graft versus host diseaseRare since implementation of universal leucocyte reduction of blood components in the UK in 1999Post-transfusion purpuraRare since implementation of universal leucocyte reduction of blood components in the UK in 1999Transfusion transmitted infection: HIV1/6.25 million Hepatitis B virus1/1 million Hepatitis C virus 1/100 millionBMJ | 20 JULY 2013 | VOLUME 347 3637Table 4. Workup of an Acute Transfusion ReactionIf an acute transfusion reaction occurs :Stop blood component transfusion immediatelyVerify the correct unit was given to the correct patientMaintain IV access and ensure adequate urine output with an appropriate crystalloid or colloid solutionMaintain blood pressure, pulseMaintain adequate ventilationNotify attending physician and blood bankObtain blood / urine for transfusion reaction workupSend blood bag and administration set to blood transfusion service immediatelyBlood bank performs workup of suspected transfusion reaction at follows :Check paper work to ensure correct blood component was transfused to the right patient Evaluate plasma for hemoglobinemiaPerform direct antiglobulin setRepeat other serologic testing as needed (ABO/RH)Adapted from snyder EL. Transfusion reaction. In : Hoffman R, Benz. EF Jr, Shattil SJ, et al. Hematology : Basic Principle and practice, 2nd ed. Ney York : Chruchill Livingstone, 1995 ; 2045-5338Table 4. Workup of an Acute Transfusion ReactionIf intravascular hemolytic reaction is confirmed

10. Monitor renal status (BUN, creatinine)11. Initiate a diuresis12. Analyze urine for hemoglobinuria 13. Monitor coagulation status (prothrombin time, partial tromboplastin time, fibrinogen, platelet count)14. Monitor for sign of hemolysis (lactate dehydrogenase, bilirubin, haptoglobin, plasma hemoglobin)15. Repeat compatibility testing (cross match) 16. If sepsis is suspected, culture unit and patients, and treat as appropiate Adapted from snyder EL. Transfusion reaction. In : Hoffman R, Benz. EF Jr, Shattil SJ, et al. Hematology : Basic Principle and practice, 2nd ed. Ney York : Chruchill Livingstone, 1995 ; 2045-533940Reaksi Non-Hemolitik41Alergi Pirogen Kontaminasi bakteriOverloading Gangguan irama jantungKeracunan citratKeracunan kalium Gangguan pembekuanEmboli Reaksi Non-Hemolitik42434445464748495051525354555657Penularan Penyakit5859606162Pemeriksaan pd Reaksi transfusi63Segera periksa:Kesalahan administrasiPeriksa sisa darah apakah ada hemolisis: warna merahPeriksa DAT (direk antiglobulin tes)Bila reaksi transfusi hemolitikPeriksa:Kesalahan administrasiKesalahan golongan darahUji silang golongan darah (crossmatch)Hemoglobinemia menyebabkan hemoglobinuriaDAT, positifBila reaksi Non-hemolitik (immune-mediated)Pasien akan menggigil, demam, sesak napas, edema paruReaksi alergi berat anafilaksis (anti IgA)Purpura krn antiplatelet64Bila hemolisis (lanjutan), periksa:Bilirubin serum 5-7 pasca transfusiSerum Haptoglobulin, methemalbumin, LDHHemosiderin urineHitung jlh retikulositFragilitas osmotikApus darah, utk melihat sferositosisBila hemolisis non-imunologik, periksa:Kesalahan penyimpananKesalahan pemeriksaan Kesalahan cairan infusSickle cellsRBC abnormal65Bila tdk ada kesalahan ABO, crossmatch, maka periksa:Antibodi penderitaAntibodi donorPenyebab hemolisis lain

Bila hasil pemeriksaan negatif, lakukan:Pemeriksaan fenotipe dan genotipe penderita dan donorPeriksa antibodi pd serum donor dan penderitaKirim sampel ke UTD pusat66Pemeriksaan Lab RHAPem hemoglobinemiaVisual, sampel pre dan pasca tranfusi Plasma yg kemerah-merahan (Hb 20 mg/dL)Plasma jelas merah (Hb 30 mg/dL)Laboratorik, bila visual negatifHb plasmaSerum haptoglobinSerum methemoglobinPem antibodiAntiglobulin test direk dan indirekIdentifikasi Ab dgn panel cells Pem bil terutama indirekVisual: sampel pre dan pasca transfusiKuning muda: normalKuning tua, akan jelas stlh 5 jamLaboratorik: bil kuantitatifPem urineHemoglobinuria: sampel pasca transfusiVisual: jambon, merah, coklatLaboratorik: mikroskopik bila meragukanHemosiderinuria Pem lainKadar Hb, trombosit, aPTT, PPT67Bila diduga RHA cari penyebabnya dgn:Inspeksi visualWarna plasma resipien: merahWarna urine resipien: merahUji ulang pem gol ABO dan Rh: donor dan resipienHrs cocok (tdk ada perbedaan)Uji AHG direkBila krn inkompatibilitas ABO tes AHG direk posBila RHA68Bila terjadi demam, cek penyebabnyaInspeksi visualWarna plasma resipien: normalWarna urine resipien: normalUji ulang tes ABO dan RhHrs cocok (tdk ada perbedaan)Uji AHG direkHrs negatifDemam/Febris non-hemolitik69Reaksi anafilaksis Plasma atau urine merahBila Inkompatibilitas ABO pre dan paska; AHG direk pos bukan reaksi anafilaksisPemeriksaan anti IgASerum/plasma resipien pre transfusi (+) berarti reaksi anafilaksisPemeriksaan IgA sampel resipien pre transfusi menyingkirkan diagnosis70Bila diduga kontaminasi bakteri:Inspeksi visual: perubahan warna, gumpalan darah/PLYBiakan darah dari contoh darah diagnosis Pemeriksaan utk menyingkirkan reaksi hemolitik (krn gejala mirip)71TRALIBila terjadi dugaan TRALI, maka dilakukan:Pemeriksaan BNP edema paru TRALI atau edema paru pada reaksi transfusi krn kelebihan cairanMenyingkirkan kemungkinan sepsis krn mempunyai gejala yang miripMenyingkirkan gejala yang mirip krn mempunyai gejala yang mirip72Pengiriman sampel darah ke UTD pusatTujuan:Utk penelusuran antigen eritrosit dan serum antibodi penderitaCaranya:5 mL darah penderita tanpa antikoagulan5 ml darah penderita dgn antikoagulan citras 0.7 mLDikirim melalui UTDC dilengkapi dgn:Identitas penderitaMasalah yang ada73Sekian74