transfusi darah.ppt

TRANSFUSI DARAH

Agus Arifin SST., PGDEmergency Departement

REAKSI REAKSI TRANSFUSI DARAH

• Bila dilaksanakan pemeriksaan laboratorium pra- transfusi darah, mayoritas transfusi darah tidak memberikan efek samping ke pada pasien

• Namun, kadang kadang timbul reaksi pada pasien, walaupun pemeriksaan laboratorium pra-transfusi darah telah dilaksanakan dan hasilnya “COMPATIBLE” (= cocok antara darah resipien dan donor)

• Reaksi: reaksi RINGAN (suhu meningkat, sakit kepala) s/d BERAT (reaksi hemolisis), bahkan dapat meninggal

KOMPLIKASI TRANSFUSI DARAH

• Komplikasi LOKAL: - kegagalan memperoleh akses vena - fiksasi vena tidak baik - masalah ditempat tusukan - vena pecah saat ditusuk, dll

• Komplikasi UMUM: - reaksi reaksi transfusi - penularan/transmisi penyakit infeksi - sensitisasi imunologis - kemokromatosis

REPORTING of SERIOUS HAZARDS of REPORTING of SERIOUS HAZARDS of TRANSFUSION (SHOT)TRANSFUSION (SHOT)

• Suspected or confirmed transfusion – transmitted infection (bacterial, viral, etc)

• All instances where blood intended for one patient is given to another

• Immediate or delayed haemolysis • Post – transfusion purpura• Transfusion – associated graft-versus-host disease• Transfusion-related acute lung injury

CLERICAL ERROR• Kesalahan administrasi kesalahan manusia

REAKSI TRANSFUSI DARAH

• Reaksi Tranfusi Darah AKUT: hemolitik, panas, alergi, hipervolume, sepsis bakteria, lung injury, dll• Reaksi Transfusi Darah LAMBAT


• Yang paling sering timbul: - reaksi febris - reaksi alergi - reaksi hemolitik

REAKSI FEBRIS

• Nyeri kepala menggigil dan gemetar tiba tiba suhu meningkat

• Reaksi jarang berat• Berespon terhadap pengobatan

REAKSI ALERGI

• Reaksi alergi berat (anafilaksis): jarang

• Urtikaria kulit, bronkospasme moderat, edema larings: respon cepat terhadap

pengobatan

REAKSI HEMOLITIK

• REAKSI YANG PALING BERAT• Diawali oleh reaksi: - antibodi dalam serum pasien >< antigen corresponding pada eritrosit donor - antibodi dalam plasma donor >< antigen corresponding pada eritrosit pasien• Reaksi hemolitik: - intravaskular - ekstravaskular

REAKSI HEMOLITIK

• REAKSI INTRAVASKULAR: - hemolisis dalam sirkulasi darah - jaundice dan hemogolobinemia - antibodi IgM - paling bahaya anti-A dan anti-B spesifik dari sistem ABO - fatal akibat perdarahan tidak terkontrol dan gagal ginjal

REAKSI HEMOLITIK

• REAKSI EKSTRAVASKULAR: - jarang sehebat reaksi intravaskular - reaksi fatal jarang - disebabkan antibodi IgG destruksi eritrosit via makrofag - menimbulkan penurunan tiba triba kadar Hb s/d 10 hari pasca transfusi


• Bila dilaksanakan pemeriksaan laboratorium pra- transfusi darah, mayoritas transfusi darah tidak memberikan efek samping ke pada pasien

• Namun, kadang kadang timbul reaksi pada pasien, walaupun pemeriksaan laboratorium pra-transfusi darah telah dilaksanakan dan hasilnya “COMPATIBLE” (= cocok antara darah resipien dan donor)

• Reaksi: reaksi RINGAN (suhu meningkat, sakit kepala) s/d BERAT (reaksi hemolisis), bahkan dapat meninggal

GOLONGAN DARAH

• A,B, AB, O• Rhesus + / -• Golongan darah jarang

Sistem golongan darah eritrosit utama pada manusia

Tahun ditemukan

190119261926194019451946194619501951195519561962196519671974

Sistem

ABOMNSsPRhLutheran (Lu)KellLewis (Le)Duffy (Fy)Kidd (Jk)Diego (Di)Cartwright (Yt)XgDombrock (Do)Colton (Co)Scianna (Sc)

Antigen utamapada eritrosit

H,A,BM,N,S,sP1,pD,C,E,c,eLua.Lub

K,k,Kpa,Kpb,Kpc,Jsa,Jsb

Lea,Leb

Fya,Fyb

Jka,Jkb

Dia,DibYta,Ytb

Xga

Doa,Dob

Coa,Cob

Sc1,Sc2

Antibodi timbul secara alamiah

SelaluTak

Kadang – kadangTakTakTak

Kadang – kadangTakTakTakTakTakTakTakTak

Golongan darah ABO

Fenotip

O

A1

A2

B

A1B

A2B

Genotip

OO

A1A1

A1OA1A2

A2A2

A2O

BBBO

A1B

A2B

Antigen eritrosit

H

A + A1

A + H

B + (H)

A + A1 + B

A + B + (H)

Antibodi serum

Anti-AAnti-B

Anti-B

Anti-B(Anti A1)

Anti-A

tidak ada

(Anti A1)

FrekuensiKaukasia Oriental

45 30

41 38

11 22

3 10

PEMERIKSAAN SEROLOGI GOLONGAN DARAH PRA TRANSFUSI

• PEMERIKSAAN GOLONGAN DARAH ABO dan Rhesus pada PASIEN DAN DONOR

• Pemeriksaan CROSSMATCHING (reaksi kecocokan silang)

• PEMERIKSAAN GOLONGAN DARAH ABO, dari 2 arah: - Cell grouping: ada/tidaknya antigen A atau B pada permukaan eritrosit - Serum grouping (back typing): ada/tidaknya antibodi A, B, AB dalam serum/plasma • PEMERIKSAAN GOLONGAN DARAH RHESUS: - hanya antigen-D atau Du yang diperiksa pada eritrosit

Table 1. Blood Components and Plasma Derivatives (1)Table 1. Blood Components and Plasma Derivatives (1)

Component/Product Composition Volume Indications

Whole Blood RBCs (approx. Hct 40%); plasma; 500 ml Increase both cell mass & plasma WBCs; platelets volume (WBCs & platelets not

functional; plasma deficient in labile clotting Factors V and VIII)

Red Blood Cells RBC (approx. Hct 75%); reduced 250 ml Increase red cell mass in symptomplasma, WBCs, and platelets atic anemia (WBCs & platelets not

functional)

Red Blood Cells, RBC (approx. Hct 60%); reduced 330 ml Increase red cell mass in symptomatic Adenine-Saline plasma, WBCs, and platelets; anemia (WBCs and platelets notAdded 100 ml of additive solution functional)

RBCs Leukocytes > 85% original volume of RBC; 225 ml Increased red cell mass; < 5 x 106 WBCsReduced (prepa- < 5 x 106 WBC; few platelets; to decrease the likelihood of febrile reac-red by filtration) minimal plasma tions, immunization to leukocytes (HLA)

antigens) of CMV transmission

RBCs Washed RBCs (approx, Hct 75%); 180 ml Increase red cell mass; reduced risk of< 5 x 108 WBCs; no plasma allergic reactions to plasma proteins

RBCs Frozen; RBC (approx. Hct 75%); 180 ml Increased red cell mass; minimize RBCs Deglycerolized < 5 x 108 WBCs; no platelets; febrile or allergic transfusion reaction;

no plasma use for prolonged RBS blood storage

(Continued)

Table 1. Blood Components and Plasma Derivatives (2)Table 1. Blood Components and Plasma Derivatives (2)


Garnulocytes Granulocytes (>1.0 x 1010 220 ml Provide granulocytes for selected patientsPheresis PMN/unit); lymphocytes; with sepsis and severe neutropenia

platelets (>2.0 x 1011/unit); (< 500 PMN/µL)some RBCs

Platelets Platelets (> 5.5 x 1010/unit); 300 ml Bleeding due to thrombocytopenia orRBC; WBCs; plasma thrombocytopathy

Platelets Pheresis Platelets (> 3 x 1011); 300 ml Same as platelets;l sometimes HLARBCs; WBCs; plasma matched

Platelets Leukocytes Platelets (as above);< 5 x 106 300 ml Same as platelets; < 5 x 106 WBCs toReduced WBCs per final dose of pooled decrease the likehood of febrile reactions,

platelets alloimmunization to leukocytes (HLAantigens), or CMV transmission

FFP; FFP Donor Plasma; anticoagulation factors; 220 ml Treatment of some coagulation disordersRetested plasma; complement (no platelets)Solvent/detergent-Treated plasma

Cryoprecipitated Fibrinogen; Factors VIII and XIII;15 ml Deficiency of fibrinogen; Factor XIII;AHF von Willebrand factor second choice in treatment of

hemophilia A, von Willebrand’s disease

(Continued)

Table 1. Blood Components and Plasma DerivativesTable 1. Blood Components and Plasma Derivatives


Factor VIII Factor VIII; trace amount of other 25 ml Hemophilia A (Factor VIII deficiency); (consentraes; plasma proteins (products vary Willebrand’s disease (off-label use forRecombinant human in purity) selected products only)Factor VIII)

Factor IX (concen- Factor IX; trace amount of other 25 ml Hemophilia B (Factor IX deficiency)Trates, recombi plasma proteins (products varyNant human in purity)Factor IX)

Albumin/PPF Albumin, some -, ß-globulins (5%); Volume expansion (25%)

Immune Globulin IgG antibodies preparations for varies Treatment of hypo-or agammaglobuline-IV and / or IM use mia; disease prophylaxis; autoimune

thrombocytopenia (IV only)

Rh Immune IgG anti-D; preparations for IV 1 ml Prevention of hemolytic disease of theGlobulin and/or IM use newborn due to D antigen; treatment of

autoimmune thrombocytopenia

Antithrombin Antithrombin; trace amount of 10 ml Treatment of antithrombin deficiency other plasma proteins

RBCs = red blood cells; Hct = hematocrit; WBCs = white blood cells; CMV = cytomegalovirus; PMN = polymorphonuclear cells;FFP = fresh frozen plasma; PPF = plasma protein fraction; IV = intravenous; IM = intramuscular

PEMBERIAN TRANSFUSI DARAHpada PASIEN

• Nilai ulang: - check list pelaksanaan transfusi darah - golongan darah pasien = donor ? (tanyakan/peneng) - identitas pasien tepat ? - identitas donor dan gol drh donor label merah muda, putih, biru muda, kuning

- awasi selama dan setelah transfusi (tanggung jawab dokter) - awasi reaksi transfusi darah

Indikasi Penggantian faktor – faktor Hemostatik pada Pasien TraumaIndikasi Penggantian faktor – faktor Hemostatik pada Pasien Trauma

-Tentukan status koagulasi pasien, bila mungkin dengan tes laboratorium yang tepat

- Pedoman klinis :* luas dan lokasi perlukaan* lama renjatan berlangsung* respon terhadap resusitasi awal* risiko komplikasi, misalnya perdarahan intrakanial

- Ganti komponen darah untuk memperbaiki kelianan spesifik

- Pedoman untuk komponen darah spesifik : Berikan transfusi * trombosit : bila jumlah trombosit < 80 – 100 x 109/L* FFP : bila masa protrombin /

masa tromboplastin parsial > 1,5 x normal* Kriopresipitat : bila kadar fibrinogen < 10 g/L

TRANSFUSI TROMBOSIT

• Trombosit disimpan dalam kondisi digoyang terus (Reciprocal agitator), pada suhu kamar (20 C Celcius)

• Harus segera diberikan (tidak boleh disimpan di kulkas/ di ruangan)

• Kecepatan cepat• Gunakan infus set khusus (jangan menggunkan set

transfusi darah merah) = Platelet Administration Set = TERUFUSSION (Terumo®)

KEBUTUHAN TROMBOSIT• Trombosit: - dosis umumnya: 1 unit per 10 kg BB (5-7 unit untuk orang dewasa) - 1 unit meningkatkan 5000/mm3 (dewasa 70 kg) - ABO-Rh typing saja, tak perlu cross match, kecuali pada keadaan tertentu

Corrected platelet increment (CI) = (P1 – P0) x BSA x n-1

P1 = platelet count before transfusion (109/l)P0 = platelet count 1 hour after transfusion (109/l)BSA = recipient’s body surface area, m2

N = number of units of platelet concentrates transfused, each > 0,55 x 1011

A corrected platelet increment 1 hour after administration that isHigher than 7,5 x 109/l indicates a successful transfusion of platelets

KEBUTUHAN PLASMA/FFP• Dosis bergantung kondisi klinis dan penyakit

dasarnya• Coagulation factor replacement: 10 – 20 ml/kg BB (= 4-6 unit pd dewasa)• Dosis ini diharapkan dapat meningkatkan

faktor koagulasi 20 % segera setelah transfusi

• Plasma yang dicairkan (suhu 30 - 37º C) harus segera ditransfusikan

• ABO-Rh typing saja (tak perlu cross match)

Content of CryoprecipitateContent of Cryoprecipitate

80 to 120 units of Factor VIII : C (procoagulant activity)250 mg fibrinogen20% to 30% of the factor XIII in the original unit40% to 70% of the factor VIII : VWF (von Willebrand factor) in theOriginal unit

KEBUTUHAN KRIOPRESIPITAT

• Diencerkan pada suhu 30 – 37 C• 1 unit akan meningkatkan fibrinogen 5

mg/dl pada dewasa• Target hemostasis level: fibrinogen > 100 mg %• Segera transfusikan dalam 4 jam• Dosis untuk pasien hemofilia: rumus

Table 5. Acute Transfusion Reactions (1) Table 5. Acute Transfusion Reactions (1)

Type Sign and Symptoms Usual Cause Treatment Prevention

Intravascular Hemoglobinemia and ABO incompatibility Stop transfusion; Avoid clerical hemolytic hemoglobinuria, fever, (clerical error) or other hydrate, support errors; ensure (immune) chills, anxiety, shock, DIC, complement – fixing blood pressure & proper sample

dyspnea, chest pain, antibody causing respiration; induce & recipient flank pain, oliguria antigen – antibody diuresis; treat shock

identification incompatibility and DIC, if present

Extravascular Fever, malaise, indirect IgG Monitor Ht, Avoid clericalHemolytic hiperbilirubinemia, non-complement- renal & hepatic error : ensure(immune) increased urine urobili- fixing antibody often function, coagulati proper sample

nogen, falling hematocrit assoclated with on profile, no acute & recipientdelayed hemolysis treatment generally identification

required

Febrile Fever, chill, rarely Antibodies to Stop transfusion; Pre transfusion hypotension leukocytes or plasma give antipyretic; antipyretic;

protein; hemolysis; eg, acetaminophen leukocyte- passive cytokines ; for rigors reduced blood

infusion; sepsis. Use meperidine 25- if recurrentCommonly due to 50 mg IV or IMpatient’s underlyingcondition

(continued)



Allergic (mild Urticaria (hives), rarely Antibodies to plasma Stop transfusion; Pre-transfusionTo severe) hypotension or anaphy- proteins; rarely anti- give; antihistamine antihitamine;

laxis bodies to IgA (PO or IM); if severe, washed RBCepinephrine and/or components, if steroids recurrent or

severe check pre- transfusion IgA

levels in patientswith a history of

of anaphylaxisto transfusion

Hypervolemic Dyspnea, hypertension Too rapid and/or Induced diuresis; Avoid rapid or pulmonary edema, excessive blood phlebotomy; excessive cardiac arrhytmias transfusion support cardio- transfusion

respiratory systemas needed

(continued)(continued)



Transfusion- Dyspnea, fever HLA or leukocyte Support blood Leukocyte-reducedrelated acute pulmonary edema, antibodies; usually pressure and RBCs if recipientlung injuri hypotension, normal donor antibody respiration (may has the antibody;(TRALI) pulmonary capillary transfused with require intubation) notify transfusion

wedge pressure plasma in compo service to quaran- nents tine remaining

components from donor

Bacterial Rigors, chills, fever, Contaminated Stop transfusion; Care in blood sepsis shock blood component support blood collection and

pressure; culture storage; careful patient and blood attention to arm- unit; give antibiotics preparation for ; notify blood trans- phlebotomy fusion service

DIC = disseminated intravascular coagulation; IV = intravenous; IM = intramuscular; PO = by mouth;RBC = red blood cellsDIC = disseminated intravascular coagulation; IV = intravenous; IM = intramuscular; PO = by mouth;RBC = red blood cells

Table 4. Workup of an Acute Transfusion ReactionTable 4. Workup of an Acute Transfusion Reaction

If an acute transfusion reaction occurs :

1. Stop blood component transfusion immediately2. Verify the correct unit was given to the correct patient3. Maintain IV access and ensure adequate urine output with an appropriate crystalloid or colloid solution4. Maintain blood pressure, pulse5. Maintain adequate ventilation6. Notify attending physician and blood bank7. Obtain blood / urine for transfusion reaction workup8. Send blood bag and administration set to blood transfusion service immediately9. Blood bank performs workup of suspected transfusion reaction at follows :

a. Check paper work to ensure correct blood component was transfused to the right patient b. Evaluate plasma for hemoglobinemiac. Perform direct antiglobulin setd. Repeat other serologic testing as needed (ABO/RH)

If intravascular hemolytic reaction in 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 : BasicPrinciple and practice, 2nd ed. Ney York : Chruchill Livingstone, 1995 ; 2045-53

transfusi darah.ppt

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