BLOOD TRANFUSION

dr. Hartanto Wijaya, SpPD

Department of Internal Medicine

Faculty of Medicine UKRIDA
2018
 SASARAN PEMBELAJARAN
 Komponen darah
 Indikasi Tranfusi darah
 Berbagai jenis Tranfusi darah
 Risiko Tranfusi darah
 Introduction
• Transfusion is only one part of the patient’s management.
• Blood Transfusion is not without hazards, you should
weigh the risk against benefit
• Use of right products to the right patient at the right time
• Hb level should not be the sole deciding factor, Clinical
evaluation is important
• Informed consent  monitor the transfused patient & if
any adverse effects occur respond immediately
Composition of the Blood

1) Plasma

2) The Formed Elements

(blood cells/cell fragments)
Formed elements include:
Erythrocytes (red blood cells, RBCs)

Platelets (cellular fragments)

Leukocytes (white blood cells, WBCs)

Granulocytes
Neutrophils
Eosinophils
Basophils
Agranulocytes
Lymphocytes
Monocytes
• WHEN WE SHOULD TRANSFUSE BLOOD ?
&
WHAT BLOOD COMPONENT

SHOULD BE TRANSFUSED ?
 INDIKASI TRANSFUSI DARAH

 Tidak direkomendasikan melakukan transfusi profilaksis

 Pertimbangkan resiko & manfaat dengan cermat sebelum
memutuskan pemberian transfusi
 Hb <7,0 atau 8,0 g/dl, kecuali untuk pasien dg penyakit kritis
 Hb<8,0 g/dl  ambang batas transfusi untuk pasien yg
akan dioperasi & tidak memiliki faktor resiko iskemik
 jika pasien dg resiko iskemik (misal acute coronary
syndrome) ambang batas dapat dinaikkan sampai 10 g/dl
 INDIKASI TRANSFUSI DARAH
 Indikasi untuk transfusi  gejala anemia, dapat diberikan
apabila kehilangan darah terjadi lebih dari 30% dari volume
darah total
 Transfusi fresh frozen plasma (FFP) dapat digunakan untuk
menghilangkan efek antikoagulan
 Transfusi trombosit  mencegah perdarahan pada pasien
dengan trombositopenia atau gangguan trombosit
 Transfusi kriopresipitat kasus hipofibrinogenemia, kejadian
yang paling sering terjadi pada perdarahan masif atau konsumtif
koagulopati
 © American Society of Hematology, 2015

1 Don’t transfuse more than the minimum number of red

blood cell (RBC) units necessary to relieve symptoms of
anemia or to return a patient to a safe hemoglobin range
(7 to 8 g/dL in stable, non-cardiac inpatients).

• A large body of evidence demonstrates that liberal RBC transfusion

strategies do not benefit patients
• Thus, liberal transfusion should be avoided in most clinical settings
• Transfusion of RBC is associated with a risk of adverse events, is expensive
at approximately $200-300 per unit, and is a limited resource
 © American Society of Hematology, 2015

Indications for Transfusion

Acutely Chronically

• Rapid decline in hemoglobin below “steady • Primary stroke prevention in

state” level children (elevated TCD)
– Acute chest syndrome • Secondary stroke prevention in
– Splenic sequestration crisis children and adults
– Aplastic crisis (parvovirus) • Prevention of severe recurrent
– Multisystem organ failure vaso–occlusive events when
– Intrahepatic cholestasis hydroxyurea is not feasible
– Unexplained symptomatic anemia
• Prior to most surgical procedures
requiring general anesthesia, for
patients with HGB less than 10 (TAPS
study)
• Stroke
Evidence-Based Management Guidelines (NHLBI). JAMA 2014; 312(10):1033-1048
Guidelines for blood component therapy

Haemoglobin
(Hb) trigger for Indications NB: Hb should not be the sole deciding factor for
transfusion transfusion.

If there are signs or symptoms of impaired oxygen transport

Lower thresholds may be acceptable in patients without symptoms
< 7 g/dL and/or where specific therapy is available e.g. sickle cell disease or iron
deficiency anemia

< 7 – 8 g/dL Preoperative and for surgery associated with major blood loss.

In a patient on chronic transfusion regimen or during marrow

suppressive therapy.
< 9 g/dL May be appropriate to control anaemia-related symptoms.

< 10 g/dL Not likely to be appropriate unless there are specific indications.
 Acute blood loss >30-40% of total blood volume.

Dr. Salwa Hindawi

 Golongan darah
 Sistem ABO
Golongan darah Ag Ab

A A Anti B
B B Anti A
AB A dan B Tidak ada
O Tidak ada Anti A, anti B, anti AB
 Sistem Rhesus

Anti Rh0 (D) Kontrol Rh Tipe Rh

Positif Negatif D+
Negatif Negatif D - /d
positif positif Harus diperikasa dengan
Rh0 (D)typing (saline tube
test)
 Blood Transfusions
A blood transfusion is a procedure in which blood is given to a patient through an
intravenous (IV) line in one of the blood vessels. Blood transfusions are done to replace
blood lost during surgery or a serious injury. A transfusion also may be done if a person’s
body can't make blood properly because of an illness.

Who can give you blood? Universal Donor

People with TYPE O blood are called

Universal Donors, because they can give
blood to any blood type.

People with TYPE AB blood are called

Universal Recipients, because they can
receive any blood type.

Rh +  Can receive + or -
Rh -  Can only receive -
Universal Recipient
 KOMPONEN DARAH
Selular
• Whole blood
• Packed red blood cell
– Packed red blood cell leucocytes reduced
– Packed red blood cell washed
– Packed red blood cell frozen
• Concentrate platelet
– Platelet concentrate leucocytes reduced
• Granulocytes pheresis
Non Selular
• Fresh frozen plasma
• Single donor plasma
• Cryoprecipitate AHF
5/2/2018
 KOMPONEN DARAH
DARAH LENGKAP/ WHOLE BLOOD
ISI: sel darah merah, trombosit, lekosit & plasma
Indikasi: meningkatkan jumlah sel darah dan volume plasma dlm
waktu yg bersamaan perdarahan aktif ( kehilangan darah 25-30
% volum darah total)
Dosis dan cara pemberian
 Dewasa : 1 unit menaikkan HB 1 g/dl
 Anak: 8 mL/kg darah lengkap1 g/dl
 Pemberian sebaiknya I unit 4 jam
 KOMPONEN DARAH
SEL DARAH MERAH PEKAT / PACK RED CELL
Isi: eritrosit, trombosit, lekosit, sedikit plasma
Indikasi : pada pasien dengan gejala anemia, yg hanya perlu
massa sel darah merah contoh: gagal ginjal, keganasan
Kontra indikasi : pemberian jumlah banyak dlm waktu
singkat  hipervolemia
 Dosis : I unit  Hb meningkat I g/dl
 KOMPONEN DARAH
SEL DARAH MERAH PEKAT DGn SEDIKIT LEKOSIT
I unit  1-3 x 10 9 lekosit
Indikasi: meningkatkan sel darah merah pd pasien yg sering
mendapat transfusi
- Sering mendapat reaksi transfusi panas yg berulang
- Reaksi alergi o.k protein plasma
 KOMPONEN DARAH

SEL DARAH MERAH PEKAT CUCI / PACK RED CELL

WASH
Sel darah merah yg di cuci dgn normal salin
( Ht 79-80 % dgn volume 180 mL)
Indikasi: mencegah reaksi alergi berat / berulang
tranfusi neonatal
Perhatian: Sering ada kontaminasi bakteri
 KOMPONEN DARAH

SEL DARAH MERAH PEKAT BEKU YG DI CUCI / PACK

RED BLOOD CELL FROZEN /PACKED RED BLOOD CELL
DEGLYSEROLID
Darah yg usianya kurang 6 hari + gliserol
Indikasi : menyimpan darah langka
 Perhatian: Resiko kontaminasi
 KOMPONEN DARAH
TROMBOSIT PEKAT / CONCENTRATE PLATELET
Isi: trombosit, lekosit, sel darah merah, plasma.
1 kantong 450 ml ( 5,5 x 10 10 trombosit dg volume 50 mL)
Indikasi
- Perdarahan akibat trombositopenia ( < 50.000/uL)/
trombositopenia kongenital/didapat
- operasi/ prosedur invasif ( trombosit < 50.000/uL)
- profilaksis ( trombosit 5-10 000 uL)
 KOMPONEN DARAH
 Kontra indikasi : - sepsis
- hipersplenisme
 Dosis : 1 unit/ 10 kg BB
CCI = (Post tx plt ct) –( Pre tx plt ct) X BSA
Plt transfused x 10 11
 Efek samping : menggigil, panas dan reaksi alergi
 Perhatian: tidak efektif pada kasus ITP, TTP, KID 
dilakukan hanya pada perdarahan aktif
Platelet Count Indications
trigger for
transfusion

< 10 x 109/L As prophylaxis in bone marrow failure.

Bone marrow failure in presence of additional risk factors: fever, antibiotics,

evidence of systemic haemostatic failure.
< 20 x 109/L

Massive haemorrhage or transfusion.

In patients undergoing surgery or invasive procedures.
Diffuse microvascular bleeding-DIC
< 50 x 109/L

< 100 x 109/L Brain or eye surgery.

Appropriate when thrombocytopenia is considered a major contributory factor.

Any Bleeding Patient

In inherited or acquired qualitative platelete function disorders, depending on

clinical features & setting.
Any platelet count

Dr. Salwa Hindawi

 KOMPONEN DARAH
TROMBOSIT DGN SEDIKIT LEKOSIT / PLATELET
LEKOSIT REDUCED
Isi: Lekosit 8,3 X 10 5 / unit
Indikasi: pencegahan alloimunisasi HLA  kemoterapi
jangka panjang
Kontra indikasi: febris
Pemberiaan  filter / saringaan khusus trombosit dgn
sedikit lekosit
 KOMPONEN DARAH

GRANULOSIT FERESIS (GRANULOCYTES PHERESIS)

Isi: granulosit, limfosit, trombosit, sel darah merah, plasma.
1 unit  1,0 x 10 10 granulosit
Indikasi  meningkatkan granulosit pd pasien sepsis
dengan leukopenia yang tidak menunjukkan perbaikan
dengan pemberian antibiotik dan pada pemeriksaan sumsum
tulang menunjukkan hipoplasia
 KOMPONEN DARAH
PLASMA SEGAR BEKU / FRESH FROZEN PLASMA (FFP)
Isi: plasma, semua faktor pembekuaan stabil dan labil,
komplemen, dan protein plasma
Indikasi: gangguan proses pembekuaan bila tidak tersedia
kriopresipitat mis KID, TTP, penyakit hati
Dosis : 10-20 ml/kg (4-6 unit untuk orang dewasa)
meningkatkan faktor koagulasi 20-30 %
Consider  clinically significant bleeding but without major
haemorrhage abnormal coagulation test results, (rothrombin time
ratio or activated partial thromboplastin time ratio above 1.5).
 KOMPONEN DARAH
KRIOPRESIPITAT FAKTOR ANTI HEMOFILIK
(CRYOPRECIPITATED / AHF)
Isi: kriopresipitat AHF berisi faktor VIII 80-120 unit
Indikasi: pasien dgn kekurangan F VIII (Hemofilia A) dan F IX (Von willebrand)
Dosis 10 kantong pd dws dgn BB 70 kg
Anak: 1 kantong/ 10 kg  fibrinogen 60-100 mg/dl
Consider cryoprecipitate transfusions for patients without major haemorrhage who have:
clinically significant bleeding and a fibrinogen level below 1.5 g/litre.
 Consider prophylactic cryoprecipitate transfusions for patients with a fibrinogen level below
1.0 g/litre who are having invasive procedures or surgery with a risk of clinically significant
bleeding.
 KOMPONEN DARAH

KONSENTRAT FKT VIII ( FC VIII CONCENTRATE)

Indikasi: pecegahan perdarahan pada hemofilia A dgn
defisiensi F VIII sedang sampai berat (titer F VIII 5-10 u/ml)
ES: malaise, panas, mual, menggigil
Dosis : Plasma volume (PV mL) = 40 ml/kg x BB (kg)
F VIII yg diinginkaan ( unit)=
PV x ( kadar yg diinginkan (%) - kadar sekarang (%) )
100
 KOMPONEN DARAH

KONSENTRAT F IX
Indikasi: defisiensi F IX (Hemofilia B)
Kontra indikaasi: penyakit hati
Dosis ; I unit  1 ml plasma
1 unit F IX  1 % F IX
 UJI COCOK SILANG

 Serangkaian prosedur yg dilakukan sebelum transfusi untuk

memastikan seleksi darah yg tepat untuk pasien
 Terdapat 2 jenis uji cocok silang
1. Mayor : tes pra transfusi, menguji reaksi antara sel darah merah
donor dengan serum resipien
2. Minor : tes rutin pd darah donor setelah pengumpulan darah,
menguji reaksi antara sel darah resipien dengan serum donor
 TRANFUSION REACTION
Imunologi
• Aloimunisasi
• Hemolitik (acute, delayed)
• Febris
• Transfusion Related Acute Lung Injury (TRALI)
• Allergy/ Anaphylactic
• Post tranfusion Purpura
• Imunosupression
• GVHD

Non imunologi
• Transfusion-associated circulatory overload
• Hypothermia, embolus
• Hemosiderosis
• Infection
5/2/2018
 Complications of Transfusion
 Most common adverse side effects are usually mild & non-life-
threatening
 Two categories:
 Infectious complications
 Non-infectious complications
 Acute (< 24°)
 Immunologic
 Non-immunologic
 Delayed (> 24°)
 Immunologic
 Non-immunologic

04/09/18
 DEMAM
Disebabkan Ab lekosit, Ab trombosit, atau senyawa pirogen
Pencegahan:
 dg uji cocok silang antara lekosi donor dg serum resipien
pd pasien yang mendapat tranfusi lekosit
 Memberikan produk darah dg yg mengandung sedikit lekosit,
 Pasang mikrofiltrasi ukuran pori 40 mm  jumlah lekosit bisa
berkurang 60%
 prednison > 50 mg atau 50 mg kortison oral setiap 6 jam
selama 48 jam sebelum transfusi
 Aspirin 1 gr saat mulai menggigil atau 1 jam sebelum transfusi
Hemolytic Transfusion Reactions
• Acute
– Presentation within 24 hrs
– Intravascular hemolysis
– Prototype: ABO incompatibility
• Delayed
– Presentation > 24 hrs
– Typically extravascular but may be
intravascular (reticuloendotelial system)
– Prototype: Rh
5/2/2018
 Clinical Presentation of HTR
• Can occur after infusion of as little as 10-15 mL ABO-incompatible
blood
• Intravascular
– Fever, chills, pain, chest pain, hemoglobinuria, dyspnea, vomiting,
shock
– Complications: renal failure, DIC, ARDS, death
– Mortality: ~10%
• Extravascular
– Fever, chills, leukocytosis, anemia
– Complications: renal failure, DIC, sickle cell crisis
– Mortality: rare

5/2/2018
 Hemolytic Transfusion Reactions
 Signs/Symptoms
 Fever
 Declining Hb
 Mild jaundice
 Hemoglobinuria
 ARF – uncommon
 Check for alloaby in both serum and RBC
 Treatment/Prevention
 Rarely necessary
 May need to monitor urine O/P, renal function, coagulation
functions
 IVIG
 Appropriate units for transfusion
04/09/18
 Hemolytic Transfusion Reactions
 Treatment/Prevention
 Stoptransfusion
 Supportive care to maintain renal function
 Goal of urine O/P 100 mL/hr. in adults for at least 18-24
hours
 Low dose dopamine
 Treatment of DIC
 ? Heparin – direct anticomplement effect
 Prevention of clerical/human errors

04/09/18
 Febrile Non-Hemolytic Transfusion Reactions
• Presentation
– Fever and/or chills
• Mechanisms
– Leukocyte antibodies in recipient
– Cytokines released in unit during storage
 Signs/Symptoms
 Chills/rigor
 HA
 Vomitting
 Treatment/Prevention
 Discontinue transfusion?
 Acetaminophen/meperidine
 Leukoreduced blood component
5/2/2018
 Allergic Reactions
 Signs/Symptoms
 Uriticarial/hives – upper trunk and neck
 Fever
 Pulmonary signs (10%) – hoarseness, stridor, “lump in throat”,
bronchoconstriction
 No cutaneous involvement

 GI – abd. pain, diarrhea

 Circulatory – tachycardia, hypotension

• Mechanisms
– Antibody to allergen or plasma protein
– Passive transfer of donor antibody
 Treatment/Prevention
 Discontinue transfusion
 Antihistamine/steroids
 Washing of blood products, prophylactic antihistamines,leukoreduction?

5/2/2018
 Anaphylactic
 Rare
 Signs/Symptoms
 In addition to uritcarial/allergic…
 Cardiovascular instability

 Cardiac arrhythmia

 Shock

 Cardiac arrest

 bronchospasm

 More pronounced respiratory involvement

 Treatment/Prevention
 Discontinue transfusion
 Supportive care
 Epinephrine
 Antihistamine/steroids
 In IgA deficient pts.  IgA-deficient product, wash blood product
04/09/18
 Transfusion Related Acute Lung Injury
(TRALI)
• Presentation: non-cardiogenic pulmonary edema
 Clinical presentation (“classic”, severe form)
 Acute respiratory distress
 Pulmonary edema
 Hypoxemia
 Hypotension
 Transfusion usually within 6 hours (majority of cases during
transfusion or within 2 hours of transfusion)
• Reduction strategy
– Plasma components from male donors
– Antibody screening

5/2/2018
 Transfusion Related Acute Lung Injury
(TRALI)
 Pathogenesis
 Two current working model hypothesis
 Both models are directed against increase in pulmonary
microvascular permeability
Bioactive Lipids
Leukocyte Antibody
“Two-Hit” Model

 Pulmonary Microvascular Permeability

04/09/18 Pulmonary Edema

 Graft-versus-host disease (GVHD)
• Incidence: rare, appears w/in 10-12 days of transfusion
• Presentation: rash, fever, diarrhea, liver dysfunction,
cytopenia
• Mechanism: engraftment of transfused T-cells
• Mortality: very high
 Treatment/Prevention
 No effective treatment
 Gamma irradiation
 Render T-cells incapable of replication
 FDA requirement
 Minimum of 2500 cGy target to the midline of
the container
 Minimum of 1500 cGy target to all other part of
5/2/2018 component
Transfusion-Associated Circulatory Overload (TACO)

• Acute pulmonary edema due to volume overload

• Incidence: Variable
• Presentation: Dyspnea, hypoxemia, pulmonary edema
• At-risk patients: heart disease, renal failure
• Mortality: ~double underlying disease
 Treatment/Prevention
 Stop transfusion
 Supportive care
 Phlebotomy
 Diuretic
 Slow transfusion
 Usually 4 hours, can be extended to 6 hours

 Other strategies

5/2/2018
 Bacterial Contamination
•Organisms involved
– Platelets: Gram neg. rods, Gram pos. cocci
– RBC: Yersinia, Pseudomonas
•Sources
– Contaminated equipment, nonsterile procedure
– Donor skin
– Donor blood
• Symptoms: fever, chills, rigors, hypo-tension,
shock, DIC
• Work-up: Gram stain, culture
5/2/2018
 Other Adverse Effects of
Transfusion
• Iron overload
• Alloimmunization
• Non-immune hemolysis
• Hypotensive reaction
• Acute pain reaction
• Air embolus
• Hypocalcemia
• Hypothermia
• Post tranfusion Purpura
5/2/2018
 Transfusion-Transmitted
Diseases
• Hepatitis (B, C, G)
• HIV/AIDS
• Cytomegalovirus
• HTLV
• Parvovirus
• Chagas’ disease
• Malaria
• Babesiosis
• Leishmania
• Variant CJD

5/2/2018
 TRANSFUSION REACTION WORK-UP FORM

This part should be filled by the physician incharge :

Patient's name:_____________________ Date /time : _________________________

File number: ______________________ Ward : _____________________________

Number of previous Number of Pregnancies/deliveries

transfusions:_______________ :________________

Diagnosis :_______________________________________________________________________________
________________________________________________________________________________________

Transfusion date/time started Transfusion time discontinued :

Reaction noted : put

Temp  if indicated and please specify time
started: reaction
Temp started and duration:
discontinued:

Chest Pain Anxiety Hematuria Pruritus

Chills Restlessness Oliguria Pain in legs

Fever Headache Anuria Pain in back

Sweating Urticaria Jaundice Rigor

Nausea Pallor Shock Bronchospasm

Vomiting Erythema Cyanosis Dyspnea

Dr. Salwa Hindawi
Precordial distress Pulmonary edema
Blood safety/ Transfusion safety

SAFE
TRANSFUSION
PROCESS

SAFE BLOOD
COMPONENT
Dr. Salwa Hindawi