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TRANSFUSI DARAH

Abdul Salam M. Sofro Fakultas Kedokteran Universitas YARSI Jakarta

Sejarah transfusi

Transfusi pertama kali tercatat pada th.1665, ketika Richard Lower di Oxford menstransfusikan darah dari anjing ke anjing lain. Dua tahun kemudian Dr. Jean Denis, dokternya raja Louis XIV di Paris melakukan transfusi pertama pada manusia ketika dia memberikan sejumlah darah domba ke anak muda yang demam.

The first recorded transfusion was in 1665, when Richard Lower transfused blood from one dog to another in Oxford. Two years later in Paris Louis XIV's physician, Jean Denis, performed the first transfusion involving a human when he gave some lambs blood to a feverish youth. (Denis thought lambs blood was healthy as the animal would not have done any evil deeds.) Amazingly, the boy recovered. Some months later, however, a man died in Paris after Denis gave him blood from a docile calf to cure his madness. Countries banned transfusions, and it was nearly 200 years before doctors risked the procedure again.

Herannya anak tadi sembuh Beberapa bulan kemudian Dr. Danis memberi darah anak sapi ke pasien lakilakinya yang gila (untuk mengobati gilanya), tetapi pasien tadi meninggal. Selama hampir 200 th kemudian transfusi darah tidak dilakukan.

200 tahun kemudian: Transfusi darah pertama kali di Irlandia

Maret 1865, Mary Ann Dooley gadis umur 14 th kena tetanus. Pengobatan dengan tembakau, kloroform dll gagal.

Akhirnya Dr Robert McDonnell memutuskan untuk memberikan darahnya pada 20 April di Dublins Jervis Street Infirmary. Dia ambil darah dari lengan kirinya, mengaduknya kemudian memasukkannya ke vena lengan kiri gadis tersebut dengan menggunakan syringe dan piston.

The Nobel Prize in Physiology or Medicine 1930


"for his discovery of human blood groups"

Karl Landsteiner Austria


Rockefeller Institute for Medical Research New York, NY, USA

b. 1868 d. 1943

Structure of RBC membrane

ISBT Human Blood Group Systems


ISBT Number 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 018 019 020 021 022 023 024 025 026 Unassigned 027 IGNT 028 P 029 GIL Name ABO MNS P Rh Lutheran Kell Lewis Duffy Kidd Diego Cartwright XG Scianna Dombrock Colton Landsteiner-Wiener Ch Hh Kx Gerbich Cromer Knops Indian Ok Raph JMH Abbreviation ABO MNS P RH LU KEL LE FY JK DI YT XG SC DO CO LW ido/Rodgers CH/RG H XK GE CROM KN IN OK RAPH JMH

Apa itu transfusi darah?

Transfusi darah adalah pemindahan (transfer) darah atau komponen darah dari seseorang (donor) ke orang lain (resipien) lewat aliran darah. Dapat dilakukan sebagai tindakan menyelamatkan nyawa untuk mengganti selsel darah atau komponen darah yang hilang lewat perdarahan

Yang paling aman?

Transfusi darah sendiri (autologous) adalah cara paling aman, tetapi memerlukan perencanaan yang baik dan belum tentu dapat dilakukan pada semua pasien

Blood collection

Bahwa pada hakekatnya Transfusi Darah merupakan tindakan medis transplantasi yang dapat menjadi penyelamat jiwa dan melibatkan petugas medik, penyumbang darah dan penerima darah.

Quality and safety in Blood Transfusion Practice

In Blood Transfusion Practice

Blood = Medicine / Drug 1 unit of blood can save 1 3 Needs Professionalism, and the blood should be Standardized Medical procedure considers risks (+) : - Donor: pain, hematoma, hemodynamic disturbance - Patient: blood transfusion complications

When we are sick

Sickness

Recovered

BLOOD TRANSFUSION COMPLICATIONS


Can be PREVENTED Can be FATAL

ACUTE Blood Transfusion Reaction: - intravacular hemolysis (hemodynamic disturbance, respiration, acute renal failure, DIC) - fever, allergy - hypervolume, transfusion related acute lung injury (TRALI) - sepsis bacteria, etc LATE Blood Tranfusion Reaction: extra vascular hemolysis, TTI (transfusion transmissible infection), etc

Transfusion Reactions
Immediate Delayed

Hemolytic

Non-hemolytic

Infections

Allergic

Febrile
Hemolytic Transfusion Reaction

Allergic

Hyper- Kalemia & Acidosis

Hypocalcemia

Acute Lung Injury

Category 1: Mild Reactions

Urticaria/rash

gatal-gatal

Category 2: Reaksi sedang


Flushing Urticaria Rigors Fever Restlessness Tachycardia

cemas gatal deg-degan dg sesak nafas ringan Sakit kepala)

Category 3: Life threatening reactions

Rigors Fever Restlessness Hypotension Tachycardia Dark Urine Unexplained bleeding (DIC)

Bingung sakit dada sakit pada tempat infus distress pernafasan sakit pinggang sakit kepala sesak nafas

Reaksi transfusi cepat

Reaksi demam Reaksi Urticarial (Allergic) Reaksi alergi berat (Anaphylactic) Reaksi haemolitik akut Kontaminasi Bakteri Kerusakan paru akut terkait transfusi Kelewat beban volume Hipothermia Toksisitas sitrat Efek Potasium

Reaksi Transfusi tertunda & jangka panjang


Haemolisis tertunda Alloimunisasi Penyakit Graft Versus Host terkait transfusi Pengaruh immunomodulasi Penimbunan zat besi Transmisi penyakit infeksi

COMPLICATIONS of ALLOGENEIC BLOOD TRANSFUSION (USA)


Risks Prediction of risks / unit of transfused blood

1. INFECTIONS: Hepatitis B Hepatitis C HTLV I and II HIV1 2. TRANSFUSION REACTIONS: Febrile reactions Allergic cutaneous reactions Anaphylaxis Acute hemolytic reactions

1 1 1 1

in in in in

63,000 103,000 641,000 1,100,000

1 1 1 1

in in in in

500 200 150,000 250,000

Risks of red blood cell transfusion (adapted from British Committee for Standards in Haematology (2001)

Risk factor Acute haemolytic reactions Hepatitis B Hepatitis C HIV Bacterial contamination of red cell concentrates

Estimated frequency per unit transfused 1 in 250 000 to 1 in 1 000 000 1 in 100 000 to 1 in 400 000* 1 in 3 000 000 1 in 4 000 000 1 in 500 000

Deaths per million units 0.67 <0.5 <0.5 <0.5 <0.25

Data from Kate Soldan, National Blood Service and Central Public Health Laboratory. Data from Dr Pat Hewitt and Dr John Barbara, National Blood Service, North London.

Taksiran IMLTD dari Medilink, ARCBS October 2004.


Virus and testing standard
HIV 1 and 2 antibody only
HIV antibody + NAT HCV antibody only HCV antibody + NAT HBV HTLV I & II vCJD

Window Period (Days)


22
9 66 7 45 51

Point estimate of residual risk 'per unit'


1 in 2,404,000
1 in 7,299,000 1 in 300,000 1 in 3,663,000 1 in 1,339,000 Considerably less than 1in 1,000,000 Possible, not yet reported in Australia

SERIOUS HAZARD of TRANSFUSION (SHOT): Overview of 618 cases: initial reports forms were received 1996 1999 (United Kingdom)

Incorrect blood/components transfused 335 (54,2 %) Acute transfusion reaction 89 (14,4 %) Delayed transfusion reaction 82 (13,3 %) Post transfusion purpura 32 (5,2 %) Transfusion related acute lung injury (TRALI) 43 (7%) Transfusion-associated graft versus host disease 11 (1,8%) Transfusion transmitted infection 19 (3 %) Unclassified 7 (1,1 %)

Jadi perlu:

Pemeriksaan laboratorium IMLTD Pemeriksaan golongan darah


Uji silang serasi

EVOLUSI DALAM DETEKSI INFEKSI MENULAR LEWAT TRANSFUSI DARAH

Shorter window period to detection

Surrogate Marker
Serum ALT T-cell count Syphilis Reagin Test

Antibody Testing
Anti-HIV Anti-HBCore Anti-HCV Anti-HTLV

Viral Antigen Detection


HIV-1 p24 Ag HBsAg HCV Ag

Viral & Bacterial RNA/DNA Detection


NAT HIV-1 HCV WNV HBV Malaria Chagas vCJD

Parvo B19
HAV Bacterial RNA Disease

Under Development

Plasma Industry Requirement

PELAKSANAAN UJI SARING


1975 1985 1992 1995

: Sifilis : Hepatitis B (HBsAg) : HIV (Anti-HIV) : Hepatitis C (Anti-HCV)

Apa anjuran / rekomendasi dalam transfusi darah?

Gunakan Strategi terintegrasi WHO

Strategi terintegrasi WHO

Didirikannya pelayanan transfusi yang terkoordinasi secara nasional dengan sistem yang setara di semua daerah. Pengambilan darah hanya hanya dari donor darah sukarela bukan bayaran dari kelompok populasi berisiko rendah Penapisan (screening) semua darah donasi terhadap penyakit infeksi menular lewat transfusi darah (IMLTD) termasuk Human Immunodeficiency Virus (HIV), virus hepatitis, syphilis and agen infeksi lain

dan praktik laboratorium yang bagus (good laboratory practice = GLP) dalam semua aspek penggolongan darah, uji kompatibilitas, preparasi komponen, penyimpanan dan transportasi darah serta produk darah. Pengurangan transfusi yang tidak perlu lewat penggunaan klinis darah dan produk darah yang tepat, dan penggunaan alternatif transfusi yang sederhana, bila dimungkinkan.

APPROPRIATE USE of BLOOD / BLOOD PRODUCTS (COMPONENTS)


Transfusion of safe blood products only to treat a condition leading to significant morbidity or mortality that cannot be prevented or managed effectively by other means (Its contraindicated if no strong indications of BT) 2. Transfusion carries the risk of adverse reactions and transfusion-transmissible infections (TTI)
1.

Cont.
3. Blood donated by family/replacement donors carries a higher risk of TTI than blood donated by voluntary non-remunerated donors 4. Blood should not be transfused unless it has been obtained from appropriately selected donors

Cont.
5. Need of transfusion can often be avoided by: prevention / early diagnosis / treatment of conditions that cause ANEMIA 6. Blood is often unnecessarily given: - to raise a Hb level before surgery - to allow earlier discharge from hospital Correction of anemia Replacement of depleted iron stores before planned surgery

Cont.
7. WB, PRC or FFP: - often given for ACUTE BLOOD LOSS - other treatments (normal saline / IV replacement fluids) would be safer, less expensive & equally effective Simple alternatives to transfusions (e.g. IV replacement fluids): safer, less expensive, may be equally effective

Factors Determining the Need for Transfusion

Blood loss Haemolysis Cardiorespiratory state and tissue oxygenation Assessment of anemia Patients tolerance of blood loss and/or anemia Anticipated need for blood

Prediction of Blood Loss based on Early Clinical Findings in Male with Body weight of 70 Kg(2)

Parameters

Class I

Class II 750 1500 15 30 %

Class III 1500 2000 30 40 %

Class IV

Blood loss (ml) Blood loss (% volume ) Pulse rate (minute) Blood pressure (mmHg) Resp. rate (minute) Urine prod. (ml/hr) CNS/mental status Fluid replacement (based on 3:1 rule)

to 750 to 15 %

> 2000 > 40 %

< 100 normal 14 20 > 30 restless mild cristaloid

>100 normal 20 30 20 30 restless moderate cristaloid

> 120 decreased 30 40 5 15 restless & confused cristaloid & blood

> 140 decreased > 35 none restless & lethargic cristaloid & blood

Based on: The American College of Surgeon Committee on Trauma(2)

Transfusion
Provides guidelines on transfusion in gastrointestinal bleeding
SEVERITY OF BLEED
1. Mild bleed

CLINICAL FEATURES
Pulse and haemog lobin normal

IV INFUSION / TRANSFUSION
Maintain intravenous access until diagnosis is clear Ensure blood is available

END POINT

2. Moderate bleed

Resting of pulse > 100/min and/or Haemoglobin <10 g/dl History of collapse and/or Shock Systolic BP <100 mmHg Pulse > 100/min

Replace fluid Order compatible red cells (4 units)

Maintain Hb > 9 g/dl*

3. Severe bleed

Replace fluid rapidly Ensure blood is available Transfuse red cells according to clinical assessment and Hb/Hct

Maintain urine output > 0.5 ml/kg/hour Maintain systolic BP > 100 mmHg Maintain Hb > 9 g/dl*

* Until you are confident that the patients is not likely to have a further large bleed. The patient may need to be referred for surgical intervention , once resuscitated

Tambahan informasi

Teman-teman sepakat membentuk perhimpunan

KONGRES NASIONAL I KEDOKTERAN TRANSFUSI DAN PEMBENTUKAN PERHIMPUNAN DOKTER TRANSFUSI DARAH INDONESIA (PDTDI) Manado, 15-18 Juli 2003 KONGRES NASIONAL II PERHIMPUNAN DOKTER TRANSFUSI DARAH INDONESIA (PDTDI) JAKARTA, 19 20 SEPTEMBER 2006

PDTDI secara resmi dikukuhkan sebagai organisasi seokupasi di bawah IDI dalam Muktamar IDI ke XXVI di Semarang 29 November 2 Desember 2006

PENGURUS PUSAT
Dewan Penasehat
Prof.DR.Dr.S.Moeslichan, SpAK Prof.DR.Dr.Ag. Sumantri, SpAK Prof.DR.Dr.AA.Sudewa Jelantik, SpPK(k) Dr.Auda S Azis,Sp.KT Dr.Masri Rustam, Sp.KT Prof. DR.Dr.Suparyatmo, SpPK(k)

Ketua Umum Prof.Dr.Abdul Salam M Sofro, PhD., Sp.KT Ketua Bidang Kerjasama & Pembinaan Masyarakat Dr.Yuyun SM Soedarmono, MSc, Sp.KT Ketua Bidang Pengembangan Organisasi Dr.H.Titis Wahyuono Ketua Bidang Pengembangan SDM Dr. Sani Sanjaya

Sekretaris Umum Dr.Franckie RR Maramis, PKK, Sp.KT Wakil Sekretaris Dr. Nova Surya Indah Hippy

Bendahara Umum Dr.Chairul Amri Wakil Bendahara Dr.Erlina S.Kartabrata, Sp.KT

Departemen-Departemen Penelitian & Pengembangan Dr.Ria Syafitri E.G, M.Bio, Sp.KT Dr.Achmad Shiddiqi Pendidikan & Pelatihan Dr.H.Udja Bahrusani Dr.Banundari Rachmawati, SpPK Kesejahteraan & Pemberdayaan Anggota Dr.Widyarman Dr.Peni Idiryati

Informasi & Pengabdian Masyarakat Dr.Samson E.Teron, SpPK Dr.Teguh Satriono. MARS

Kerjasama Luar Negeri Dr.Didik Sumarsidi Dr.Mardiani Radjuni

Kerjasama Dalam Negeri Dr.J. Swanta Dr.Nur Achmad Tjiptoprajitno, MSc