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TRANSFUSI DARAH

Agus Arifin SST., PGD Emergency Departement

REAKSI REAKSI TRANSFUSI DARAH


Bila dilaksanakan pemeriksaan laboratorium pratransfusi 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 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

REAKSI REAKSI TRANSFUSI DARAH


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

REAKSI REAKSI TRANSFUSI DARAH


Bila dilaksanakan pemeriksaan laboratorium pratransfusi 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 1901 1926 1926 1940 1945 1946 1946 1950 1951 1955 1956 1962 1965 1967 1974 Sistem Antigen utama pada eritrosit H,A,B M,N,S,s P1,p D,C,E,c,e Lua.Lub K,k,Kpa,Kpb,Kpc,Jsa,Jsb Lea,Leb Fya,Fyb Jka,Jkb Dia,Dib Yta,Ytb Xga Doa,Dob Coa,Cob Sc1,Sc2 Antibodi timbul secara alamiah Selalu Tak Kadang kadang Tak Tak Tak Kadang kadang Tak Tak Tak Tak Tak Tak Tak Tak

ABO MNSs P Rh Lutheran (Lu) Kell Lewis (Le) Duffy (Fy) Kidd (Jk) Diego (Di) Cartwright (Yt) Xg Dombrock (Do) Colton (Co) Scianna (Sc)

Golongan darah ABO


Fenotip Genotip Antigen eritrosit H Antibodi serum Anti-A Anti-B Anti-B Frekuensi Kaukasia Oriental 45 30

OO

A1

A1A1 A1O A1A2 A2A2 A2O BB BO A1B A2B

A + A1

41 A2 B A+H Anti-B (Anti A1) Anti-A 11

38

B + (H)

22

A1B A2B

A + A1 + B A + B + (H)

tidak ada 3 (Anti A1) 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)


Component/Product Whole Blood Composition Volume Indications

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) RBC (approx. Hct 75%); reduced plasma, WBCs, and platelets 250 ml Increase red cell mass in symptom atic anemia (WBCs & platelets not functional) 330 ml Increase red cell mass in symptomatic anemia (WBCs and platelets not functional)

Red Blood Cells

Red Blood Cells, Adenine-Saline Added RBCs Leukocytes Reduced (prepared by filtration)

RBC (approx. Hct 60%); reduced plasma, WBCs, and platelets; 100 ml of additive solution > 85% original volume of RBC; < 5 x 106 WBC; few platelets; minimal plasma

225 ml Increased red cell mass; < 5 x 106 WBCs to decrease the likelihood of febrile reactions, immunization to leukocytes (HLA) antigens) of CMV transmission 180 ml Increase red cell mass; reduced risk of allergic reactions to plasma proteins

RBCs Washed

RBCs (approx, Hct 75%); < 5 x 108 WBCs; no plasma

RBCs Frozen; RBC (approx. Hct 75%); RBCs Deglycerolized < 5 x 108 WBCs; no platelets; no plasma

180 ml

Increased red cell mass; minimize febrile or allergic transfusion reaction; use for prolonged RBS blood storage
(Continued)

Table 1. Blood Components and Plasma Derivatives (2)


Component/Product Composition Garnulocytes Pheresis Granulocytes (>1.0 x 1010 PMN/unit); lymphocytes; platelets (>2.0 x 1011/unit); some RBCs Platelets (> 5.5 x 1010/unit); RBC; WBCs; plasma Platelets (> 3 x 1011); RBCs; WBCs; plasma Volume 220 ml Indications Provide granulocytes for selected patients with sepsis and severe neutropenia (< 500 PMN/L)

Platelets

300 ml

Bleeding due to thrombocytopenia or thrombocytopathy Same as platelets;l sometimes HLA matched

Platelets Pheresis

300 ml

Platelets Leukocytes Platelets (as above);< 5 x 106 300 ml Reduced WBCs per final dose of pooled platelets

Same as platelets; < 5 x 106 WBCs to decrease the likehood of febrile reactions alloimmunization to leukocytes (HLA antigens), or CMV transmission

FFP; FFP Donor Retested plasma; Solvent/detergentTreated plasma

Plasma; anticoagulation factors;220 ml complement (no platelets)

Treatment of some coagulation disorders

Cryoprecipitated AHF

Fibrinogen; Factors VIII and XIII; 15 ml von Willebrand factor

Deficiency of fibrinogen; Factor XIII; second choice in treatment of hemophilia A, von Willebrands disease
(Continued)

Table 1. Blood Components and Plasma Derivatives


Component/Product Composition Factor VIII Factor VIII; trace amount of other (consentraes; plasma proteins (products vary Recombinant human in purity) Factor VIII) Factor IX (concenTrates, recombi Nant human Factor IX) Albumin/PPF Factor IX; trace amount of other plasma proteins (products vary in purity) Albumin, some -, -globulins Volume 25 ml Indications Hemophilia A (Factor VIII deficiency); Willebrands disease (off-label use for selected products only)

25 ml

Hemophilia B (Factor IX deficiency)

(5%); (25%)

Volume expansion

Immune Globulin

IgG antibodies preparations for IV and / or IM use

varies Treatment of hypo-or agammaglobulinemia; disease prophylaxis; autoimune thrombocytopenia (IV only) 1 ml Prevention of hemolytic disease of the newborn due to D antigen; treatment of autoimmune thrombocytopenia Treatment of antithrombin deficiency

Rh Immune Globulin

IgG anti-D; preparations for IV and/or IM use

Antithrombin

Antithrombin; trace amount of other plasma proteins

10 ml

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 DARAH pada 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 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 = recipients 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 is Higher 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 - 37 C) harus segera ditransfusikan ABO-Rh typing saja (tak perlu cross match)

Content of Cryoprecipitate
80 to 120 units of Factor VIII : C (procoagulant activity) 250 mg fibrinogen 20% to 30% of the factor XIII in the original unit 40% to 70% of the factor VIII : VWF (von Willebrand factor) in the Original 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)


Type Sign and Symptoms Usual Cause Treatment Prevention

Intravascular Hemoglobinemia and hemolytic hemoglobinuria, fever, (immune) chills, anxiety, shock, DIC, dyspnea, chest pain, flank pain, oliguria identification Extravascular Fever, malaise, indirect Hemolytic hiperbilirubinemia, (immune) increased urine urobilinogen, falling hematocrit

ABO incompatibility (clerical error) or other complement fixing antibody causing antigen antibody incompatibility IgG non-complementfixing antibody often assoclated with delayed hemolysis

Stop transfusion; Avoid clerical hydrate, support errors; ensure blood pressure & proper sample respiration; induce & recipient diuresis; treat shock and DIC, if present Monitor Ht, Avoid clerical renal & hepatic error : ensure function, coagulati proper sample on profile, no acute & recipient treatment generally identification required Stop transfusion; give antipyretic; eg, acetaminophen ; for rigors Use meperidine 2550 mg IV or IM Pre transfusion antipyretic; leukocytereduced blood if recurrent

Febrile

Fever, chill, rarely hypotension

Antibodies to leukocytes or plasma protein; hemolysis; passive cytokines infusion; sepsis. Commonly due to patients underlying condition

(continued)

Table 5. Acute Transfusion Reactions (2)


Type Sign and Symptoms Usual Cause Treatment Prevention

Allergic (mild Urticaria (hives), rarely To severe) hypotension or anaphylaxis

Antibodies to plasma Stop transfusion; proteins; rarely anti- give; antihistamine bodies to IgA (PO or IM); if severe, epinephrine and/or steroids

Pre-transfusion antihitamine; washed RBC components, if recurrent or severe check pretransfusion IgA levels in patients with a history of of anaphylaxis to transfusion

Hypervolemic

Dyspnea, hypertension pulmonary edema, cardiac arrhytmias

Too rapid and/or excessive blood transfusion

Induced diuresis; phlebotomy; support cardiorespiratory system as needed

Avoid rapid or excessive transfusion

(continued)

Table 5. Acute Transfusion Reactions (3)


Type Sign and Symptoms Usual Cause Treatment Prevention

Transfusionrelated acute lung injuri (TRALI)

Dyspnea, fever pulmonary edema, hypotension, normal pulmonary capillary wedge pressure

HLA or leukocyte Support blood antibodies; usually pressure and donor antibody respiration (may transfused with require intubation) plasma in compo nents

Leukocyte-reduced RBCs if recipient has the antibody; notify transfusion service to quarantine remaining components from donor
Care in blood collection and storage; careful attention to armpreparation for phlebotomy

Bacterial sepsis

Rigors, chills, fever, shock

Contaminated blood component

Stop transfusion; support blood pressure; culture patient and blood unit; give antibiotics ; notify blood transfusion service

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

Table 4. Workup of an Acute Transfusion Reaction


If an acute transfusion reaction occurs : 1. 2. 3. 4. 5. 6. 7. 8. 9. Stop blood component transfusion immediately Verify the correct unit was given to the correct patient Maintain IV access and ensure adequate urine output with an appropriate crystalloid or colloid solution Maintain blood pressure, pulse Maintain adequate ventilation Notify attending physician and blood bank Obtain blood / urine for transfusion reaction workup Send blood bag and administration set to blood transfusion service immediately 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 hemoglobinemia c. Perform direct antiglobulin set d. Repeat other serologic testing as needed (ABO/RH)

If intravascular hemolytic reaction in confirmed 10. Monitor renal status (BUN, creatinine) 11. Initiate a diuresis 12. 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 ; 2045-53