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TRANSFUSI DARAH

M.I. Diah Pramudianti


BAGIAN/SMF PATOLOGI KLINIK
RSUD DR MOEWARDI/FK UNS
SURAKARTA
2012

PENDAHULUAN
Transfusi darah : salah satu terapi
penunjang yang ikut menentukan
keberhasilan penanganan pasien yang
mengalami kekurangan salah satu/lebih
komponen darah oleh karena
penyakit/sebab lainnya.
Perlu penyediaan darah yang rasional dan
aman khususnya pada kasus-kasus
anemia/perdarahan
Skreening donor : HbsAg, Anti HCV, VDRL,

TUJUAN TRANSFUSI DARAH


Mengganti darah/komponen darah yang
hilang/mengalami penurunan
kuantitas/kualitas.
Memperbaiki transportasi O2 ke jaringan
Memperbaiki gangguan perdarahan ok
kekurangan trombosit
Merupakan terapi penunjang koagulasi ok
kekurangan protein pembentuk faktor
pembekuan

TRANSFUSI DARAH
Produk darah yang diberikan :
A.Whole blood : berisi semua komponen
darah lengkap
B.Komponen darah : sudah mengalami
pemisahan untuk memperoleh komponen
darah yang dibutuhkan.

HEMAFERESIS
Prosedur pengambilan darah dari
seseorang dimana komponen darah yang
diperlukan diambil dan yang tidak
diperlukan dimasukkan kembali ke orang
tersebut.
A. Sitoferesis : eritrositoferesis,
leukositoferesis, trombositoferesis
B. Plasmaferesis

Uji kompatibilitas pre transfusi


Komponen uji kompatibilitas :
Persiapan spesimen yang memadai
Riwayat transfusi pasien sebelumnya
ABO, Rh, dan tes antibodi
(skreening/ID)
Crossmatching (reaksi kecocokan
silang) : mayor/minor
Coombs test
Transfusi sebenarnya

PEMERIKSAAN SEROLOGI GOLONGAN


DARAH PRA TRANSFUSI
Pemeriksaan golongan darah ABO 2 cara:
- Cell grouping : ada/tidaknya antigen A/B
di permukaan eritrosit
- Serum grouping (back typing) : ada/
tidaknya antibodi A, B, AB di serum/
plasma
Pemeriksaan golongan darah Rhesus:
- hanya antigen-D / Du pada eritrosit

Sistem golongan darah eritrosit utama pada manusia


Tahun
ditemukan

Sistem

Antigen utama
pada eritrosit

1901
1926
1926
1940
1945
1946
1946
1950
1951
1955
1956
1962
1965
1967
1974

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

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

Golongan darah ABO


Fenotip

Genotip

Antigen
eritrosit

Antibodi
serum

Frekuensi
Kaukasia Oriental

OO

Anti-A
Anti-B

45

30

A1

A1A1
A1 O
A1A2

A + A1

Anti-B

46

38

A2

A2A2
A2 O

A+H

Anti-B
(Anti A1)

BB
BO

B + (H)

Anti-A

47

22

A1 B

A1 B

A + A1 + B

tidak ada

10

A2 B

A2 B

A + B + (H)

(Anti A1)

Transfusion rules for RBC di dalam sistem ABO


Pada transfusi RBC, antara eritrosit donor & plasma resipien
harus terdapat compatibilitas ABO & Rh
1.Grup O hanya dapat menerima darah dr donor grup O
2.Grup A hanya dapat menerima darah dr donor grup A & O
3.Grup B hanya dapat menerima darah dr donor grup B & O
4.Grup AB dapat menerima darah dr donor grup AB, A, B
dan O
O : donor universal
AB: resipien universal

10

Safety
bila
memungkinkan hanya eritrosit
donor dengan gol ABO yang
sama dengan penderita saja
yang diberikan

Transfusion rules for plasma di dalam sistem ABO


Pada transfusi plasma, plasma grup AB dapat diberikan
pada setiap penderita grup ABO o.k tidak mengandung
Anti A & Anti B
1. Plasma grup AB (Antibodi (-) dpt diberikan ke semua
grup ABO
2. Plasma grup A(Anti B (+) dpt diberikan ke resipien
grup A & O
3. Plasma grup B (Anti A (+) dpt diberikan ke resipien
grup B & O
4. Plasma grup O [Anti A (+) & Anti B(+)] hanya dapat
diberikan ke resipien grup O

Reaksi silang
A. Mayor : sel darah donor + serum penderita
B. Minor : serum donor + sel darah penderita
Bila hasil pemeriksaan:
Mayor (+) : tidak bisa transfusi, sebab titer reaksi
antibodi donor tetap tinggi sehingga serum
donor dapat melisiskan eritrosit resipien
Minor (+) : dapat ditransfusikan, sebab penyebab
inkompatibilitas dari donor.

RESIPIENT

Crossmatch
(major)

DONOR
-----------

Blood
specimen
(no anticoagulant)
Recipient
serum

1 unit
of
blood

Donor
red cells

Y
Y

INCOMPATIBLE

agglutination

Antibody binds to cells

Y
Y

No cell bound antibody


No agglutination
COMPATIBLE

TRANSFUSI KOMPONEN SEL


Keuntungan :
1. Tidak menambah volume darah
2. Penderita hanya mendapat komponen
yang dibutuhkan
3. Gangguan imunologi dapat dikurangi
4. Memudahkan transfusi (dapat menolong
>1 penderita yang membutuhkan)

Macam tranfusi komponen


1. Selluler
a. Eritrosit
b. Leukosit
c. Trombosit
2. Non seluler
d. Plasma
e. Fraksi plasma

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 CellsRBC (approx. Hct 75%); reduced 250 ml Increase red cell mass in symptom
plasma, 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 not
Added
100 ml of additive solution
functional)
RBCs Leukocytes
> 85% original volume of RBC;
225 ml Increased red cell mass; < 5 x 106 WBCs
Reduced (prepa< 5 x 106 WBC; few platelets;
to decrease the likelihood of febrile reacred by filtration) minimal plasma
tions, immunization to leukocytes (HLA)
antigens) of CMV transmission
RBCs Washed RBCs (approx, Hct 75%);
< 5 x 108 WBCs; no plasma

180 ml Increase red cell mass; reduced risk of


allergic reactions to plasma proteins

RBCs Frozen; RBC (approx. Hct 75%);


180 ml
Increased red cell mass; minimize
8
RBCs Deglycerolized < 5 x 10 WBCs; no platelets;
febrile or allergic transfusion reaction;
no plasma
use for prolonged RBS blood storage
(Continued)

Blood Components and Plasma Derivatives (2)


Component/Product Composition

Volume

Garnulocytes
Granulocytes (>1.0 x 1010
Pheresis
PMN/unit); lymphocytes;
platelets (>2.0 x 1011/unit);
some RBCs

220 ml
Provide granulocytes for selected patients
with sepsis and severe neutropenia
(< 500 PMN/L)

Platelets

Indications

Platelets (> 5.5 x 1010/unit); 300 ml


Bleeding due to thrombocytopenia or
RBC; WBCs; plasma
thrombocytopathy

Platelets Pheresis
Platelets (> 3 x 1011);
RBCs; WBCs; plasma

300 ml
matched

Same as platelets;l sometimes HLA

Platelets Leukocytes Platelets (as above);< 5 x 106 300 ml


Same as platelets; < 5 x 106 WBCs to
Reduced
WBCs per final dose of pooled
decrease the likehood of febrile reactions,
platelets
alloimmunization to leukocytes (HLA
antigens), or CMV transmission
FFP; FFP Donor Plasma; anticoagulation factors;
Retested plasma;
complement (no platelets)
Solvent/detergentTreated plasma

220 ml

Treatment of some coagulation disorders

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 Willebrands disease
(Continued)

Blood Components and Plasma Derivatives (III)


Component/Product Composition

Volume

Factor VIII
Factor VIII; trace amount of other
(consentraes; plasma proteins (products vary
Recombinant human
in purity)
Factor VIII)

25 ml
Hemophilia A (Factor VIII deficiency);
Willebrands disease (off-label use for
selected products only)

Factor IX (concenFactor IX; trace amount of other


Trates, recombi plasma proteins (products vary
Nant human
in purity)
Factor IX)
Albumin/PPF

Albumin, some -, -globulins


(25%)

Indications

25 ml

(5%);

Hemophilia B (Factor IX deficiency)

Volume expansion

Immune Globulin
IgG antibodies preparations for
varies Treatment of hypo-or agammaglobulineIV and / or IM use
mia; disease prophylaxis; autoimune
thrombocytopenia (IV only)
Rh Immune
Globulin

IgG anti-D; preparations for IV


1 ml Prevention of hemolytic disease of the
and/or IM use
newborn due to D antigen; treatment of
autoimmune thrombocytopenia

Antithrombin Antithrombin; trace amount of


other plasma proteins

10 ml

Treatment of antithrombin deficiency

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

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), suhu kamar
(20C)
Harus segera diberikan (tidak boleh
disimpan di kulkas/di ruangan)
Kecepatan cepat
Gunakan infus set khusus [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
crossmatch, 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 tergantung kondisi klinis dan penyakit
dasar
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)

CRYOPRECIPITATE
80-120 unit Factor VIII : C (procoagulant
activity)
250 mg fibrinogen
20-30% factor XIII in the original unit
40-70% factor VIII : VWF (von Willebrand
factor) in the original unit

KEBUTUHAN KRIOPRESIPITAT
Berisi :
- 80-120 unit Factor VIII : C (procoagulant
activity)
- 250 mg fibrinogen
- 0-30% factor XIII in the original unit
- 40-70% factor VIII : VWF (von Willebrand
factor)
Diencerkan pada suhu 3037 C
1 unit : me fibrinogen 5 mg/dl (dewasa)
Target hemostasis: fibrinogen > 100 mg%
Segera transfusikan dalam 4 jam

PEMBERIAN TRANSFUSI DARAH


pada PASIEN
Nilai ulang:
- check list pelaksanaan transfusi darah
- golongan darah pasien = donor ? (tanyakan)
- 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

Reaksi transfusi
Suatu reaksi efek samping yang berkaitan
dengan transfusi dan komponen darah
Kejadian yang tidak mengancam sampai
fatal
Hemolitik/non-hemolitik, dapat menyebabkan
destruksi eritrosit
Akut
: onset cepat
Lambat : hari sampai mingguan
Melibatkan interaksi Ag-Ab, penyebab
infeksi

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 clerical
Hemolytic
hiperbilirubinemia, non-complementrenal & hepatic
error : ensure
(immune)
increased urine urobilifixing antibody often
function, coagulati proper sample
nogen, falling hematocrit
assoclated with
on profile, no acute & recipient
delayed hemolysis
treatment generally identification
required
Febrile
hypotension

Fever, chill, rarely


Antibodies to
Stop transfusion;
Pre transfusion
leukocytes or plasma give antipyretic;
antipyretic;
protein; hemolysis;
eg, acetaminophen leukocytepassive cytokines
; for rigors
reduced blood
infusion; sepsis.
Use meperidine 25- if recurrent
Commonly due to
50 mg IV or IM
patients underlying
condition
(continued)

Table 5. Acute Transfusion Reactions (2)


Type

Sign and Symptoms

Usual Cause

Treatment

Prevention

Allergic (mild Urticaria (hives), rarely


Antibodies to plasma Stop transfusion;
To severe)
hypotension or anaphyproteins; rarely anti- give; antihistamine
laxis
bodies to IgA (PO or IM); if severe, washed RBC
epinephrine and/or components, if
steroids
recurrent or

Pre-transfusion
antihitamine;

severe check
pretransfusion IgA
levels in patients
with a history of
of anaphylaxis
to transfusion
Hypervolemic Dyspnea, hypertension
Too rapid and/or
Induced diuresis;
pulmonary edema,
excessive blood
phlebotomy;
excessive
cardiac arrhytmias transfusion
support cardio- transfusion
respiratory system
as needed

Avoid rapid or

(continued)

Acute Transfusion Reactions (3)


Type

Sign and Symptoms

Usual Cause

Treatment

Prevention

Transfusion- Dyspnea, fever


HLA or leukocyte
Support blood
Leukocyte-reduced
related acute pulmonary edema,
antibodies; usually pressure and
RBCs if recipient
lung 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 quarannents
tine remaining
components from
donor
Bacterial
sepsis

Rigors, chills, fever,


Contaminated
Stop transfusion;
Care in blood
shock
blood component support blood
collection and
pressure; culture
storage; careful
patient and blood
attention to armunit; give antibiotics preparation for
; notify blood trans- phlebotomy
fusion service

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

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

TERIMA KASIH