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TRANSFUSI DARAH

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
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 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 Sistem Antigen utama Antibodi timbul


ditemukan pada eritrosit secara alamiah

ABO H,A,B Selalu


1901
MNSs M,N,S,s Tak
1926
P P1,p Kadang kadang
1926
Rh D,C,E,c,e Tak
1940
Lutheran (Lu) Lua.Lub Tak
1945
Kell K,k,Kpa,Kpb,Kpc,Jsa,Jsb Tak
1946
Lewis (Le) Lea,Leb Kadang kadang
1946
Duffy (Fy) Fya,Fyb Tak
1950
Kidd (Jk) Jka,Jkb Tak
1951
Diego (Di) Dia,Dib Tak
1955
Cartwright (Yt) Yta,Ytb Tak
1956
Xg Xga Tak
1962
Dombrock (Do) Doa,Dob Tak
1965
Colton (Co) Coa,Cob Tak
1967
Scianna (Sc) Sc1,Sc2 Tak
1974
Golongan darah ABO
Fenotip Genotip Antigen Antibodi Frekuensi
eritrosit serum Kaukasia Oriental

O OO H Anti-A 45 30
Anti-B

A1 A1 A1 A + A1 Anti-B
A1 O
A1 A2
41 38
A2 A2 A2 A+H Anti-B
(Anti A1)
A2 O

B B + (H) Anti-A 11 22
BB
BO
A1 B A + A1 + B tidak ada
A1 B 3 10
A2 B A + B + (H) (Anti A1)
A2 B
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 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 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 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)

Component/Product Composition Volume Indications

Garnulocytes Granulocytes (>1.0 x 1010 220 ml Provide granulocytes for selected patients
Pheresis PMN/unit); lymphocytes; with sepsis and severe neutropenia
platelets (>2.0 x 1011/unit); (< 500 PMN/L)
some RBCs

Platelets Platelets (> 5.5 x 1010/unit); 300 ml Bleeding due to thrombocytopenia or


RBC; WBCs; plasma thrombocytopathy

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

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; 220 ml Treatment of some coagulatio
Retested 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 Willebrands disease
(Continued)
Table 1. Blood Components and Plasma Derivatives

Component/Product Composition Volume Indications

Factor VIII Factor VIII; trace amount of other 25 ml Hemophilia A (Factor VIII deficiency);
(consentraes; plasma proteins (products vary Willebrands disease (off-label use for
Recombinant 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 vary
Nant human in purity)
Factor IX)

Albumin/PPF Albumin, some -, -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 the


Globulin 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 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 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-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 & recipient
delayed 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 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; Pre-transfusion
To severe) hypotension or anaphy- proteins; rarely anti- give; antihistamine antihitamine;
laxis bodies to IgA (PO or IM); if severe, washed RBC
epinephrine and/or components, if
steroids recurrent or
severe check
pre-
transfusion IgA
levels in patients
with a history of
of anaphylaxis
to 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 system
as needed

(continued)
Table 5. 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 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 cells
Table 4. Workup of an Acute Transfusion Reaction
If an acute transfusion reaction occurs :

1. Stop blood component transfusion immediately


2. Verify the correct unit was given to the correct patient
3. Maintain IV access and ensure adequate urine output with an appropriate crystalloid or colloid solution
4. Maintain blood pressure, pulse
5. Maintain adequate ventilation
6. Notify attending physician and blood bank
7. Obtain blood / urine for transfusion reaction workup
8. Send blood bag and administration set to blood transfusion service immediately
9. 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