TRANFUSI DARAH PADA

KASUS DI BAGIAN ILMU

PENYAKIT DALAM

Mika Lumbantobing
Sub Bagian Hematologi - Onkologi Medik
FK UNDIP / RS Dr Kariadi Semarang
PENDAHULUAN

Blood is

are
xpensive

angerous
Blumberg 1988

Penderita kanker
Tranfusi durante operasi
Relaps lebih awal / cepat
Reaksi tranfusi ?
USA 1990

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Indonesia 2 0 0 5

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Pemberian tranfusi

Indikasi yang jelas dan tepat

Kapan dimulai dan diakhiri
Jenis & Jumlah tranfusi
Meminimaliser reaksi tranfusi
Indikasi

Anemia berat, Hb 7 gr%, Ht 21 %

Trombositopenia
< 20.000
> 20.000 dg perdarahan spontan
Gangguan Koagulasi
Persiapan pemberian sitostatika
 Sitostatika

Hb 10 gr%
Lekosit 4000 / mm3
Trombosit 100.000 / mm3
 Jenis tranfusi (1)

Meningkatkan Oxygen Carryng Capacity

Meningkatkan volume
Ideal pada kehilangan volume darah
Fungsi trombosit & faktor koagulasi bisa
mengalami degradasi
 Jenis tranfusi (2)

Meningkatkan Oxygen Carryng Capacity

Anemia defisiensi Fe
Anemia on Chronic disease
Anemia on Malignancy
Anemia aplastik
Auto Immune Hemolytic Anemia (AIHA)
Lekemia akut
Thalassemia
 Jenis tranfusi (3)

Mengurangi Insiden Perdarahan

Hitung trombosit < 20.000/mm3
Hitung trombosit > 20.000/mm3 disertai
perdarahan spontan.
DHF
Anemia aplastik berat
DIC
Jenis tranfusi (4)

Mengandung faktor koagulasi.

Juga protein plasma
Gangguan koagulasi
 Jenis tranfusi (5)

Sumber dari Fibrinogen, Faktor VIII & von

Willebrand Factor (vWF)
Cocok pada penderita yang sensitif pada
peningkatan plasma.
Dapat digunakan untuk pengganti faktor VIII
I (satu) unit Cryoprecipitate mengandung
80 U faktor VIII
Disfungsi & tdk terdpt von Willebrand Factor
Perkiraan Jumlah Tranfusi
Component Volume Content Clinical
(ml) Response
PRBC 180 - 200 RBCs with variable Increase Hb 10
leukocyte content g/L and Ht 3 %
and small amount
of plasma

Platelets 5.5 x 1OlO/RD unit Increase platelet

50 - 70
count 5000
-10,000/μL
≥3.0 x 1011/SDAP CCI ≥ 10 x 109/L
200 - 400 within 1 h and ≥
product
7,9 x 109/Lwithin
24 h post
transfusion
Perkiraan Jumlah Tranfusi
Component Volume Content Clinical
(ml) Response
FFP 200 - 250 Plasma proteins Increase
coagulation coagulation
factors, protein C factors about 2 %
and S, antitrombin

Cryoprecipitate 10 -15 Cold insoluble Topical fibrin

plasma protein, glue, also 80 IU
fibrinogen, factor factor VIII
VIII, vWF
Meminimaliser
Reaksi Tranfusi

Usia Lanjut
Fungsi ginjal / kondisi jantung
Keracunan citrate
Reaksi hemolitik akut
TRANSFUSION RELATED LUNG INJURY
(TRALI)
• Acute respiratory disstres during
transfusion
• Caused by immunological reaction
• Symptom of lung edema and respiratory
disstres
• Stop transfusion and treated lung edema
(corticosteroid or ventilator)
 TRANSFUSION
REACTION
1. Acute Intravascular Immune hemolytic
- ABO incompatibility reactions
- Many form symptoms (hemoglobulinurIa, feyer, chills,
coaagulopathy, chest pain, circulatory collaps)
2. Delayed lmmune hemolytic reactions.
- Non ABO antigen-antibody Incompatibilities .
- Symtomp appear within 3-10 day : fever, malaise
hyperbilirubinemla, falling hematocrit.
3. Febrile reactions.
- Caused by circulating recipient antlbodies to donor Leucocyt or
platellet contaminant.
- Cytokine mediated
- The Incidence can be diminished greatly by the use of a
Ieucodepletlon filter
Occur approx 5%, fatal hemolytic reaction
less than 1 : 1 million, febril reaction 1 : 100
 Transfusion-Transmitted
Disease

Disease transmitted through transfusion:

HIV
Hepatitis B & C
Cytomegalovirus
Malaria, Lues, Toxoplamosis
 blood donor should be screen
 IMMUNOMODULATION

Caused by allogeneic blood transfusion

Macrophage function is altered :
- decrease migratory capability
- decrease eicosanoid and IL-2 production
Lymphocyte responses to antigen and mitogen are supressed
Positive association between postoperative morbidity and
mortality
Increased susceptibility to bacteial infectlon
Earlier recurrence of cancer
Increased cancer-related mortality
Shortenad disease free interval
Dose-response relationship between number of transfusion
and immunologic effect.
effect
 IMMUNOMODULATION

Infectious complications despite antibiotic prophylaxis is

strongly related to blood transfusion.

Blood transfusion was significantly predictive of tumor

relapse. Perioperative blood transfusion is significantly
coreIated to worse prognosis in patients undergoing
surgery for stage I lung cancer.

Immunosuppression associated with surgery and blood

loss was reflected in a reduced frequency of Natural
Killer precursor (NKp) and decreased interferon gamma.
This Immunosuppression was reversed by transfusion of
autologous salvaged blood, suggesting that this fluid
contained immunostimulants.
 STORAGE DEFECTS

Elevated level of potassium .

Decreased level of 2,3 - diphosphoglycerate
(2,3 DPG)  increased red-cell oxygen affinity
impaired release of oxygen to tissue.
Red cells may be damaged by free radicals.
Treatment of donors with antioxidant helps
reduce this effect.
Citrate intoxications ( 4 U PRC Gluconas
calcicus 1 amp)
 Management of transfusion
reactions

• Fever/Chills/Nausea
• Flushing
First 5-15 min • Chest/Abdominal pain
Q 15 min X 2 • Dyspnea
• Hypotension
Q 30 min X 2
• Tachycardia
Q 60mln • Tachypnea
• Bleeding
Management of transfusion
reactions

Stop blood transfusion

Keep IV line open
Check paper work
Notify blood bank
Notify physician
 Management of transfusion
reactions
Return blood container
Submit post-transfusion blood for tests
Complete transfusion reaction form
Submit urine sample within 6h
Document transfusion reactions
· Reactions
· Whom notified
· Treatment/response to treatment
· Equipment send back to blood bank
 KASUS . 1
Ny. S 72 th masuk RS dengan Hipertensi 170/100 mmHg,
Coronary Insufficiency dengan Hb 5 gr%

Pengobatan : Antihipertensi, Cedocard 5 mg 3 x 1tab

Transfusi PRC 2 Unit /hari
Pre medikasi Furosemid 1 amp. I.V
Progressnotes : Benzidin test positif, SI menurun,
TIBC meningkat
Dijumpai ulkus yang soliter 4 x 6 cm di
antrum gaster
Kesimpulan : Ulkus gaster dengan anemia defisiensi Fe
Sesudah pemberian transfusi PRC 6 U penderita pulang
dengan Hb 12 gr% dan diberikan Hemobion 2 x 1tablet.
 KASUS . 2
Ny. R 62 th masuk RS dengan Hematemesis Melena
TD 90/60 mmHg, HR 120 /menit dan Hb 7 gr%

Pengobatan : Infus 2 jalur , (I) NaCI 0,9 % 60 tetes/menit,

(II) HES 30 tetes/menit,
Transfusi Whole Blood 3 U
Progressnotes : Dijumpai rupture varices oesophagus
grade 3 - 4, studi koagulasi masih normal

Sesudah transfusi Whole Blood 6 U Hb 11 gr% dan

sesudah keadaan stabil dilanjutkan dengan
sclerotherapy
 KASUS . 3
Nn N 18 th masuk RS dg demam 39° C
Bronkhopneumonia dan anemia berat Hb 5 gr%

Pengobatan : Antibiotika (sephalosforin gen III )

Rencana transfusi PRC 3 U.
Lab PMI menunjukan hasil :
DCT (Direct Combs Test) 4
ICT (Indirect Combs Test) 2
Crossmatch mayor (-)
Crossmatch minor (+)
Catatan : Darah akan diberikan bila ada catatan dari
dokter yang merawat.
 KASUS . 3

Rencana: diberikan Washed Red Cell ( WRC ) 3 U

Premedikasi medixon 32,5 mg i.v.
Medixon parenteral 62,5 mg /12 jam i.v
Progressnotes : ANA positif dan ACA Negatif
 penderita mengidap SLE dengan
disease activity mild to moderate
Perawatan 7 hari dan transfusi WRC 6 U Hb 12 gr% dan
penderita pulang dengan kortikosteroid (prednison ) 1
mg / kgBB / hari.
Anemia yang terjadi pada penderita ini adalah suatu Auto
Immune Hemolytic Anemia (AIHA)
 KASUS 4

Ny D 53 th menderita Myeloma Multiple masuk RS utk

menjalani pemberian sitostatika MP ( Melphalan
Prednison ) siklus ke 3.

Lab : Hb 8 gr%, Ureum 76 mg%, Kreatinin 3 mg%

Na 138 mmol/l, K 4 mmol/l
Rencana pemberian transfusi PRC 2 U/hari premed
Furosemide 1 amp i.v dan obat-obatan utk Renal
Insufficiency.
Sesudah mendapat transfusi PRC 4 U nilai Hb menjadi 12,3
gr% & Ureum menjadi 60 mg% kreatinin 2,1 mg%.

Sitostatika masuk dan penderita pulang dgn keadaan umum

yang lebih baik.
 KASUS 5

Tn H 23 th dirawat dengan Leptospirosis berat, Sepsis

dan DIC.
( Trombosit 25.000 /mm3, PT, PTTK memanjang 2 x
normal dg perdarahan gusi)

Rencana transfusi Trombosit 3 U dan FFP 3 U

Sesudah transfusi trombosit 6 U & FFP 6 U perdarahan
gusi berhenti dan trombosit meningkat menjadi
65.000/mm3 dan studi koagulasi makin mendekati nilai
normal.

Dengan pemberian hidrasi yang baik, antibiotika yang

optimal dan pemberian transfusi, Sepsis dapat diatasi
dan DIC juga menjadi reda