Materi Transfusi Darah

TRANSFUSI DARAH

REAKSI REAKSI TRANSFUSI DARAHBila 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 DARAHKomplikasi 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 anotherImmediate or delayed haemolysis Post transfusion purpuraTransfusion associated graft-versus-host diseaseTransfusion-related acute lung injury

CLERICAL ERRORKesalahan administrasi kesalahan manusia

REAKSI TRANSFUSI DARAHReaksi Tranfusi Darah AKUT: hemolitik, panas, alergi, hipervolume, sepsis bakteria, lung injury, dllReaksi Transfusi Darah LAMBAT

REAKSI REAKSI TRANSFUSI DARAHYang paling sering timbul: - reaksi febris - reaksi alergi - reaksi hemolitik

REAKSI FEBRISNyeri kepala menggigil dan gemetar tiba tiba suhu meningkatReaksi jarang beratBerespon terhadap pengobatan

REAKSI ALERGIReaksi alergi berat (anafilaksis): jarang

Urtikaria kulit, bronkospasme moderat, edema larings: respon cepat terhadap pengobatan

REAKSI HEMOLITIKREAKSI YANG PALING BERATDiawali oleh reaksi: - antibodi dalam serum pasien >< antigen corresponding pada eritrosit donor - antibodi dalam plasma donor >< antigen corresponding pada eritrosit pasienReaksi hemolitik: - intravaskular - ekstravaskular

REAKSI HEMOLITIKREAKSI 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 HEMOLITIKREAKSI 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 DARAHBila 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, ORhesus + / -Golongan darah jarang

Sistem golongan darah eritrosit utama pada manusiaTahun ditemukan190119261926194019451946194619501951195519561962196519671974SistemABOMNSsPRhLutheran (Lu)KellLewis (Le)Duffy (Fy)Kidd (Jk)Diego (Di)Cartwright (Yt)XgDombrock (Do)Colton (Co)Scianna (Sc)

Antigen utamapada eritrositH,A,BM,N,S,sP1,pD,C,E,c,eLua.LubK,k,Kpa,Kpb,Kpc,Jsa,JsbLea,LebFya,FybJka,JkbDia,DibYta,YtbXgaDoa,DobCoa,CobSc1,Sc2Antibodi timbul secara alamiahSelaluTakKadang kadangTakTakTakKadang kadangTakTakTakTakTakTakTakTak

Golongan darah ABOFenotip

O

A1

A2

B

A1B

A2B

Genotip

OO

A1A1A1OA1A2

A2A2A2O

BBBO

A1B

A2B

Antigen eritrosit

H

A + A1

A + H

B + (H)

A + A1 + B

A + B + (H)

Antibodi serum

Anti-AAnti-B

Anti-B

Anti-B(Anti A1)

Anti-A

tidak ada

(Anti A1) FrekuensiKaukasia Oriental

30

38

22

3 10

PEMERIKSAAN SEROLOGI GOLONGAN DARAH PRA TRANSFUSIPEMERIKSAAN GOLONGAN DARAH ABO dan Rhesus pada PASIEN DAN DONORPemeriksaan 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 BloodRBCs (approx. Hct 40%); plasma; 500 mlIncrease both cell mass & plasma WBCs; plateletsvolume (WBCs & platelets not functional; plasma deficient in labile clotting Factors V and VIII)

Red Blood CellsRBC (approx. Hct 75%); reduced 250 mlIncrease red cell mass in symptomplasma, WBCs, and plateletsatic anemia (WBCs & platelets not functional)

Red Blood Cells,RBC (approx. Hct 60%); reduced 330 mlIncrease red cell mass in symptomatic Adenine-Salineplasma, WBCs, and platelets; anemia (WBCs and platelets notAdded100 ml of additive solutionfunctional)

RBCs Leukocytes> 85% original volume of RBC; 225 mlIncreased red cell mass; < 5 x 106 WBCsReduced (prepa-< 5 x 106 WBC; few platelets;to decrease the likelihood of febrile reac-red by filtration)minimal plasmations, immunization to leukocytes (HLA)antigens) of CMV transmission

RBCs WashedRBCs (approx, Hct 75%); 180 mlIncrease red cell mass; reduced risk of< 5 x 108 WBCs; no plasmaallergic reactions to plasma proteins

RBCs Frozen;RBC (approx. Hct 75%);180 mlIncreased red cell mass; minimize RBCs Deglycerolized< 5 x 108 WBCs; no platelets;febrile or allergic transfusion reaction;no plasmause for prolonged RBS blood storage(Continued)

Table 1. Blood Components and Plasma Derivatives (2)

Component/ProductCompositionVolumeIndications

GarnulocytesGranulocytes (>1.0 x 1010 220 mlProvide granulocytes for selected patientsPheresisPMN/unit); lymphocytes;with sepsis and severe neutropenia platelets (>2.0 x 1011/unit);(< 500 PMN/L)some RBCs

PlateletsPlatelets (> 5.5 x 1010/unit);300 mlBleeding due to thrombocytopenia orRBC; WBCs; plasmathrombocytopathy

Platelets PheresisPlatelets (> 3 x 1011); 300 mlSame as platelets;l sometimes HLARBCs; WBCs; plasmamatched

Platelets LeukocytesPlatelets (as above);< 5 x 106 300 mlSame as platelets; < 5 x 106 WBCs toReducedWBCs per final dose of pooled decrease the likehood of febrile reactions,plateletsalloimmunization to leukocytes (HLAantigens), or CMV transmission

FFP; FFP DonorPlasma; anticoagulation factors;220 mlTreatment of some coagulation disordersRetested plasma;complement (no platelets)Solvent/detergent-Treated plasma

CryoprecipitatedFibrinogen; Factors VIII and XIII;15 mlDeficiency of fibrinogen; Factor XIII;AHFvon Willebrand factorsecond choice in treatment of hemophilia A, von Willebrands disease(Continued)

Table 1. Blood Components and Plasma Derivatives

Component/ProductComposition Volume Indications

Factor VIIIFactor VIII; trace amount of other 25 ml Hemophilia A (Factor VIII deficiency); (consentraes;plasma proteins (products vary Willebrands disease (off-label use forRecombinant 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, recombiplasma proteins (products varyNant human in purity)Factor IX)

Albumin/PPFAlbumin, some -, -globulins (5%); Volume expansion (25%)

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

Rh ImmuneIgG anti-D; preparations for IV 1 ml Prevention of hemolytic disease of theGlobulinand/or IM use newborn due to D antigen; treatment of autoimmune thrombocytopenia

AntithrombinAntithrombin; trace amount of10 mlTreatment of antithrombin deficiency other plasma proteinsRBCs = 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 DARAHpada PASIENNilai 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 TraumaTentukan 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 TROMBOSITTrombosit disimpan dalam kondisi digoyang terus (Reciprocal agitator), pada suhu kamar (20 C Celcius) Harus segera diberikan (tidak boleh disimpan di kulkas/ di ruangan)Kecepatan cepatGunakan infus set khusus (jangan menggunkan set transfusi darah merah) = Platelet Administration Set = TERUFUSSION (Terumo)

KEBUTUHAN TROMBOSITTrombosit: - 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-1P1 = platelet count before transfusion (109/l)P0 = platelet count 1 hour after transfusion (109/l)BSA = recipients body surface area, m2N = number of units of platelet concentrates transfused, each > 0,55 x 1011

A corrected platelet increment 1 hour after administration that isHigher than 7,5 x 109/l indicates a successful transfusion of platelets

KEBUTUHAN PLASMA/FFPDosis bergantung kondisi klinis dan penyakit dasarnyaCoagulation factor replacement: 10 20 ml/kg BB (= 4-6 unit pd dewasa)Dosis ini diharapkan dapat meningkatkan faktor koagulasi 20 % segera setelah transfusiPlasma yang dicairkan (suhu 30 - 37 C) harus segera ditransfusikanABO-Rh typing saja (tak perlu cross match)

Content of Cryoprecipitate80 to 120 units of Factor VIII : C (procoagulant activity)250 mg fibrinogen20% to 30% of the factor XIII in the original unit40% to 70% of the factor VIII : VWF (von Willebrand factor) in theOriginal unit

KEBUTUHAN KRIOPRESIPITATDiencerkan pada suhu 30 37 C1 unit akan meningkatkan fibrinogen 5 mg/dl pada dewasaTarget hemostasis level: fibrinogen > 100 mg %Segera transfusikan dalam 4 jamDosis untuk pasien hemofilia: rumus

Table 5. Acute Transfusion Reactions (1) Type Sign and SymptomsUsual Cause Treatment Prevention

Intravascular Hemoglobinemia andABO 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, oliguriaantigen antibody diuresis; treat shock identification incompatibility and DIC, if present

Extravascular Fever, malaise, indirectIgG Monitor Ht, Avoid clericalHemolytic hiperbilirubinemia,non-complement- renal & hepatic error : ensure(immune) increased urine urobili-fixing antibody often function, coagulati proper sample nogen, falling hematocritassoclated with on profile, no acute & recipientdelayed hemolysis treatment generally identification required

Febrile Fever, chill, rarelyAntibodies 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 recurrentCommonly due to 50 mg IV or IMpatients underlyingcondition

(continued)

Table 5. Acute Transfusion Reactions (2) Type Sign and SymptomsUsual Cause TreatmentPrevention

Allergic (mild Urticaria (hives), rarelyAntibodies to plasma Stop transfusion; Pre-transfusionTo severe) hypotension or anaphy-proteins; rarely anti-give; antihistamineantihitamine; laxis bodies to IgA(PO or IM); if severe,washed RBCepinephrine and/orcomponents, if steroidsrecurrent or severe check pre- transfusion IgAlevels in patientswith a history of of anaphylaxisto transfusion

Hypervolemic Dyspnea, hypertensionToo rapid and/or Induced diuresis;Avoid rapid or pulmonary edema,excessive blood phlebotomy; excessive cardiac arrhytmiastransfusionsupport cardio-transfusionrespiratory systemas 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-reducedrelated acute pulmonary edema, antibodies; usually pressure and RBCs if recipientlung 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 serviceDIC = disseminated intravascular coagulation; IV = intravenous; IM = intramuscular; PO = by mouth;RBC = red blood cells

Table 4. Workup of an Acute Transfusion ReactionIf an acute transfusion reaction occurs :

Stop blood component transfusion immediatelyVerify the correct unit was given to the correct patientMaintain IV access and ensure adequate urine output with an appropriate crystalloid or colloid solutionMaintain blood pressure, pulseMaintain adequate ventilationNotify attending physician and blood bankObtain blood / urine for transfusion reaction workupSend blood bag and administration set to blood transfusion service immediatelyBlood 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 hemoglobinemiac. Perform direct antiglobulin setd. Repeat other serologic testing as needed (ABO/RH)

If intravascular hemolytic reaction in confirmed

10. Monitor renal status (BUN, creatinine)11. Initiate a diuresis12. 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 : BasicPrinciple and practice, 2nd ed. Ney York : Chruchill Livingstone, 1995 ; 2045-53