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Reaksi Transfusi

Hj.Banundari Rachmawati
Bagian Patologi FK Klinik
UNDIP
ReaKsi Transfusi
 Angka 2% (selama 24 jam stl pemberian)
 Biasanya ringan
 2kategori:
 InfeKsi
 i.e HIV dan HCV  1 penularan /2 juta transfusi
 Non infeksi
Reaksi transfusi Non-infeksi
Pedoman
 Acut (< 24jam)
 Immunologik
 Non-immunologik

 Delayed (> 24 jam)


 Immunologik
 Non-immunologik
Akut (< 24°) Immunologi
 Hemolytic
 Panas , tidak hemolitik
 Urticaria/Allergi
 Anaphylactic
akut (< 24°) Non-Immunologi
 Hipotensi
 Injuri paru akut akibat Transfusi
 overload
 Hemolitik Nonimmun
 Emboli udara
 Hipokalsemia
 Hipotermia
Delayed (> 24°) Immunologi
 Allo-immunisasi
 RBC antigens
 HLA
 Hemolitik
 Graft-versus-host disease (GVHD)
 Post-transfusion purpura
 Immuno-modulation
Delayed (> 24°) Non-Immunologi

 Iron overload
Akut (< 24°)
Immunologi

Hemolitik
Panas , non-hemolitik
Urticarial/Allergic
Anafilaktik
Hemolitik
 Paling berat , terjadi pada transfusi PRC
bereaksi terhadap Antibodi
 Bisa terjadi walau baru mendapat 10-15 mL
ABO-incompatible blood
 Penyebab
 Kejadian: 1:38,000 sampai 1:70,000
 Clerical and other human error pada compatible
transfusion
 Mortalitas 1:1,000,000 transfusi
Hemolytic
 Highly variable in acuity and severity
 Severe
 Fevers and/or chills
 Hypotension
 Dyspnea
 Tachycardia
 Pain
 DIC
 ARF
 Shock
Hemolytic
 Pathophysiology
Intravascular hemolysis, opsonization,
generation of anaphylotoxins
Complement activation  classical
pathway
Cytokines activation
 TNF, IL-1, IL-6, IL-8
Coagulation activation
 Bradykinin
Hemolytic
 Laboratory findings
 Hemoglobinemia
 Hemoglobinuria
 LDH
 Hyperbilirubinemia
  Haptoglobin
  BUN, creatinine in ARF
 DAT +
Hemolytic
 Treatment/Prevention
 Stoptransfusion
 Supportive care to maintain renal function
 Goal of urine O/P 100 mL/hr. in adults for at least 18-
24 hours
 Low dose dopamine
 Treatment of DIC
 ? Heparin – direct anticomplement effect
 Prevention of clerical/human errors
Akut (< 24°)
Immunologik
Hemolytic
Panas, non-hemolytic
Urticarial/Allergi
Anafilaktik
Panas, non-hemolitik
 Suhu tubuh naik 1°C atau lebih .
 Insidens
 43-75% of semua reaksi transfusi.
 SDMP /PRC 0.5-6%
 Trombosit 1-38%
 Signs/Symptoms
 Panas, menggigil
 Mual, Muntah
Cont....
 Etiologiy
 Reaksi
 Antara WBC antibodies resipien (HLA, WBC antigens) dengan
WBC donor
 Sitokin yang terakumulasi selama penyimpanan

 Differential Diagnosis:
 Semua kasus panas ok hemolitik atau bakteri/sepsis
 Pengobatan/pencegahan
 Hentikantransfusi?
 Obat penurun panas
 Leukoreduced blood component
Akut (< 24°)
Immunologik
Hemolytic
Fever/chills, non-hemolytic
Urticaria/Allergic
Anafilaktik
Urtikaria/Allergi
 Derajat
 Urtikaria ringan
 Anafilaktoid
 Berat : anafilaktik
 Insidens
 1-3% dari semua reaksi transfusi.
 Signs/Symptoms
 Uriticaria pada badan dan leher
 Panas
 Tanda kelainan paru
 Gastro Intestinal : abdominal pain, diarrhea
 Sirkulasi – takikardia, hipotensi
Urtikaria/Allergi
 Etiologi
 Antibodi pada sirkulasi resipien terhadap material dalam darah donor
(Protein pada plasma donor)
 Ikatan IgE antibody pada mast cells
 Release of histamine
 Vasoactive substances
 C3a, C5a, leukotrienes
 Differential Diagnosis:
 Hemolytic
 Bacterial
 Injuri paru karena Reaksi Transfusi akut
 Pengobatan/Pencegahan
 Hentikan transfusi
 Antihistamine/steroids
 Washing of blood products, pretreatment,leukoreduction?
Akut (< 24°)
Immunologik
Hemolytic
Fever/chills, non-hemolytic
Urticarial/Allergic

Anafilaktik
Anafilaktik
 jarang
 Insidens
 1:18,000
- 170,000
 Plt 1:1598-9630
 FFP 1:28,831
 RBCs 1:23,148-57,869
 Signs/Symptoms
 cardiovascular instability
 Cardiac arrhythmia
 Shock
 Cardiac arrest

 Gangguan respirasi
Anafilaktik
 Etiology
 Antibodi IgA (IgE, IgG, IgM) pada defisiensi IgA
 Serum IgA < 5 mg/dL
 1 diantara 342 darah donor
 Ab C4
 Defisiensi Haptoglobin (IgG / IgE anti-haptoglobin)
?
 Differential Diagnosis:
 Hemolitik
 Bakteri
 Injuri paru karena Reaksi transfusi akut I
 overload
Anfiilactik
 Pengobatan/pencegahan
 Hentikan transfusi
 Terapi Supportif
 Epinephrine
 Antihistamine/steroids
 Pada pasien defisiensi IgA  IgA-deficient product, wash
blood product
Akut (< 24°) Non-
Immunologik
Hipotensi
Injuri paru akut karena Transfusi
overload
Hemolisis non imun
Emboli udara
Hipokalsemia
Hipotermia
Hipotensi

 Treatment/Prevention
 Terapisupportatif
 Jangan berikan albumin
Akut (< 24°) Non-
Immunologik
Hipotensi
Injuri paru akut karena transfusi
Overload
Hemolisis non imun
Emboli udara
Hipokalsemia
Hipotermia
Injuri paru akut karena transfusi darah
 Definisi
 Transfusiyang berhubungan dengan oedem paru non
kardiogenik
 Deferensialal Diagnosis
 overload
 Allergic/Anafilaktik
 Bacterial
 Acute hemolytic reaction
 Tanda klinik( pada keadaan berat)
 Acute respiratory distress

 Oedem paru

 Hipoksia

 Hipotensi

 Biasanya terjadi 2-6 jam pasca transfusi


Akut (< 24°) Non-
Immunologik
Hipotensi
Injuri paru akut karena transfusi
overload
Hemolisis non imun
Emboli udara
Hipokalsemia
Hipotermia
overload
 Oedem paru karena overload
 Insidens
 Sering terjadi
 Risiko tinggi pada anak kecil dan orang tuak
 Gangguan pada jantung dan paru
 Anemi kronik dengan volume plasma meningkat
 Infus 25% albumin
 Terjadi perpindahan vol ekstravasc dalam jumlah besar ke intra
vaskuler
 Signs/Symptoms
 Dyspnea, cyanosis, orthopnea, dll segera setelah
transfusi
overload
 Pengobatan/pencegahan
 Hentikan transfusi
 Supportive care
 Phlebotomy
 Diuretic
 Transfusi diperlambat ( 4 jam jadi 6 jam)
Akut (< 24°) Non-
Immunologik
Hipotensi
Injuri paru akut karena transfusi
overload
Nonimmune hemolysis
Emboli udara
Hipokalsemia
Hipotermia
Hemolitik non imun
 SDM lisis karena penyimpanan, penangan
transfusi yang tidak tepat
 Jarang
 Signs/Symptoms
 Perubahan hemodinamik
 Gangguan paru
 Gangguan ginjal
 Hemoglobinemia and hemoglobinuria
 Hiperkalemia (renal failure)
 Panas
Cont...
 Differential diagnosis
 Hemolitik
 Autoimmune
 Bacterial/sepsis dll
 Pengobatan, pencegahan
 Hentikan transfusi
 Cek kantong
 Investigasi untuk reaksi transfusi hemolitik.
 Periksa kalium serum
 Supportive care
 Monitor volume urin
Akut (< 24°) Non-
Immunologi
Hipotensi
Injuri paru akut karena transfusi
overload
Hemolitik Nonimmun
Emboli udara
Hipokalsemia
Hipotermia
Emboli udara
 Lewat selang infus
 Jarang
 Batuk, dyspnea, chest pain, shock
Hipokalsemia
 Transfusi >> FFP, whole blood, Trombosit
secara cepat  kadar plasma citrate
meningkat  mengikat ion Ca+2
Hipotermia
 Pemberian transfusi dengan cold blood
secara cepat

 Blood warmer
Delayed (> 24°)
Immunologik
Allo-immunization
Hemolitik
Graft-versus-host disease (GVHD)
Post-transfusion purpura
Immuno-modulation
Allo-immunization
 Dijumpai bbrp minggu sampai bulan
postransfusi
 Insidens
 1-1.6% karena Ag SDM
 10% to HLA
Delayed (> 24°)
Immunologik
Allo-immunization
Hemolytik
Graft-versus-host disease (GVHD)
Post-transfusion purpura
Immuno-modulation
Hemolytic
 Terjadi beberapa jam sampai 6 minggu disebabkan karena
Antibodi IgG bereaksi dengan SDM
 Insidens
 1 in 2082 recipients
 1 in 11,328 units
Delayed (> 24°)
Immunologik
Allo-immunization
Hemolytic
Graft-versus-host disease (GVHD)
Post-transfusion purpura
Immuno-modulation
Graft-versus-host disease
(GVHD)
 Komplikasi fatal
Attackrecipient tissues
Pada pasien imunokompromise
 Keganasan yang mendapat terapi radiasi
 Stem cell transplant dll

 2-30 hari pasca transfusi


 Jarang
Delayed (> 24°)
Immunologik
Allo-immunization
Hemolytic
Graft-versus-host disease (GVHD)
Post-transfusion purpura
Immuno-modulation
Post-transfusion Purpura (PTP)
 Trombositopenia berat (< 10K)
 Terjadi sekitar 1-24 hari setelah mendapatkan WB/PRC

 Insidens
 Jarang
 Male:Female 1:5
 Usia 16-83
 Tanda klinik
 self-limited, recovery dalam 21 hari
 10-15% mortality
PTP
 Signs/Symptoms
Profound thrombocytopenia
Purpura
Bleeding
Fever (reported)
Delayed (> 24°)
Immunologic
Allo-immunization
Hemolytic
Graft-versus-host disease (GVHD)
Post-transfusion purpura
Immuno-modulation
Immuno-modulation
 ? Risiko recurrent cancer dan infeksi
bakteri
Delayed (> 24°)
Non-Immunologik
Iron overload
Iron overload
 Tiap unit PRC  200-225 mg Fe
 Transfusi kronik
 > 50-100 units of PRC
 Fe disimpan di RE sites  saturasi 
disimpan ditempat lain
 Heart, liver, endocrine glands (pancreas)
 Removal of Fe
 Desferoxamine – Fe-chelating agent
 Transfusi kronik pada hemoglobinopati
Transfusion transmissible
Viruses
 Plasma-borne  Cell-associated
 hepatitis C and viruses
variants  CMV
 hepatitis A (rarely)  EBV(95% adults
 hepatitis B immune)
 parvo B19  HTLV
 HIV-1 and HIV-2
Transfusion transmissible
Bacteria and Parasites
 Bacteria  Parasites
 occasional  plasmodium
bacterial  trypanosoma cruzi
contaminants (Chagas disease)-endemic in
Latin America
(pseudomonas,
serretia)  Toxoplasma gondii - only
a risk in pregnant and
 treponema immunosuppressed recipients
pallidum  Babesia microti - potential
 brucellosis
risk in certain areas of N.
America
Highlight Case from SHOT 2003

Wrong blood administered and a delay in recognising an acute reaction:


The patient, who was being treated in an intensive care unit for oesophageal
carcinoma, received an ABO incompatible blood transfusion resulting in
major morbidity but he survived…the patient developed fever, chest pain
and haemoglobinuria but observations were not recorded at appropriate
intervals and the transfusion reaction was not recognised until almost a whole
unit had been transfused.
Key Points

• Patients receiving a blood / blood component transfusion should be


nursed in an area where they are visible and can be observed.

• Patients should be informed and aware of any possible transfusion


reactions, and what signs and symptoms they may experience should
this happen.

• Record patients’ observations (minimum requirements) pre-transfusion,


15 minutes after commencing each unit and post-transfusion.

• If you suspect a transfusion reaction, stop the transfusion and inform


the doctor / nurse in charge of the patient immediately.
Question 1 of 4

Patients receiving a blood transfusion should be nursed


in an area where they are visible and can be observed.

True / False
Question 2 of 4

Observations must be performed and recorded (minimum


requirements)

A. Pre and post transfusion


B. Pre transfusion and 30 minutes after
commencement
C. Pre transfusion, 15 minutes after commencement
and post transfusion
D. Only if a reaction is suspected
Question 3 of 4

Possible signs and symptoms of a possible transfusion


reaction include (more than one correct answer):
A. Nausea / Vomiting
B. Breathlessness
C. Agitation / Confusion
D. Diarrhoea
E. Haemaglobinuria
F. Pyrexia
G. Change in Blood Pressure
H. Urticaria (itchy rash)
I. Abdominal Pain
Question 4 of 4

An acute transfusion reaction is a medical emergency –


the doctor or nurse in charge of the patient must be
informed immediately.

True / False
Module 10 quiz answers

 Question 1: True
 Question 2: C
 Question 3: All are correct
 Question 4: True