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  • 1. 1
    Reaksi Transfusi
    Tutor Imunologi Putaran I
    Bastiana/Siswanto Darmadi
    Departemen Patologi Klinik
    FK UNAIR/RSUD DR. SOETOMO
    29 Agustus 2008
  • 2. 2
    Hiper / Hipotensi
    Takikardia
    Sakit kepala
    demam
    Diare
    Urtikaria
    menggigil
    Hemoglobinuria
    syok
    Mual / muntah
    Nyeri dada, perut, otot, tulang, punggung
    Flushing
    Cemas, gelisah, bingung
    sesak/batuk
    Reaksi transfusi
    merasa tidak sehat
    Satu atau lebih dari gejala tsb menunjukkan kemungkinan reaksi transfusi…
  • 3. 3
    Reaksi transfusi
    3
    1
    2
    Komponen darah
    –Platelets
    (FNHTR,
    kontaminasi
    bakteri)
    – Plasma ( RT
    alergi)
    Kecerobohan (clerical error)
    –tidak mengikuti
    prosedur
    Karakteristik Px
    – Multipara atau
    multitransfusi
    (PTP, DHTR)
    – defisiensi IgA
    (anafilaksis)
    Faktor Penyebab
  • 4. 4
    Klasifikasi Reaksi transfusi
  • 5. 5
    Reaksi Transfusi Segera dan Tertunda
  • 6. 6
    Reaksi Transfusi Segera dan Tertunda
  • 7. 7
  • 8. 8
  • 9. 9
    Topik Reaksi Transfusi
    1
    Reaksi Transfusi hemolitik akut
    2
    Reaksi Transfusi demam non hemolitik
    Reaksi Transfusi Alergi
    3
    Reaksi Transfusi Anafilaksis
    4
    5
    TRALI (Transfusion Realated Acute Lung Injury)
    6
    Reaksi Transfusi Kontaminasi bakteri
  • 10. 10
    Hemolitik Akut = 1:250.000-600.000
    demam non hemolitik = 1:200
    RT Alergi = 1:33.000
    RT Anafilaksis = 1: 20.000-50.000
    TRALI (TR Acute Lung Injury) = 1:5000
    RT Kontaminasi bakteri = 1:700
    Frekuensi Reaksi transfusi
  • 11. 11
    Data UTD PMI Surabaya
    20 orang (dewasa 17, anak-anak 3)
  • 12. 12
    Reaksi transfusi hemolitik akut
    • Inkompatibilitas SDM donor & plasma resipien, terutama ABO
    • Faktor penyebab utama: clerical error
    • Insidens bervariasi:
    RTHA imun fatal= 1:250.000-600.000
    RTHA imun non fatal= 1:6.000-33.000
    RTHA non imun= jarang
    • Sering terjadi pada tahap awal transfusi
    • Gejala/tanda: demam, menggigil, sakit punggung, hipotensi, urine warna merah (hemoglobinuria)
    Tahap lanjut: Gagal ginjal akut, DIC
  • 13. 13
  • 14. 14
    Klasifikasi RTHA
    Non Imunologik:
    - SDM rusak sebelum transfusi
    Imunologik:
    • Ig M antiA, antiB, antiA,B
    -IgG,Rh,Kell,dll
    RTHA
    Hemolis ekstravaskularSelama trasfusi
    • Umumnya anti D
    • demam, menggigil
    • Tidak diikuti dengan gagal ginjal
    Hemolisis tertunda
    • 7 hari kemudianr
    • Demam, ikterus,
    Insidens 1 / 4000
    Hemolisis intravaskular
    Segera
    • Anti A, B
    • Ansietas
    • muntah, diare
    • demam, menggigil, nyeri dada dan pingggang
    • Circulatory collapse
    •Hemoglobinemia, haemoglobinuria
    Angka kematian 10%
  • 15. 15
    Investigasi lab RTHA
    1
    2
    3
    Inspeksi Visual
    • Warna plasma
    resipien:merah
    • Warna urine
    resipien:merah
    Uji ulang:
    • Golongan
    darah donor
    • Golongan
    darah resipien
    paska transfusi
    Tes AHG direk :
    RT karena ABO inkompatibel hasil tes AHG direk +
  • 16. 16
    Analisis Laboratorik RTHA
  • 17. 17
    Prinsip pemeriksaan ABO
    Reaksi aglutinasi spesifik antara antigen pada SDM dan antibodi Ig M pada serum.
    Ada 2 cara:
    1.Penggolongan ditentukan melalui pemeriksaan SDM individu dengan reagen golongan darah yang telah diketahui(anti A, antiB, antiA,B)
    2.Pemeriksaan serum individu tersebut dengan sel A, sel B dan sel O yang telah diketahui.
  • 18. 18
    Hasil pemeriksaan dengan melihat aglutinasi (+) atau (-)
  • 19. 19
    Penentuan golongan darah Rhesus
    • yang ditentukan hanya antigen D (Rho)
    • 20. menggunakan anti D (anti Rho )
  • 20
    Dua macam Reaksi Silang
    Reaksi silang mayor
    serum penderita + sel darah merah donor
    Reaksi silang minor
    plasma donor + sel darah merah penderita
  • 21. 21
    Contoh Reaksi silang
    Contoh :
    Donor A Resipien B
    Reaksi silang mayor
    sel darah merah donor + plasma resipien
    ag A anti A
    hasil +
    Reaksi silang minor
    plasma donor + sel darah merah resipien
    anti B antigen B
    hasil +
  • 22. 22
    Penyebab Reaksi silang mayor +
    1.Terjadi kesalahan penentuan golongan darah ABO dari penderita atau donor
    Penentuan gol. darah ABO harus segera diulang.
    2.Ada allo antibodi dalam serum penderita yang bereaksi dengan antigen sel darah merah donor.
    3.Ada oto antibodi dalam serum penderita yang bereaksi dengan antigen sel darah merah donor.
  • 23. 23
    Penyebab Reaksi silang mayor +
    4.Serum penderita yang abnormal
    • myeloma dan macro globulinemia
    • 24. dextran atau plasma expander
    • 25. antibodi terhadap albumin
    5.Sel darah merah telah tercoated IgG dan atau komplemen.
    6.Kontaminasi sampel oleh bakteri, alat gelas yang kotor, fibrin clots, dan lain-lain.
  • 26. 24
    Prinsip Tes AHG (Anti Human Globulin)
    • SDM yang telah disensitisasi dengan Ab inkomplet (IgG) menunjukkan aglutinasi dengan penambahan AHG.
    • 27. Sensitisasi bisa terjadi secara in vivo atau in vitro (setelah inkubasi dengan serum yang berisi antibodi).
  • 25
  • 28. 26
    Reaksi transfusi demam non hemolitik
    • Peningkatan suhu>1°C di atas baseline
    • Penyebab:
    – Antibodi resipien terhadap lekosit donor
    – Zat Bioreaktif pada produk (darah) simpan
    • Insidens 1:200 transfusi sel darah merah
    • sampai 30% pada transfusi trombosit PRP
    • Penanganan: antipiretika dan produk minim lekosit
    • DD :
    – Kontaminasi bakteri
    - Reaksi transfusi hemolitik
  • 29. 27
    1
    2
    3
    Inspeksi Visual
    • Warna plasma
    resipien : normal
    • Warna urine resipien:
    normal
    Uji ulang tes ABO/RhD: cocok/tidak ada perbedaan
    Tes AHG direk :negatif
    Investigasi lab RT demam non hemolitik
  • 30. 28
    Reaksi transfusi alergi
    • terjadi 1-3%
    • Terbanyak karena produk plasma
    • Reaksi ringan:
    – Urtikaria tanpa gejala lain
    – Penanganan dengan antihistamin
    • Reaksi lebih serius:
    – hypotensi dan sesak nafas(wheeze)
    – Penanganan seperti anafilaksis
  • 31. 29
    Reaksi transfusi anafilaksis
    • 1:20 000 – 50 000
    • Terjadi pada awal transfusi
    • Gejala pada sistem pernapasan-jantung, gastrointestinal, dan kulit.
    • Stop transfusi
    • Penanganan dengan resusitasi cairan, adrenalin/hidrocortison/antihistamin
    • Pertimbangkan defisiensi IgA
  • 32. 30
    1
    2
    3
    Plasma/urine merah, Ketidaksesuaian go darah ABO pre dan paska , AHG direk(+)  mengekslusi Dx RT anafilaksis
    Pemeriksaan anti IgA sampel serum/plasma resipien pre transfusi (+)Dx tegak
    Pemeriksaan IgA sampel resipien sebelum transfusi mengekslusi Dx
    Investigasi lab RT Anafilaksis
  • 33. 31
    Transfusion reaction acute lung injury
    • ARDS ( Acute Respiratory Distress Syndrome) dalam 1-6 jam
    – Resp distress, tachycardia, demam,
    hypotensi
    – Kabut ‘white out’ pada CXR (Chest-X
    Ray)
    • Respiratory support - 80% pulih
    • Ab donor terhadap netrofil atau HLA Antigen
  • 34. 32
    Investigasi lab TRALI
    1
    2
    3
    Pemeriksaan BNP edema paru TRALI atau edema paru pada RT kelebihan cairan
    Mengekslusi kemungkinan sepsis karena mempunyai gejala yang mirip
    Mengekslusi reaksi hemolisis karena mempunyai gejala yang mirip
  • 35. 33
    Reaksi transfusi kontaminasi bakteri
    • Lebih sering terjadi pada produk trombosit
    (karena disimpan pada suhu ruang)
    • 1:100 000 pada transfusi trombosit
    • sumber: kontaminasi kulit atau bakteriemia pada donor
    • Gejala: demam, menggigil, takikardia, dan hipotensi
    • Penanganan: resusitasi cairan dan AB
  • 36. 34
    Reaksi transfusi kontaminasi bakteri
    Onset cepat, tingkat mortalitas tinggi
    Adanya bakteri pada darah transfusi dapat menimbulkan reaksi panas pada resipien (ok pyrogen) atau manifestasi serius sepsis dan syok endotoksik.
    Umumnya disebabkan endotoksin yang diproduksi bakteri yang mampu tumbuh pada temperatur dingin, spt Pseudomonas species, E. coli, Yersinia enterocolitica.
  • 37. 35
    Sumber kontaminasi bakteri
    • Kontaminasi permukaan kulit
    • 38. Tempat flebotomi
    • 39. Bakteriemia dari donor
    • 40. Kontainer dan alat sekali pakai
    • 41. Lingkungan
  • 36
    Bacterial species in platelets implicated in clinical sepsis
    Compilation of data from Clin Micro Rev 1994; 7:290-302; Transfusion 2001;41:1493-99; www.shot.demon.co.uk/toc
    n = 86
  • 42. 37
    Perbedaan antara spesies penyebab morbiditas dan mortalitas sepsis pada komponen trombosit
    S. epidermidis lebih jarang didapati pada sepsis yang fatal namun lebih sering pada reaksi sepsis
    Klebsiella lebih sering menyebabkan sepsis yang fatal
    Gram negatif berakibat lebih fatal (60%)daripada gram positif (40%); gram positives penyebab mayoritas dari reaksi sepsis (56%)
  • 43. 38
    Organisme penyebab sepsis pada produk trombosit
    Hampir 30% adalah flora normal kulit
    Hampir 56% adalah gram positif
    Semua aerobik atau anerobik fakultatif
    (A rare (single case) exception: Clostridium perfringens fatality from a pooled platelet unit Trans Med 1998;8:19-22)
  • 44. 39
    1
    2
    3
    Inspeksi visual
    -perubahan warna,
    -penggumpalan
    pada sediaan
    darah/trombosit
    Kultur darah transfusi/Px untuk menegakkan diagnosa
    Mengekslusi reaksi transfusi hemolitik karena mempunyai gejala yang mirip
    Investigasi lab Kontaminasi bakteri
  • 45. 40
    Skema Pemeriksaan Fisik Reaksi Transfusi
  • 46. 41
    Lanjutan skema…(2)
  • 47. 42
    Lanjutan skema…(3)
  • 48. 43
    Tata Cara Pengiriman Sampel Darah ke Laboratorium PMI Pusat (PUTDP)
     untuk keperluan Penelusuran antigen eritrosit dan serum antibodi penderita.
    • 5 ml darah penderita tanpa larutan
    pembeku darah
    • 5 ml darah penderita dengan larutan
    pembeku darah 0.7 ml (Larutan citras)
    • Dikirim melalui Bank Darah PMI (UTDC)
    setempat dengan identitas penderita
    dan problematik yang jelas.
  • 49. 44
    Management of severe acute reaction
    Symptoms/Signs of Acute Transfusion Reaction
    Fever, chills, tachycardia, hyper or hypotension, collapse, rigors, flushing, urticaria, bone, muscle, chest and/or abdominal pain, shortness of breath, nausea, generally feeling unwell, respiratory distress
    Stop the transfusion and call a doctor
    Measure temperature, pulse, BP, respiratory rate, O2 saturation
    Check the identity of recipient, the details on the unit and compatibility form
    Febrile non-haemolytic transfusion reaction
    If temp rise less than 1.5oC, the observations are stable and the patient is otherwise well give Paracetamol.Restart infusion at slower rate and observe more frequently
    Mild
    fever
    Mild Allergic reaction
    Give Chlorpheniramine 10mg slowly i.v. and restart the transfusion at a slower rate and observe more frequently.
    Reaction involves mild fever or urticarial rash only?
    Urticaria
    No
    Suspected ABO incompatibility?
    Recheck pack and patient ID
    Severe allergic reaction
    Bronchospasm, angioedema, abdominal pain, hypotension. Discontinue transfusion.
    Return intact to blood bank along with all other used/unused units. Give Chlopheniramine 10mg slowly i.v. Commence O2, give salbutamol nebuliser. If severe hypotension, give adrenaline 0.5 ml of 1 in 1000 (i.e. 0.5 mg) i.m. Clotted sample to transfusion laboratory. Saline wash future components.
    Yes
    ABO Incompatibility
    Take down unit and giving set.
    Return intact to blood bank. Commence I.V. saline infusion. Monitor urine output/catheterise. Maintain urine output at >100 mls/hr. Give frusemide if urine output falls/absent. Treat any DIC with appropraite blood components. Inform Hospital Transfusion Department immediately.
    No
    Yes
    Severe Allergic Reaction?
    No
    Continued on next slide
  • 50. 45
    Continued from previous slide
    Haemolytic reaction/bacterial infection of unit
    Take down unit and giving set. Return intact to blood bank with all other used/unused units.
    Take blood cultures, repeat blood group / crossmatch / FBC, co ag screen, Biochemistry, urinanalysis.
    Monitor urine output.
    Commence broad spectrum antibiotics if suspected bacterial infection.
    Commence oxygen and fluid support
    Seek Haematological advice
    Yes
    Other Haemolytic reaction /bacterial contamination?
    No
    Acute dyspnoea/hypotension
    Monitor blood gases
    Perform CXR, measure CVP/Pulmonary capillary pressure
    Raised CVP
    Normal CVP
    TRALI
    Dyspnoea, chest x ray, “whiteout”. Discontinue transfusion. Give 100% Oxygen. Treat as ARDS – Ventilate if hypoxia indicates
    Fluid Overload
    STOP INFUSION
    Give oxygen and Frusemide 40-80 mg i.v.
    From: ‘Handbook of Transfusion
    Medicine 3rd Edition’.
    © Crown Copyright material is reproduced with the permission of the Controller of HMSO and Queen’s printer for Scotland.
  • 51. 46
    Thank You !
  • 52. 47
    Kasus
    Laki-laki, Tuan A, 55 tahun
    MRS:
    persiapan operasi Ca abdomen.
    Riwayat transfusi sebelumnya: (-)
  • 53. 48
    Perawatan Rs
    Hb saat mrs: 10 g/dL
    Gol darahPx: O-Rh(+), Hasil skrining Ab (-)
    Permintaan darah untuk transfusi: 2 unit RBCs
    Hasil crossmatched 2 unit darah tsb: kompatibel
    Selama operasi, setelah menerima 2 unit darah tsb, Px mengalami perdarahan merembes pada tempat operasi(experienced oozing at the surgical site).
    TD menurun :
    120/70 mm Hg  80/40 mm Hg
    (sebelum operasi) (sesudah transfusi)
    Transfusi di stop, hipotensi coba diatasi
    Sampel Px lalu dikirim untuk pemeriksaan
  • 54. 49
    Temuan Laboratorium
    Hasil sampel darah paska transfusi dari bank darah:
    Uji ulang pemeriksaan spesimen darah Px pre transfusi: O-Rh(+)
    Spesimen paska transfusi: aglutinasi campuran ketika dites dengan antisera antiA
    Kemungkinan telah terjadi reaksi imun hemolitik
  • 55. 50
    Clerical Checks
    Clerical checks dilakukan di bank darah dan ruang operasi.
    Hasil temuan:
    unit darah yang diberikan kepada Px ternyata salah.
    Dua Px dengan nama yang sama menjalani operasi pada saat yang bersamaan.
    Unit darah diambil hanya dengan berdasarkan nama Px saja tanpa memeriksa no identifikasi RS Px.
    Unit darah yang diambil ternyata adalah golongan A-Rh(+).
  • 56. 51
    Investigasi laboratorium
    Tes DAT: negatif, menunjukkan telah terjadi destruksi cepat dari SDM inkompatibel yang ditransfusikan.
    Skrining Ab pre transfusi and paska transfusi: negatif.
    Crossmatch pada spesimen pretransfusi deangan donor original kompatibel.
    Hemoglobinemia dan hemoglobinuria (+)
    PXx mengalami koagulopati hemoragik dengan afibrogenemia. Trombosit menurun. FDP meningkat,
    Px mengalami anuria. Proses perdarahan tidak teratasi. Px meninggal
    Hasil Otopsi: Hemoglobin cast pada tubulus renal.
  • 57. 52
    Kesimpulan
    Px mengalami reaksi transfusi hemolitik imun akut disebabkan inkompatibilitas ABO
  • 58. 53
    Thank You !
  • 59. 54
    Prosedur DAT
    Siapkan tabung 2 buah untuk tes dan kontrol
    Isi masing-masing dengan 1 tetes suspensi SDM 3% yang akan dites
    Cuci dengan salin 4 kali, lalu buang semua salin
    Pada tabung tes tambahkan 1-2 tetes AHG, campur
    Pada tabung kontrol tanbahkan 1-2 tetes bovine albumin dalam salin
    Sentrifus kedua tabung pada 500 RCF selama 15-20 detik
    Setelah disentrifus, tabung digoyang/dimiringkan beberapa kali, lalu baca aglutinasi secara makroskopis atau mikroskopis
    Bila tidak terjadi aglutinasi inkubasi tabung tersebut selama 5 menit,ulangi tahap 6-7
    Kontrol: pada semua tabung dengan hasil negatif tambahkan 1 tetes control cell, ulangi tahap 6-7. Hasil akan positif, berarti AHG masih berfungsi. Tabung kontrol seharusnya memberi hasil negatif, jika (+)berarti ada autoaglutinasi
  • 60. 55
    Prosedur IAT
    Masukkan 2-4 tetes serum yang diperiksa ke tabung lalu tambahkan1 tetes % suspensi sel darah merah yang sudah dicuci
    Dicampur dan diinkubasi selama 30 menit pada waterbath dngan suhu 37 C
    Disentrifus dengan kecepatan 500 RCF selama 15-20 detik
    Setelah disentrifus, tabung digoyang/ dimiringkan beberapa kali lalu baca adanya aglutinasi
    Bila tidak terjadi aglutinasi, cuci dengan Salin3-4 kali, buang sisa salin sampai habis
    Tambahkan 1-2 tetes AHG, campur.
    Ulangi prosedur 3-4
    Kontrol: Pada tabung yang negatif tambahkan sel kontrol yang sudah disensitisasi dengan Ig G, campur. Ulangi prosedur 3-4. Jika hasil (+), berarti tes yang negatif tsb adalah benar. Jika hasil (-), maka tes harus diulang.
  • 61. 56
    Deteksi Antibodi
    Memeriksa sampel serumresipien terhadapsel skrining yang telah dipilih untuk mendeteksi Ab yang penting untuk klinis (misalnyamenyebabkan reaksi transfusi hemolitik, umur SDM yang ditransfusikan pendek,HDN)
    Identifikasi Antibodi
    Dilakukan bila deteksi Ab positif. Pemeriksaan ini sering disebut dengan panel tes.
    Cara deteksi Antibodi
    Sama denganreaksi silang
    Ada 3 fase:- suhu kamar, 37 C, dan Antiglobulin
    Keterbatasan: tak dapat mendeteksi semua antibodi yang tak diharapkan
  • 62. 57
    Interpretasi Tes Deteksi Antibodi, Reaksi silang
    Deteksi Ab(-), Reaksi silang(-):
    Tidak berarti bahwa serum resipien/donor tak punya antibodi yang tak diharapkan. Ini berarti bahwa tes hanya negatif terhadap sel/antigen yang dipakai saja.
    Deteksi Ab(+), Reaksi silang(+):
    Alloantibodi
    Auto antibodi
    Deteksi Ab(-), Reaksi silang(+):
    Ab terhadap Ag yang tak terdapat dalam reagen SDM
    ABO inkompatibel (lihat apa ada kesalahan label,dll)
    SDM donor telah dicoated IgG/komplemen, sehingga reaksi silang hasilnya positif.
    Deteksi Ab(+), Reaksi silang(-):
    Ada anti Le bH yang bereaksi dengan SDM O yang Le(a-,b+) pada semua reagen RBC
    SDM A1 atau A1B yang Le(a-,b+) tak bereaksi dengan anti Le bH
  • 63. 58
  • 64. 59
    Investigations of transfusion reaction are necessary for :
    Diagnosis
    Selection of appropriate therapy
    Transfusion management
    Prevention of future transfusion reaction.
    Investigations should include correlations of clinical data with
    laboratory result .
    Important clinical data :
    Diagnosis
    Medical history of pregnancies, transplant, and previous transfusion.
    Current medication
    Clinical signs and symptoms of the reaction.
  • 65. 60
    5. Question related to the transfusion:
    Amount of blood transfused to cause the reaction.
    How fast , how long ?
    The use of blood warmer.
    Any filter used ? Other solutions.
    Any drugs given at the time of transfusion
  • 66. 61
    Laboratory investigation outline of transfusion reaction.
    Immediate procedures
    • Clerical checks.
    • 67. Visual inspection of serum and plasma for free hemoglobin ( pre and post transfusion )
    • 68. Direct anti – globulin test. ( post transfusion EDTA sample )
  • 62
    2. As recquired procedures
    • ABO grouping and RH typing, pre and post transfusion
    • 69. Major compatibility testing , pre and post transfusion
    • 70. Antibody screening test , pre and post transfusion
    • 71. Alloantibody identification
    • 72. Antigen typings
    • 73. Free hemoglobin in first voidedurine post transfusion
    • 74. Unconjugated bilirubin 5 – 7 hours post transfusion.
  • 63
    3. Extended procedures
    • Gram stain and bacterial culture of unit
    • 75. Quantitative serum Hemoglobin.
    • 76. Serum Haptoglobin , pre and post transfusion
    • 77. Peripheral blood film.
    • 78. Coagulation and renal output study
    • 79. Urine hemosiderin
  • 64
    Sumber infeksi (Kontaminasi bakteri)
    Infeksi dari darah simpan sangat jarang.
    Kontaminan kulit tidak terlalu sering ada pada darah segar transfusi (organisme ini (terutama staphylococci tidak bertahan pada suhu simpan 4 º C namun dapat tumbuh cepat pada konsentrat trombosit yang disimpan pada 22 º C.
    Darah donor yang mengalami bacteremia pada saat mendonorkan. Mayoritas adalah Yersinia enterocolitica, yang tumbuh sangat baik pada komponen sel darah merah karena ketergantungannya pada sitrat dan besi.
    Gram negatif, endotoksin – produk/ kontaminan yang ditemukan pada tanah, tempat kotor, feses dapat tumbuh pada darah simpan.
  • 80. 65
    Bacterial Detection Options in Platelet Products
    Visual examination for discoloration, clumping or abnormal morphology
    Microscopy
    Gram stain
    Acridine orange
    Measuring Biochemical changes
    Lowered pH
    Reduced Glucose
    Bacterial culture
    Detection through oxygen consumption
    Detection through CO2 production
  • 81. 66
    Bacterial Detection Options in Platelet Products
    Visual Examination
    Inspect product prior to transfusion for discoloration or abnormal clumping
    Perform “swirl” procedure to detect morphologic changes in platelets
    Normal shaped platelets will align with fluid flow and “shimmer” when swirled
    Contaminated platelets, among others, lose discoid shape and do not “shimmer” when swirled– Not a specific marker for contamination
  • 82. 67
    Swirling
    Alignment with flow
    SENSITIVITY: 75%
    SPECIFICITY: 95%
    No alignment with flow
    Low pH
    Metabolic disturbance
    Leach MF et al. Vox Sang 1998;74(suppl 1):1180.
  • 83. 68
    Bacterial Detection Options in Platelet Products
    Microscopic Methods
    Gram Stain or Acridine Orange preferred methods
    Limitations:
    Must be performed by the Transfusion Service prior to product issue for transfusion
    Lack sensitivity with low bacterial load
  • 84. 69
    Bacterial Detection Options in Platelet Products
    Measuring Biochemical Changes
    Measure changes in glucose consumption against a control. Variances of >2 S.D. may indicate bacterial contamination
    “Dipstick” testing
    Limitations:
    Both this method and staining methods are subjective, require high levels of contamination, and must be performed prior to issue by the Transfusion Service
  • 85. 70
    Detecting Bacteria in Platelets:
    Biochemical Changes
    Glucose, % Day 0
    -2 SD
    Storage Time, d
    after Burstain JM et al. Transfusion 1997;37:255-8.
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    Chemical Tests - Dipsticks
    Must be performed immediately before issue because of its
    relative insensitivity and the need for high bacterial counts
  • 87. 72
    Bacterial Detection Options in Platelet Products
    Blood Culture Methods
    Two methodologies presently approved by FDA for Quality Control use
    bioMeriuex BacT/Alert System
    Pall Biomedical BDS System
  • 88. 73
    Bacterial Detection Options in Platelet Products
    bioMeriuex BacT/Alert System
    Detects bacterial growth in culture bottles by measuring CO2 production
    Automated reader continuously monitors samples
    Sampling interval of >24 hours post phlebotomy
    Culturing interval of >24 hours post sampling (aerobic and anaerobic cultures)
    Cultures incubate for 5-7 days; may identify positive cultures post-transfusion
    FDA-Approved for Q.C. purposes only on Leukoreduced Apheresis Platelets
  • 89. 74
    Bacterial Detection Options in Platelet Products
    Pall Biomedical BDS System
    Detects bacterial contamination by measuring O2 consumption
    Automated reader measures O2 levels in headspace of culture pouch
    Sampling interval of >24-48 hours
    Culture performed for >24-30 hours
    FDA-Approved for Q.C. on leukoreduced platelet concentrates and leukoreduced apheresis platelets
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    Detecting Bacteria in Platelets:
    Detection of Growth by O2 Consumption
    Pall BDS system
    Measure %O2
    in headspace
    24 h
    Limit: 19.5%
    Filter: Stops
    WBCs+Plts
    Passes: Bacteria
    24 h at 35C
    Gas impermeable bag
  • 91. 76
    Bacterial Contamination of PlateletsPrevention and Detection Options
    Donor screening – not feasible except for arm screening. Can’t detect asymptomatic bacteremic donors
    Arm Preparation-Limited effectiveness of arm scrub
    Pathogen reduction – not yet available. May not inactivate spore forming organisms
    Better phlebotomy methods and initial blood diversion
    Bacterial detection offers best confirmatory option
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    Practical Application of Culturing
    in a Transfusion Service Laboratory
    Aubuchon, Dartmouth
    Experience in first 3 years:
    3,927 apheresis units cultured
    (5 mL into aerobic bottle, BacT/Alert automated system)
    23 initial positives (0.5%) in 28 h (10-69)
    14 not confirmed on repeat culture
    5 not able to be recultured
    4 confirmed positives
    RATE = 1/1,000 units (95% CI: to 1/600)
  • 93. 78
    Bacterial Detection Options in Platelet Products
    Limitations of Blood Culture Methods
    Early sampling/testing may not detect small # bacteria per bag. Approved methods require 24-30 hour wait before sampling
    Two FDA-Approved methods require bacteria to grow up after sampling to detectable levels, so culture must be done well before planned transfusion (Blood Center)
    The two time intervals (collection to sampling and sampling to release/transfusion) dominate the logistic considerations
  • 94. 79
    Bacterial Detection Options in Platelet Products
    Limitations of Blood Culture Methods
    Both options require leukoreduced platelets
    BacT/Alert requires continued culture after product release
    Release and recall (BacT/ALERT) or hold to end of culture to release (PALL BDS)
  • 95. 80
    Bacterial Detection Options in Platelet Products
    Limitations of Blood Culture Methods
    Need to balance the risk of platelet shortages versus the risk of platelet contamination
    The two available devices are FDA-Approved for Q.C, and not approved as pre-release tests
    Cost
    Probable negative impact on outdates
    Possible extension of platelet storage to seven days or pooling/storing whole blood derived platelets
  • 96. 81
    Bacterial Contamination in Transfusable Blood Products
    AABB Guidance
    Association Bulletin #03-07 issued May 16, 2003
    Provides guidance for methods to limit contamination and to detect contamination
  • 97. 82
    AABB Association Bulletin #03-07May 16, 2003
    Methods to Limit Contamination:
    Careful phlebotomy – No green soap prep
    Iodine based scrub recommended
    Consider phlebotomy diversion – “sample first” technologies
    Consider increased use of apheresis platelets
  • 98. 83
    AABB Association Bulletin #03-07May 16, 2003
    Methods to Detect Contamination:
    Culture methods optimal. Two approved products cited. Other culture methods can be validated. No label claims allowed
    Due to insensitivity, staining and dipstick methods should be used as close in time to issue as possible
    Validation of all methods is required
    “Swirl” procedure useful for inspection but does not by itself meet AABB Standard 5.1.5.1
  • 99. 84
    Contoh pemeriksaan identifikasi Ab dengan gelcard (serascan Diana)
  • 100. 85
    Frekuensi Reaksi Transfusi akut
    USA
    Acute hemolytic, immune mediated (fatal) - 1 case per 250,000-600,000 population
    Acute hemolytic, immune mediated (nonfatal) - 1 case per 6000-33,000 population
    Acute hemolytic, nonimmune - Infrequent
    Febrile, nonhemolytic - 1 case per 200 population
    Allergic - 1 case per 333 population
    Anaphylactic - 1 case per 20,000-50,000 population
    TRALI - 1 case per 5000 population
    Circulatory (volume) overload - Varies with concurrent illness
    Bacterial contamination/endotoxemia -The incidence of septic reactions may be as high as 1 case per 700 pooled random donor platelet concentrates, 1 case per 4000 single-donor (pheresis) platelet products, and 1 case per 31,000 red cell transfusions.
  • 101. 86
    Investigasi lab RTHA
    Inspeksi visual plasma resipien
    • sampel vena dengan antikoagulan disentrifus plasma : merah muda- merah
    • 102. Warna merah dpt timbul meski baru bbrp ml darah inkompatibel yg ditransfusikan
    Inspeksi visual urine resipien: merah
    ( Dalam bbrp menit stlh transfusi darah grup ABO yang inkompatibel)
  • 103. 87
    Febrile transfusion reaction
    •>1°C rise in temp and >38°C during
    transfusion or within 4 hours
    • Possibilities…
    – Acute haemolytic transfusion reaction
    – Febrile non-haemolytic transfusion reaction
    – Bacterial contamination
    – Fever unrelated to transfusion
  • 104. 88
    Febrile transfusion reaction
    Management
    1. Stop transfusion
    & maintain access with IV saline
    2. Record vital signs
    3. Recheck ID of patient and unit of blood
    4. Advise medical officer
    5. Report reaction to transfusion laboratory
  • 105. 89
    Febrile transfusion reaction
    • Transfusion reaction pack
    • Investigations
    – Return unit with clamped giving set
    – Samples to recheck blood group and cross-match
    – Urine to check for haemoglobinuria
    – Take peripheral blood cultures (not from line)
    – Complete transfusion reaction form
  • 106. 90
  • 107. 91
    Reaksi transfusi kontaminasi bakteri
    Onset cepat, tingkat mortalitas tinggiid onset and high mortality in recipients.
    The presence of bacteria in transfused blood may lead either to febrile reactions in the recipient ( due to pyrogens ) or serious manifestations of septic or endotoxic shock.
    Commonly caused by endotoxin produced by bacteria capable of growing in cold temperatures such as Pseudomonas species, E. coli, Yersinia enterocolitica.
  • 108. 92
    Source of infection (bacterial contamination)
    Infection of stored blood is extremely rare.
    Skin contaminants are not infrequently present in freshly donated blood but these organisms ( predominantly staphylococci ) do not survive storage at 4 º C although they will grow profusely in platelet concentrates stored at 22 º C.
    Healthy donor who are bacteremic at the time of donation. The majority are due to Yersinia enterocolitica, which grows well in red cell components due to its dependence on citrate and Iron.
    Gram negative, endotoxin – producing contaminants found in dirt, soil and faeces may rarely grow in the storage condition of blood.
  • 109. 93
    • According to CDC , most are caused by blood components contaminated by Yersinia enterocolitica.
    • 110. Since 1987, from 20 cases reported to CDC, 12 are caused by this organism.
  • 94
    Clinical manifestation (bacterial contamination)
    Usually appear rapidly during transfusion or within about 30 minutes after transfusion with dryness, flushing of skin.
    Fever, Hypotension, Chills, Muscle pain, vomiting, Abdominal cramps, Bloody diarrhoea, Hemoglobinuria, Shock, Renal failure, DIC.
  • 111. 95
    Management (bacterial contamination)
    Rapid recognition is essential
    Immediately stop the transfusion.
    Therapy of shock, steroids, vassopressors, fluid support, respiratory ventilation and maintenance of renal function.
    Broad spectrum IV antibiotics
    The blood component unit and any associated fluids and transfusion equipment should be sent immediately to blood bank for investigation ie: gram stain and culture.
    Blood C & S from the recepient.
  • 112. 96
    Compatibility testing
    • Agglutination
    - IgM antibodies
    - IgG anti A or anti B
    • Indirect anti human globulin (Coombs) test
    • Crossmatch
  • 113. 97
    Why transfuse?
    • Bleeding
    • Hb less than normal
    •Wound healing
    • Rapid recuperation
    • A tonic
  • 114. 98
    Management of acute transfusion reaction
    1. Stop transfusion
    2. Keep IV open
    3. Verify correct unit and patient
    4. Notify laboratory
    5. Send report of reaction, blood and urine
    sample, blood unit, giving set to laboratory
  • 115. 99
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    Thank You !
    www.themegallery.com
  • 119. 103
    Interpretation
    In an anesthetized patient the only symptoms of an HTR may be oozing, bleeding, or hypotension,, as experienced by this patient. The erroneously trans­fused group A donor unit RBCs reacted with the pa­tient's anti^A^antTbody, resulting in destruction of the transfused cionor cells. The coagulation system was activated, resulting in a hemorrhagic diathesis with resultant acute renal failure and death.
    To prevent HTR, identity of the patient and donor blood component by two persons is essential to en­sure that the appropriate blood component is trans­fused. Blood must never be released if it is identified by a patient's name. There must be not only verifi­cation policies but also monitoring to ensure that established policies are adhered to. At the first sign of a transfusion reaction, the transfusion must be stopped, a line left open for normal saline adminis-
  • 120. 104
    tration, the patient immediately attended to, and an immediate investigation initiated. Most errors in ABO mismatch of blood transfusion are misidenti-fication of either the patient or blood sample. Hu­man errors resulting in serious or fatal transfusion reactions are often litigated, not excused.