TRANSFUSI

RISTIAWAN MUJI LAKSONO

LAB/SMF ANESTESI DAN TERAPI INTENSIF
FKUB-RSSA
BLOOD TRANSFUSION

Acut & delayed complictions

Transmissible infections:
(HIV, hepatitis, viruses, syphilis,
malaria & chagas disease)

LIVE SAVING
BLOOD IS R ARE
BLOOD IS E XPENSIVE
BLOOD IS D ANGEROUS
Physiologic principles of
fluid management

Hemorrhage

ISF IVF ICF

The need for transfusion can often be minimized by:

1. The prevention or early Dx & Tx of anemia

2. The correction of anemia & the
replacement of
depleted iron store before planned surgery
3. The use of simple alternatives to tranfusion
(fluid replacement)
4. Good anaesthetic & surgical management
 Blood and blood components
Whole blood:
• contains it all: colloids (plasma proteins), clotting
factors including platelets, red blood cells for oxygen
carrying capacity
• relatively easy to collect and store
• indications: acute blood loss, concurrent anemia and
hypoproteinemia, clotting defects
• stored blood is not quite as useful as fresh blood:
reduced oxygen carrying capacity (review 2,3-DPG),
platelets are inactive, clotting factors may be
degraded
• A blood filter must be always used to sieve
microthrombi from the blood product.
• In massive transfusion, defined as blood
volume replacement greater than 1.5 times
the recipient volume, abnormal bleeding may
occur.
• This homeostatic defects is characterized by
oozing from the operative wound, mucous
membranes, and intravenous puncture sites.
• Blood Types and crossmatching
– Crossmatching between donor and recipient will
minimize a fatal outcome.
– Always administer slowly in the beginning so as to
allowing adequate time to detect any adverse
reactions, such as rashes, edema, vomiting, fever,
DIC, dyspnea, hypotension, unconsciousness and
tachycardia
Packed red blood cells:
• red cell fraction of separating plasma from
whole blood
• usually has a PCV of 70%
• useful in treating anemia
• reduces risk of fluid overload
• reconstitute with equal volumes of 0.9% saline
Plasma:
• two types: fresh or frozen
• fresh plasma contains colloids, active
platelets, and clotting factors
• useful in treating coagulation defects
• frozen plasma can be stored for periods up to
a year; serve as a source of colloids (plasma
proteins); often collected from stored whole
blood when the red cell fraction is no longer
viable
Complications of blood and plasma
transfusions:
• immune response to red cell antigens
• immune response to white cell antigens
• in vitro (storage) changes
• coagulation defects
• citrate intoxication
• hyperkalemia
• hypothermia
• sepsis/infeksi
 Topics
• Why?
• When?
• Who?
• Risks
• Massive Haemmorrhage
 Why?
• The body at rest uses
approx 250ml O2/L blood
• O2 delivery can fall with a
reduction in any of:
– Cardiac Output
– Hb concentration
– O2 saturation
• Organs most sensitive to
hypoxia are Heart and
Brain
 Why?
• The purpose of a red cell transfusion is to
improve the oxygen carrying capacity of the
blood.
• Oxygen delivery to tissues (O2 Flux)
= Cardiac Output x Oxygen content of
blood
Hb x Sa02
 Transport oksigen
• CaO2 = arterial oxygen content = Oksigen
terikat Hb + Oksigen larut plasma
• CaO2 = (Hb x SaO2 x 1.3) + (pO2 x 0.003)
• CO = Cardiac Output

• DO2 = delivered oxygen = CaO2 x CO

 When?
• Consider the context:
• Cause and severity of anaemia
• Patients ability to compensate for anaemia (
cardiorespiratory disease)
• Rate of ongoing blood loss
• Likliehood of further blood loss
• Balance of risks vs benefits of transfusion
 Transfusion Triggers
• RBC transfusion not indicated when Hb>10g/dl

• Hb < 7g/dl- strong indication for transfusion

• RBC Transfusion less clear when Hb between 7-10 g/dl

• Cardiopulmonary reserve needs to be assessed.
• Symptomatic patients should be transfused. (fatigue,
dizziness, shortness of breath, new or worsening angina)
 Risks
• Think before you transfuse!

• Does your patient really need blood?

• Weigh up the benefits vs risks of transfusion.

• A fit patient with a compound fracture of the
tibia and a post operative Hb of 7.5 g/dl
should be transfused?
 Massive Transfusion
Definitions
• Replacement of one blood volume in a 24
hour period
• Transfusion of >10 units RCC in 24 hours
• Transfusion of 4 or more RCC within 1 hour
when ongoing need is foreseeable
• Replacement of >50% of the total blood
volume within 3 hours
“Bloody Vicious Cycle”
 The Massively Bleeding Patient…
• Restore Circulating
Volume:
• X 2 14G IV cannulae
• Resuscitate with
warmed
crystalloid/colloid
• Warm patient
• Consider invasive
monitoring: arterial line
+ central venous access
 Tata Cara Transfusi (1)
• Infusi NaCl 0.9 %, jarum besar #18-19 G
• Kantong darah dari lemari es jangan diguncang
• Jika lapisan plasma di atas berwarna coklat hitam = tanda
hemolisis, darah jangan diberikan
• Sebelum mulai transfusi, ukur dulu tekanan darah, nadi,
nafas dan suhu pasien
• Darah diteteskan pelan, 100 ml pertama jangan lebih
cepat dari 10 menit
• 15 menit pertama harus ditunggui di samping pasien,
awasi keluhan, tekanan darah, nadi, nafas, suhu, adakah
rasa gatal, sesak nafas, demam, mual, nyeri pinggang
 Tata Cara Transfusi (2)

• Evaluasi dan pengukuran diulang tiap jam sampai 2 jam

setelah transfusi berakhir
• Setiap selesai transfusi satu unit, infus set dibilas dengan
NaCl sebelum transfusi berikutnya
• Pakai macrofilter 170 micron untuk menyaring gumpalan /
microaggregates yang terbentuk selama penyimpanan
• Pada transfusi masif pakai microfilter 20 micron untuk
menyaring mikro-emboli untuk prevensi “Adult
Respiratory Distress Syndrome”
Macro-filter 140-170 micron
 Tata Cara Transfusi (3)
• Jika jantung baik dan tidak ada hipovolemia, batas aman
transfusi adalah 1 ml/kg/jam (1 unit dalam + 3 jam) atau 1000 ml
per 24 jam
• Satu unit jangan lebih lama dari 5 jam agar tidak tumbuh kuman
selama darah berada dalam suhu ruangan
• Tidak perlu obat antihistamin, antipiretika atau diuretika sebelum
transfusi kecuali ada indikasi khusus
• Obat premedikasi mungkin menutupi tanda-tanda-awal reaksi
transfusi yang lebih berbahaya

Jangan transfusi pada malam hari

jika tidak sangat mendesak
 Reaksi Transfusi

• Jika ada gejala atau keluhan ke arah Reaksi Transfusi,

transfusi HARUS SEGERA DIHENTIKAN
• Infus set diganti set baru, berikan NaCl 0.9%
• Ukur tekanan darah, nadi dan suhu
• Hipotensi sistolik < 90 mmHg memerlukan ephedrin i.v
atau dopamin drip dan atau adrenalin 0.0-0.3 mg i.v
• Perhatikan produksi dan warna urine
• Urine yang berkurang atau berhenti atau warnanya
menjadi merah gelap menandakan reaksi hemolitik
 Risiko transfusi
• REAKSI TRANSFUSI
– 1-1.5% jarang fatal (Ellison, 1993)
– 1.5% dari unit darah, 4.1% dari pasien (Rahardjo, 1991)

• TRANSMISI PENYAKIT
– HEPATITIS pasca transfusi 3-10 % (USA)
– HIV di USA 0.02-0.03 %
– HIV Indonesia 500,000 - 2 juta (Linnan,1994)
– Hep B 4 - 17 % (MULYANTO, 1994)
– HEP.C 3,4% / MESIR 14,5 % / ARAB 26,2 %

• PERUBAHAN IMUNOLOGIS
– kambuh kanker pasca bedah > sering & > dini (Blumberg, 88)
– daya tahan infeksi turun, sepsis pasca trauma > sering (Agarwal,93)
Bagaimana agar transfusi seaman mungkin?
• PILIH DONOR:
– Anamnesa / self assessment dengan formulir penuntun,
dengan sanksi penjara
• KERJA UTD:
– Screen maksimal sebelum darah diambil
– Kampanye cari donor lebih luas
– Fasilitas penyimpanan yang baik / andal
• DOKTER BEDAH / ANESTESIOLOGI:
– Cegah berdarah
– Gunakan cairan pengganti transfusi darah
– Kurangi jumlah transfusi
Golongan darah donor & penerima

• A • A

• B • B

• AB • AB

• O • O
AB = penerima universal
Donor O dapat memberi pasien apapun

• A • A

• B • B

• AB • AB

• O • O

O = donor universal
It must be the responsibility of all doctors to ensure
that blood component therapy is given only when
clearly indicated

(McGrath et al 2001)