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1. 1Reaksi TransfusiTutor Imunologi Putaran IBastiana/Siswanto DarmadiDepartemen Patologi KlinikFK UNAIR/RSUD DR. SOETOMO29 Agustus 2008
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2. 2Hiper / HipotensiTakikardiaSakit kepalademam DiareUrtikaria menggigilHemoglobinuriasyokMual / muntahNyeri dada, perut, otot, tulang, punggungFlushingCemas, gelisah, bingungsesak/batukReaksi transfusimerasa tidak sehatSatu atau lebih dari gejala tsb menunjukkan kemungkinan reaksi transfusi 3. 3Reaksi transfusi312Komponen darahPlatelets (FNHTR, kontaminasi bakteri) Plasma ( RT alergi)Kecerobohan (clerical error)tidak mengikuti prosedurKarakteristik Px Multipara atau multitransfusi (PTP, DHTR) defisiensi IgA (anafilaksis)Faktor Penyebab 4. 4Klasifikasi Reaksi transfusi
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5. 5Reaksi Transfusi Segera dan Tertunda 6. 6Reaksi Transfusi Segera dan Tertunda 7. 7 8. 8 9. 9Topik Reaksi Transfusi1Reaksi Transfusi hemolitik akut2Reaksi Transfusi demam non hemolitikReaksi Transfusi Alergi3Reaksi Transfusi Anafilaksis45TRALI (Transfusion Realated Acute Lung Injury)6Reaksi Transfusi Kontaminasi bakteri 10. 10Hemolitik Akut = 1:250.000-600.000 demam non hemolitik = 1:200RT Alergi = 1:33.000RT Anafilaksis = 1: 20.000-50.000TRALI (TR Acute Lung Injury) = 1:5000RT Kontaminasi bakteri = 1:700Frekuensi Reaksi transfusi
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11. 11Data UTD PMI Surabaya20 orang (dewasa 17, anak-anak 3) 12. 12Reaksi 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
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14. 14Klasifikasi RTHA Non Imunologik:- SDM rusak sebelum transfusiImunologik:Ig M antiA, antiB, antiA,B -IgG,Rh,Kell,dllRTHAHemolis ekstravaskularSelama trasfusi Umumnya anti D demam, menggigil Tidak diikuti dengan gagal ginjalHemolisis tertunda 7 hari kemudianr Demam, ikterus, Insidens 1 / 4000Hemolisis intravaskularSegera Anti A, B Ansietas muntah, diare demam, menggigil, nyeri dada dan pingggang Circulatory collapseHemoglobinemia, haemoglobinuriaAngka kematian 10% 15. 15Investigasi lab RTHA123Inspeksi VisualWarna plasma resipien:merahWarna urine resipien:merahUji ulang:Golongan darah donorGolongan darah resipien paska transfusiTes AHG direk :RT karena ABO inkompatibel hasil tes AHG direk + 16. 16Analisis Laboratorik RTHA 17. 17Prinsip pemeriksaan ABOReaksi 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. 18Hasil pemeriksaan dengan melihat aglutinasi (+) atau (-) 19. 19Penentuan golongan darah Rhesusyang ditentukan hanya antigen D (Rho)menggunakan anti D (anti Rho ) 20. 20Dua macam Reaksi SilangReaksi silang mayor serum penderita + sel darah merah donorReaksi silang minor plasma donor + sel darah merah penderita 21. 21Contoh Reaksi silangContoh : Donor A Resipien BReaksi 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 Bhasil +
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22. 22Penyebab 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. 23Penyebab Reaksi silang mayor +4.Serum penderita yang abnormal myeloma dan macro globulinemiadextran atau plasma expanderantibodi terhadap albumin5.Sel darah merah telah tercoated IgG dan atau komplemen.6.Kontaminasi sampel oleh bakteri, alat gelas yang kotor, fibrin clots, dan lain-lain. 24. 24 Prinsip Tes AHG (Anti Human Globulin)SDM yang telah disensitisasi dengan Ab inkomplet (IgG) menunjukkan aglutinasi dengan penambahan AHG. Sensitisasi bisa terjadi secara in vivo atau in vitro (setelah inkubasi dengan serum yang berisi antibodi). 25. 25 26. 26Reaksi transfusi demam non hemolitik Peningkatan suhu>1C 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 27. 27123Inspeksi VisualWarna plasma resipien : normalWarna urine resipien: normalUji ulang tes ABO/RhD: cocok/tidak ada perbedaan Tes AHG direk :negatifInvestigasi lab RT demam non hemolitik 28. 28Reaksi 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 29. 29Reaksi 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 30. 30123Plasma/urine merah, Ketidaksesuaian go darah ABO pre dan paska , AHG direk(+) Dx RT anafilaksis Pemeriksaan anti IgA sampel serum/plasma resipien pre transfusi (+) Dx tegakPemeriksaan IgA sampel resipien sebelum transfusi mengekslusi DxInvestigasi lab RT Anafilaksis 31. 31Transfusion 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 32. 32Investigasi lab TRALI123Pemeriksaan BNP edema paru TRALI atau edema paru pada RT kelebihan cairanMengekslusi kemungkinan sepsis karena mempunyai gejala yang miripMengekslusi reaksi hemolisis karena mempunyai gejala yang mirip 33. 33Reaksi 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 34. 34Reaksi transfusi kontaminasi bakteri Onset cepat, tingkat mortalitas tinggiAdanya 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. 35. 35Sumber kontaminasi bakteriKontaminasi permukaan kulitTempat flebotomiBakteriemia dari donorKontainer dan alat sekali pakaiLingkungan 36. 36Bacterial species in platelets implicated in clinical sepsisCompilation of data from Clin Micro Rev 1994; 7:290-302; Transfusion 2001;41:1493-99; www.shot.demon.co.uk/tocn = 86 37. 37Perbedaan antara spesies penyebab morbiditas dan mortalitas sepsis pada komponen trombositS. 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%) 38. 38Organisme penyebab sepsis pada produk trombositHampir 30% adalah flora normal kulit Hampir mengekslusi
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56% adalah gram positifSemua aerobik atau anerobik fakultatif(A rare (single case) exception: Clostridium perfringens fatality from a pooled platelet unit Trans Med 1998;8:19-22) 39. 39123Inspeksi visual-perubahan warna, -penggumpalan pada sediaan darah/trombositKultur darah transfusi/Px untuk menegakkan diagnosa Mengekslusi reaksi transfusi hemolitik karena mempunyai gejala yang miripInvestigasi lab Kontaminasi bakteri 40. 40Skema Pemeriksaan Fisik Reaksi Transfusi 41. 41Lanjutan skema(2) 42. 42Lanjutan skema(3) 43. 43Tata 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. 44. 44Management of severe acute reactionSymptoms/Signs of Acute Transfusion ReactionFever, chills, tachycardia, hyper or hypotension, collapse, rigors, flushing, urticaria, bone, muscle, chest and/or abdominal pain, shortness of breath, nausea, generally feeling unwell, respiratory distressStop the transfusion and call a doctorMeasure temperature, pulse, BP, respiratory rate, O2 saturationCheck the identity of recipient, the details on the unit and compatibility formFebrile non-haemolytic transfusion reactionIf 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 frequentlyMildfeverMild Allergic reactionGive 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?UrticariaNoSuspected ABO incompatibility?Recheck pack and patient IDSevere allergic reactionBronchospasm, 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.YesABO IncompatibilityTake 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.NoYesSevere Allergic Reaction?NoContinued on next slide 45. 45Continued from previous slideHaemolytic reaction/bacterial infection of unitTake 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 supportSeek Haematological adviceYesOther Haemolytic reaction /bacterial contamination?NoAcute dyspnoea/hypotensionMonitor blood gasesPerform CXR, measure CVP/Pulmonary capillary pressureRaised CVPNormal CVPTRALIDyspnoea, chest x ray, whiteout. Discontinue transfusion. Give 100% Oxygen. Treat as ARDS Ventilate if hypoxia indicatesFluid OverloadSTOP INFUSIONGive 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 Queens printer for Scotland. 46. 46Thank You ! 47. 47KasusLaki-laki, Tuan A, 55 tahunMRS: persiapan operasi Ca abdomen. Riwayat transfusi sebelumnya: (-) 48. 48Perawatan RsHb saat mrs: 10 g/dL Gol darahPx: O-Rh(+), Hasil skrining Ab (-)Permintaan darah untuk transfusi: 2 unit RBCsHasil crossmatched 2 unit darah tsb: kompatibelSelama 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 49. 49Temuan LaboratoriumHasil 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 antiAKemungkinan telah terjadi reaksi imun hemolitik 50. 50Clerical ChecksClerical checks dilakukan di bank darah dan ruang operasi.Hasil temuan: unit darah
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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(+). 51. 51Investigasi laboratoriumTes 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 meninggalHasil Otopsi: Hemoglobin cast pada tubulus renal. 52. 52KesimpulanPx mengalami reaksi transfusi hemolitik imun akut disebabkan inkompatibilitas ABO 53. 53Thank You ! 54. 54Prosedur DATSiapkan tabung 2 buah untuk tes dan kontrolIsi masing-masing dengan 1 tetes suspensi SDM 3% yang akan ditesCuci dengan salin 4 kali, lalu buang semua salinPada tabung tes tambahkan 1-2 tetes AHG, campurPada tabung kontrol tanbahkan 1-2 tetes bovine albumin dalam salinSentrifus kedua tabung pada 500 RCF selama 15-20 detikSetelah disentrifus, tabung digoyang/dimiringkan beberapa kali, lalu baca aglutinasi secara makroskopis atau mikroskopisBila tidak terjadi aglutinasi inkubasi tabung tersebut selama 5 menit,ulangi tahap 6-7Kontrol: 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 55. 55Prosedur IATMasukkan 2-4 tetes serum yang diperiksa ke tabung lalu tambahkan1 tetes % suspensi sel darah merah yang sudah dicuciDicampur dan diinkubasi selama 30 menit pada waterbath dngan suhu 37 CDisentrifus dengan kecepatan 500 RCF selama 15-20 detik Setelah disentrifus, tabung digoyang/ dimiringkan beberapa kali lalu baca adanya aglutinasiBila tidak terjadi aglutinasi, cuci dengan Salin3-4 kali, buang sisa salin sampai habisTambahkan 1-2 tetes AHG, campur.Ulangi prosedur 3-4Kontrol: 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. 56. 56Deteksi AntibodiMemeriksa 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 AntibodiSama denganreaksi silangAda 3 fase:- suhu kamar, 37 C, dan AntiglobulinKeterbatasan: tak dapat mendeteksi semua antibodi yang tak diharapkan 57. 57Interpretasi Tes Deteksi Antibodi, Reaksi silangDeteksi 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 antibodiDeteksi 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 58. 58 59. 59Investigations of transfusion reaction are necessary for :DiagnosisSelection of appropriate therapyTransfusion managementPrevention of future transfusion reaction.Investigations should include correlations of clinical data with laboratory result .Important clinical data :DiagnosisMedical history of pregnancies, transplant, and previous transfusion.Current medicationClinical signs and symptoms of the reaction. 60. 605. 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 61. 61Laboratory investigation outline of transfusion reaction.Immediate proceduresClerical checks.Visual inspection of serum and plasma for free hemoglobin ( pre and post transfusion )Direct anti globulin test. ( post transfusion EDTA sample ) 62. 622. As recquired proceduresABO grouping and RH typing, pre and post transfusionMajor compatibility
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testing , pre and post transfusionAntibody screening test , pre and post transfusionAlloantibody identificationAntigen typingsFree hemoglobin in first voidedurine post transfusionUnconjugated bilirubin 5 7 hours post transfusion. 63. 633. Extended proceduresGram stain and bacterial culture of unitQuantitative serum Hemoglobin.Serum Haptoglobin , pre and post transfusion Peripheral blood film.Coagulation and renal output studyUrine hemosiderin 64. 64Sumber 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 C namun dapat tumbuh cepat pada konsentrat trombosit yang disimpan pada 22 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. 65. 65Bacterial Detection Options in Platelet ProductsVisual examination for discoloration, clumping or abnormal morphologyMicroscopyGram stain Acridine orange Measuring Biochemical changesLowered pHReduced GlucoseBacterial cultureDetection through oxygen consumptionDetection through CO2 production 66. 66Bacterial Detection Options in Platelet ProductsVisual ExaminationInspect product prior to transfusion for discoloration or abnormal clumpingPerform swirl procedure to detect morphologic changes in plateletsNormal shaped platelets will align with fluid flow and shimmer when swirledContaminated platelets, among others, lose discoid shape and do not shimmer when swirled Not a specific marker for contamination 67. 67SwirlingAlignment with flowSENSITIVITY: 75%SPECIFICITY: 95%No alignment with flowLow pHMetabolic disturbanceLeach MF et al. Vox Sang 1998;74(suppl 1):1180. 68. 68Bacterial Detection Options in Platelet ProductsMicroscopic MethodsGram Stain or Acridine Orange preferred methodsLimitations:Must be performed by the Transfusion Service prior to product issue for transfusionLack sensitivity with low bacterial load 69. 69Bacterial Detection Options in Platelet Products Measuring Biochemical ChangesMeasure changes in glucose consumption against a control. Variances of >2 S.D. may indicate bacterial contaminationDipstick testingLimitations:Both this method and staining methods are subjective, require high levels of contamination, and must be performed prior to issue by the Transfusion Service 70. 70Detecting Bacteria in Platelets:Biochemical ChangesGlucose, % Day 0-2 SDStorage Time, dafter Burstain JM et al. Transfusion 1997;37:255-8. 71. 71Chemical Tests - DipsticksMust be performed immediately before issue because of itsrelative insensitivity and the need for high bacterial counts 72. 72Bacterial Detection Options in Platelet ProductsBlood Culture MethodsTwo methodologies presently approved by FDA for Quality Control usebioMeriuex BacT/Alert SystemPall Biomedical BDS System 73. 73Bacterial Detection Options in Platelet ProductsbioMeriuex BacT/Alert SystemDetects bacterial growth in culture bottles by measuring CO2 productionAutomated reader continuously monitors samplesSampling interval of >24 hours post phlebotomyCulturing interval of >24 hours post sampling (aerobic and anaerobic cultures)Cultures incubate for 5-7 days; may identify positive cultures post-transfusionFDA-Approved for Q.C. purposes only on Leukoreduced Apheresis Platelets 74. 74Bacterial Detection Options in Platelet ProductsPall Biomedical BDS SystemDetects bacterial contamination by measuring O2 consumptionAutomated reader measures O2 levels in headspace of culture pouchSampling interval of >24-48 hoursCulture performed for >24-30 hoursFDA-Approved for Q.C. on leukoreduced platelet concentrates and leukoreduced apheresis platelets 75. 75Detecting Bacteria in Platelets:Detection of Growth by O2 ConsumptionPall BDS systemMeasure %O2in headspace24 hLimit: 19.5%Filter: StopsWBCs+PltsPasses: Bacteria24 h at 35CGas impermeable bag
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76. 76Bacterial Contamination of PlateletsPrevention and Detection OptionsDonor screening not feasible except for arm screening. Cant detect asymptomatic bacteremic donorsArm Preparation-Limited effectiveness of arm scrubPathogen reduction not yet available. May not inactivate spore forming organismsBetter phlebotomy methods and initial blood diversionBacterial detection offers best confirmatory option 77. 77Practical Application of Culturing in a Transfusion Service LaboratoryAubuchon, DartmouthExperience 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 positivesRATE = 1/1,000 units (95% CI: to 1/600) 78. 78Bacterial Detection Options in Platelet ProductsLimitations of Blood Culture MethodsEarly sampling/testing may not detect small # bacteria per bag. Approved methods require 24-30 hour wait before samplingTwo 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 79. 79Bacterial Detection Options in Platelet ProductsLimitations of Blood Culture MethodsBoth options require leukoreduced plateletsBacT/Alert requires continued culture after product releaseRelease and recall (BacT/ALERT) or hold to end of culture to release (PALL BDS) 80. 80Bacterial Detection Options in Platelet ProductsLimitations of Blood Culture MethodsNeed to balance the risk of platelet shortages versus the risk of platelet contaminationThe two available devices are FDA-Approved for Q.C, and not approved as pre-release tests CostProbable negative impact on outdatesPossible extension of platelet storage to seven days or pooling/storing whole blood derived platelets 81. 81Bacterial Contamination in Transfusable Blood ProductsAABB GuidanceAssociation Bulletin #03-07 issued May 16, 2003Provides guidance for methods to limit contamination and to detect contamination 82. 82AABB Association Bulletin #03-07May 16, 2003 Methods to Limit Contamination:Careful phlebotomy No green soap prepIodine based scrub recommendedConsider phlebotomy diversion sample first technologiesConsider increased use of apheresis platelets 83. 83AABB 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 allowedDue to insensitivity, staining and dipstick methods should be used as close in time to issue as possibleValidation of all methods is requiredSwirl procedure useful for inspection but does not by itself meet AABB Standard 5.1.5.1 84. 84Contoh pemeriksaan identifikasi Ab dengan gelcard (serascan Diana) 85. 85Frekuensi Reaksi Transfusi akutUSAAcute 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. 86. 86Investigasi lab RTHAInspeksi visual plasma resipien sampel vena dengan antikoagulan disentrifus plasma : merah muda- merahWarna merah dpt timbul meski baru bbrp ml darah inkompatibel yg ditransfusikanInspeksi visual urine resipien: merah( Dalam bbrp menit stlh transfusi darah grup ABO yang inkompatibel) 87. 87Febrile transfusion reaction>1C rise in temp and >38C during transfusion or within 4 hours Possibilities Acute haemolytic transfusion reaction Febrile non-haemolytic transfusion reaction Bacterial contamination Fever unrelated to transfusion 88. 88Febrile transfusion reactionManagement1. Stop transfusion & maintain access with IV saline2. Record vital signs3. Recheck ID of patient and unit of blood4. Advise medical officer5. Report reaction to transfusion laboratory
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89. 89Febrile 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 90. 90 91. 91Reaksi transfusi kontaminasi bakteriOnset 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. 92. 92Source 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 C although they will grow profusely in platelet concentrates stored at 22 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. 93. 93According to CDC , most are caused by blood components contaminated by Yersinia enterocolitica.Since 1987, from 20 cases reported to CDC, 12 are caused by this organism. 94. 94Clinical 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. 95. 95Management (bacterial contamination)Rapid recognition is essentialImmediately stop the transfusion.Therapy of shock, steroids, vassopressors, fluid support, respiratory ventilation and maintenance of renal function.Broad spectrum IV antibioticsThe 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. 96. 96Compatibility testing Agglutination - IgM antibodies- IgG anti A or anti B Indirect anti human globulin (Coombs) test Crossmatch 97. 97Why transfuse? Bleeding Hb less than normalWound healing Rapid recuperation A tonic 98. 98Management of acute transfusion reaction1. Stop transfusion2. Keep IV open3. Verify correct unit and patient4. Notify laboratory5. Send report of reaction, blood and urine sample, blood unit, giving set to laboratory 99. 99 100. 100 101. 101 102. 102Thank You !www.themegallery.com 103. 103InterpretationIn 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 adminis104. 104tration, 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.
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