Transfusion shock: when someone else's blood becomes a poison. Complications associated with transfusion of incompatible blood Hemotransfusion shock emergency care algorithm
A large number of various classifications of post-transfusion complications have been proposed. They are most fully represented in the classification of A. N. Filatov (1973). Despite the fact that it has existed for more than two decades, its main provisions are still acceptable today.
A. N. Filatov identified three groups of complications: mechanical, reactive and infectious.
- MECHANICAL COMPLICATIONS
- acute expansion of the heart,
- air embolism,
- thrombosis and embolism,
- circulatory disorders in the extremity after intra-arterial transfusions.
- ACUTE HEART EXPANSION
The cause of this complication is an overload of the heart with a large amount of blood quickly poured into the venous bed. In the system of hollow veins and the right atrium, blood stagnation occurs, the general and coronary blood flow is disturbed. Violation of blood flow affects metabolic processes, which leads to a decrease in conductivity and contractility of the myocardium up to atony and asystole. Especially dangerous is the rapid transfusion of large volumes of blood to elderly and senile patients, as well as to persons with severe concomitant pathology of the cardiovascular system.
clinical picture. During a blood transfusion or towards the end of it, the patient feels difficulty in breathing, tightness in the chest, pain in the region of the heart. Cyanosis of the lips and skin of the face appears, arterial pressure decreases sharply and central venous pressure rises, tachycardia and arrhythmia are observed, and then cardiac weakness comes to the fore, which, in the absence of emergency assistance, leads to the death of the patient.
Treatment consists in the immediate cessation of blood transfusion, intravenous administration of cardiotonic agents (1 ml of a 0.05% solution of strophanthin or 1 ml of a 0.06% solution of corglycone), vasopressors, giving the patient an elevated position, warming the legs, administering diuretics (40 mg of Lasix), breathing humidified oxygen. According to the indications, a closed heart massage and artificial ventilation of the lungs are performed.
Prevention of acute cardiac dilatation consists in reducing the rate and volume of infusion therapy, control of central venous pressure and diuresis.
- AIR EMBOLISM
some air. Air with the blood flow enters the right parts of the heart, and from it into the pulmonary artery, clogging its main trunk or small branches and creating a mechanical obstruction to blood circulation.
The cause of this complication is most often the incorrect filling of the system with blood, its leaky installation. When transfused into the subclavian vein, air may enter after the end of the transfusion due to the negative pressure in it during inspiration.
The clinical picture is characterized by a sudden deterioration in the patient's condition, agitation, difficulty breathing. Cyanosis of the lips, face, neck develops, blood pressure decreases, the pulse becomes thready, frequent. Massive air embolism leads to the development of clinical death.
Treatment involves the introduction of cardiac funds, you should lower the head and raise the foot end of the bed. An attempt to puncture the pulmonary artery and suction of air from it is justified. With the development of clinical death - resuscitation measures in full.
Prevention consists in the careful collection of the system for hemotransfusion and constant monitoring of the patient during its implementation.
- THROMBOSIS AND EMBOLIS
clinical picture. When a large number of blood clots enter, a clinical picture of thromboembolism of the branches of the pulmonary artery develops: sudden chest pains, a sharp increase or occurrence of shortness of breath, coughing, sometimes hemoptysis, pallor of the skin, cyanosis.
Treatment consists of thrombolytic therapy with fibrinolysis activators (streptodecasis, urokinase), continuous administration of heparin (up to 24,000-40,000 units per day), immediate injection of at least 600 ml of fresh frozen plasma under the control of a coagulogram.
Prevention consists in the use of plastic systems with special filters, in the correct preparation, storage and transfusion of blood.
- IMPAIRMENT OF BLOOD CIRCULATION IN THE LIMB
A complication is rare, since intra-arterial blood injection is currently practically not performed.
When an artery wall is injured, its thrombosis or embolism of peripheral arteries with blood clots occurs. A clinical picture of an acute arterial circulation disorder is developing, requiring appropriate treatment.
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Complications during blood transfusion can be caused by technical errors or arise as a result of the so-called post-transfusion reactions. Complications of the first kind include: a) vascular embolism with blood clots and air; b) the formation of extensive hematomas in the area of puncture of the blood vessel. In relation to the total number of complications, they make up a small percentage and are rare.
Much more often you have to deal with various post-transfusion reactions. Nonspecific reactions may be associated with the properties of the transfused blood itself (exogenous factors) or depend on the individual characteristics of the reactivity of the recipient's body (endogenous factors). Their severity may vary. In mild cases, 15-30 minutes after the transfusion, the wounded begins to complain of chills, his temperature rises slightly, subjective disorders are expressed in a feeling of slight malaise.
With a moderate reaction, the chills are much more pronounced, the temperature rises to 39 °, the wounded complains of a feeling of weakness, headache. A severe reaction is manifested in a tremendous chill, fever up to 39 ° and above, vomiting and a drop in cardiac activity. Sometimes reactions can be manifested by symptoms of an allergic nature, a slight increase in temperature, the appearance of an urticarial skin rash (urticaria) and swelling of the eyelids.
Common causes of post-transfusion reactions are technical errors in blood preparation (insufficient processing of dishes, poor distillation of water, improper preparation of a preservative solution, etc.), as well as the impact on the blood of various external factors leading to labilization, instability, and ease of flocculation of blood proteins.
It should also be known that with the introduction of very large doses of preserved blood, the toxic effect of citrate in the form of the so-called "nitrate shock" may appear. To prevent this complication, after transfusion of massive doses of blood, a solution of calcium chloride is administered intravenously (3-5 ml of a 10% solution after each ampoule of canned blood).
Mild to moderate reactions are usually transient and do not require special treatment. However, when chills appear, the patient must be well warmed (covered with blankets, overlaid with heating pads), and if the reaction intensifies, resort to symptomatic agents (camphor and caffeine, promedol, intravenously - 40% glucose solution in an amount up to 50 ml). In case of allergic phenomena, a 10% solution of calcium chloride is administered intravenously in an amount of 10 ml and a 2% solution of Diphenhydramine subcutaneously 2-3 ml.
The most severe complication is hemotransfusion shock, which developed as a result of transfusion of incompatible, as well as hemolyzed blood. It should be borne in mind the possibility of developing hemotransfusion shock from transfusion of Rh-incompatible blood. Therefore, in the working conditions of field military medical institutions, if the wounded have a history of significant post-transfusion reactions, one should refrain from blood transfusion and instead introduce various plasma-substituting solutions. In hospitals, in such cases, the Rh-affiliation of the recipient's blood is determined or Rh-negative blood is transfused.
A characteristic symptom of hemotransfusion shock is the appearance of a sharp pain in the lower back. In the wounded, blood pressure drops, the pulse becomes small and frequent, shortness of breath occurs, the face becomes pale, and then cyanotic. In severe cases, vomiting may begin, the wounded loses consciousness, involuntary discharge of feces and urine occurs.
After some time, the symptoms of shock subside, blood pressure is restored, breathing improves. Then the condition worsens again - symptoms associated with impaired functions of internal organs (hemoglobinuria, jaundice, oliguria, high temperature persists for a long time) join.
With a persistent violation of the function of the nights and the accumulation of nitrogenous products and urea in the blood, it is possible to remove patients from the state of intoxication by using hemodialysis using the so-called artificial night or by peritoneal dialysis. Of course, these rather complex procedures can only be performed in specially equipped front-line or rear hospitals.
In the treatment of transfusion shock, all therapeutic measures in the acute stage should be aimed at restoring blood pressure and cardiac activity.
Along with the introduction of the above symptomatic agents, it is necessary to bleed 300-400 ml of blood, followed by the introduction of compatible blood or plasma to the wounded. It is also advisable to administer anti-shock solutions intravenously by drip. In view of the fact that with hemotraisfusion shock, the function of the kidneys is sharply impaired as a result of the onset of spasm of their vessels, a bilateral perirenal novocanne blockade according to Vishnevsky with the introduction of a 0.25% solution of novocaine, 100-150 ml on each side, is highly indicated.
With persistent, systematic and timely implementation of the above measures, it is often possible to bring patients out of a threatening state, even in very severe cases.
The most common cause of blood transfusion complications is transfusion of blood that is incompatible with the AB0 system and the Rh factor (approximately 60%). Less common are incompatibility for other antigenic systems and transfusion of poor-quality blood.
The main and most severe complication in this group, and indeed among all blood transfusion complications, is blood transfusion shock.
Transfusion shock
When transfusing blood that is not compatible according to the AB0 system, a complication develops, called "hemotransfusion shock".
Cause The development of complications in most cases becomes a violation of the rules provided for by the instructions for the technique of blood transfusion, the methodology for determining the blood group according to the AB0 system and conducting tests for compatibility. When transfusing blood or erythrocyte mass that is incompatible with the group factors of the AB0 system, massive intravascular hemolysis occurs due to the destruction of the donor's erythrocytes under the influence of the recipient's agglutinins.
In pathogenesis transfusion shock, the main damaging factors are free hemoglobin, biogenic amines, thromboplastin and other products of hemolysis. Under the influence of high concentrations of these biologically active substances, a pronounced spasm of peripheral vessels occurs, which is quickly replaced by their paretic expansion, which leads to impaired microcirculation and oxygen starvation of tissues. An increase in the permeability of the vascular wall and blood viscosity worsens the rheological properties of the blood, which further disrupts microcirculation. The consequence of prolonged hypoxia and the accumulation of acid metabolites are functional and morphological changes in various organs and systems, that is, a complete clinical picture of shock unfolds.
A distinctive feature of transfusion shock is the occurrence of DIC with significant changes in the system of hemostasis and microcirculation, gross violations of central hemodynamics. It is DIC that plays a leading role in the pathogenesis of damage to the lungs, liver, endocrine glands and other internal organs. The starting point in the development of shock is the massive influx of thromboplastin from destroyed erythrocytes into the bloodstream.
Characteristic changes occur in the kidneys: hematin hydrochloride (a metabolite of free hemoglobin) and the remains of destroyed erythrocytes accumulate in the renal tubules, which, along with spasm of the renal vessels, leads to a decrease in renal blood flow and glomerular filtration. The described changes are the cause of the development of acute renal failure.
clinical picture.
During the complication of transfusion of blood that is not compatible according to the AB0 system, there are three periods:
- hemotransfusion shock;
- acute renal failure;
- convalescence.
Hemotransfusion shock occurs directly during transfusion or after it, lasts from several minutes to several hours.
Clinical manifestations are first characterized by general anxiety, short-term agitation, chills, pain in the chest, abdomen, lower back, shortness of breath, shortness of breath, cyanosis. Pain in the lumbar region is considered the most characteristic symptom of this complication. In the future, circulatory disturbances characteristic of a state of shock gradually increase (tachycardia, a decrease in blood pressure, sometimes a violation of the rhythm of cardiac activity with symptoms of acute cardiovascular insufficiency). Quite often, a change in complexion (redness, followed by pallor), nausea, vomiting, fever, marbling of the skin, convulsions, involuntary urination and defecation are noted.
Along with the symptoms of shock, acute intravascular hemolysis becomes one of the early and permanent signs of hemotransfusion shock. The main indicators of increased breakdown of red blood cells: hemoglobinemia, hemoglobinuria, hyperbilirubinemia, jaundice, liver enlargement. The appearance of brown urine is characteristic (in the general analysis - leached erythrocytes, protein).
A violation of hemocoagulation develops, clinically manifested by increased bleeding. Hemorrhagic diathesis occurs as a result of DIC, the severity of which depends on the degree and duration of the hemolytic process.
When transfusing incompatible blood during surgery under anesthesia, as well as against the background of hormonal or radiation therapy, reactive manifestations can be erased, symptoms of shock are most often absent or expressed slightly.
The severity of the clinical course of shock is largely due to the volume of incompatible erythrocytes transfused, the nature of the underlying disease and the general condition of the patient before hemotransfusion.
Depending on the magnitude of blood pressure, there are three degrees of hemotransfusion shock:
- I degree - systolic blood pressure above 90 mm Hg;
- II degree - systolic blood pressure 71-90 mm Hg;
- III degree - systolic blood pressure below 70 mm Hg.
The severity of the clinical course of shock and its duration determine the outcome of the pathological process. In most cases, therapeutic measures can eliminate circulatory disorders and bring the patient out of shock. However, some time after the transfusion, the body temperature may rise, a gradually increasing yellowness of the sclera and skin appears, and the headache intensifies. In the future, impaired renal function comes to the fore: acute renal failure develops.
Acute renal failure
Acute renal failure occurs in the form of three successive phases: anuria (oliguria), polyuria and restoration of kidney function.
Against the background of stable hemodynamic parameters, daily diuresis sharply decreases, hyperhydration of the body is noted, and the content of creatinine, urea and plasma potassium increases. Subsequently, diuresis is restored and increased (sometimes up to 5-6 liters
per day), while high creatininemia may persist, as well as hyperkalemia (polyuric phase of renal failure).
With a favorable course of complications, timely and proper treatment, kidney function is gradually restored, the patient's condition improves.
convalescence period
The period of convalescence is characterized by the restoration of the functions of all internal organs, the homeostasis system and water and electrolyte balance.
PRINCIPLES OF TREATMENT OF HEMOTRANSFUSION SHOCK.
- immediate cessation of blood transfusion and erythrocyte mass;
- the introduction of cardiovascular, antispasmodic, antihistamines;
- IVL in the absence of spontaneous breathing, severe hypoventilation, pathological rhythms
- massive plasmapheresis (about 2-2.5 liters) to remove free hemoglobin, products
fibrinogen degradation. The removed volume is replaced with the same amount.
fresh frozen plasma or fresh frozen plasma in combination with colloidal
blood substitutes;
- intravenous drip of heparin;
- maintaining diuresis of at least 75-100 ml / h;
- correction of the acid-base state with 4% sodium bicarbonate solution;
- elimination of severe anemia (hemoglobin level of at least 60 g / l) by transfusion
individually selected washed erythrocytes;
- conservative treatment of acute hepatorenal insufficiency: restriction of fluid intake,
salt-free diet with protein restriction, vitamin therapy, antibiotic therapy regulation of water
electrolyte balance and acid-base status;
- in cases of ineffectiveness of conservative treatment of renal failure and uremia in patients
requires hemodialysis in specialized departments.
Post-transfusion complications of the hemolytic type can occur in people who are immunized as a result of pregnancy or repeated blood and red blood cell transfusions.
For their prevention, it is necessary to take into account the obstetric and transfusion history of recipients. If patients have a history of post-transfusion reactions or hypersensitivity to the administration of even ABO- and Rh-compatible erythrocytes, then an indirect Coombs test is necessary to select a compatible erythrocyte-containing transfusion medium.
Transfusion complications of non-hemolytic type.
Post-transfusion non-hemolytic reactions are due to the interaction between highly immunogenic antigens of leukocytes, platelets and plasma proteins and antibodies directed to them. As a rule, these reactions occur in cases of alloimmunization of the recipient to HLA antigens of leukocytes and platelets of patients who have previously undergone transfusions of blood, its components, or in repeated pregnancies.
Immediately after the start of the transfusion, facial flushing occurs, and after 40-50 minutes there is a high temperature rise, chills, headache, pruritus, urticaria, back pain, shortness of breath, restless behavior of the patient. Sometimes develops bronchospasm, acute respiratory failure, angioedema.
The frequency of antigenic reactions is especially high in hematological patients who received repeated blood transfusions.
Transfusion of blood, red blood cells, platelet concentrates containing leukocytes also contributes to the occurrence of immunosuppression and can create favorable conditions for the transmission of infections, such as cytomegalovirus.
To prevent transfusion complications of a non-hemolytic type, especially in people with a history of blood transfusions, it is recommended to use blood components after washing and filtering them to reduce the content of leukocytes (to less than 0.5x10.6) and platelets, as well as individual selection of a donor, taking into account established conditions. the patient's antibodies to group antigens of leukocytes, platelets and plasma proteins. IV. Allergic reactions.
They are caused by sensitization of the body to various immunoglobulins. The formation of antibodies to immunoglobulins occurs after transfusion of blood, plasma and cryoprecipitate. Sometimes these antibodies exist in the blood of people who have not tolerated blood transfusions and have not had pregnancies. To eliminate allergic reactions (hyperemia, chills, suffocation, nausea, vomiting, urticaria), desensitizing agents (diphenhydramine, suprastin, calcium chloride, corticosteroids), cardiovascular and narcotic drugs are used according to indications.
Prevention of allergic reactions includes the use of washed thawed erythrocytes, blood, platelet and leukocyte concentrates, selected taking into account the nature of the antibodies in the recipient.
Anaphylactic reactions.
May occur during transfusion of blood, plasma, serum. The blood groups of plasma proteins are linked by allogeneic variants of immunoglobulins, which can cause sensitization in repeated plasma transfusions and induce unwanted immune responses.
The clinical picture of an anaphylactic reaction includes acute vasomotor disorders: anxiety, reddening of the skin of the face, cyanosis, asthma attacks, shortness of breath, increased heart rate, decreased blood pressure, erythematous rash.
These symptoms can develop both immediately after the transfusion, and after 2-6 days. Late reactions are manifested by fever, urticaria, joint pain.
Patients become restless, complain of difficulty in breathing. On examination, attention is drawn to hyperemia of the skin, cyanosis of the mucous membranes, acrocyanosis, cold sweat, wheezing, thready and frequent pulse, pulmonary edema. Patients in a state of anaphylactic shock need urgent help.
Prevention of anaphylactic reactions consists in a careful history taking in order to identify sensitization during vaccination and serotherapy, as well as after the administration of protein preparations.
Transfusion complications associated with the conservation and storage of blood.
Post-transfusion reactions and complications can be caused by preservative solutions, metabolic products of cells resulting from blood storage, and the temperature of the transfusion medium.
Hypocalcemia occurs with the rapid introduction of large doses of whole blood and plasma, prepared on citrate-containing preservative solutions, to the patient. When this complication occurs, patients note discomfort behind the sternum that makes breathing difficult, a metallic taste in the mouth, and convulsive twitching of the muscles of the tongue and lips can be noticed.
Prevention of hypocalcemia consists in identifying patients with initial hypocalcemia or persons in whom its occurrence may be associated with a medical procedure or surgical intervention. These are patients with hypoparathyroidism, D-avitaminosis, chronic renal failure, cirrhosis of the liver and active hepatitis, congenital hypocalcemia, pancreatitis, infectious-toxic shock, thrombophilic conditions, post-resuscitation disease, who received corticosteroid hormones and cytostatics for a long time.
Hyperkalemia can occur with rapid transfusion (about 120 ml / min) of long-term stored canned blood or erythrocyte mass and is accompanied by bradycardia, arrhythmia, myocardial atony of the flesh to asystole.
Prevention of complications consists in the use of freshly prepared canned blood or erythrocyte mass.
Blood transfusion is often the only method of saving patients with massive blood loss, hematopoietic diseases, poisoning, purulent-inflammatory pathologies. Transfusion shock, which occurs when blood is incompatible, is an extremely serious condition that can be fatal. With a competent approach to the expediency of the procedure, taking into account contraindications for the patient, careful prevention, proper treatment and active monitoring of the patient, such a complication does not arise.
What is transfusion shock
Hemotransfusion shock refers to pathological conditions of extremely severe - life-threatening - disorders of all body functions that occur during blood transfusion.
The term blood transfusion comes from the Greek "haem" - blood and the Latin word "transfusion", which means transfusion.
Blood transfusion shock is a dangerous and difficult-to-treat complication that manifests itself in the form of a rapidly developing powerful inflammatory-anaphylactic reaction affecting all organs and systems.
Transfusion shock is a life-threatening complication of blood transfusion.According to medical statistics, this condition occurs in almost 2% of all cases of blood transfusion.
Transfusion shock occurs either during the transfusion process or immediately after the procedure and lasts from 10–15 minutes to several hours. So, the first signs of infusion of blood of the wrong group occur when only 20-40 ml enters the patient's body. It happens that an extended reaction is recorded after 2-4 days.
In rare cases, the pathology does not give clear clinical signs, especially with general anesthesia, but more often it is accompanied by severe manifestations that, without intensive and emergency therapy, lead to the death of the patient.
The danger of hemotransfusion shock is a serious disruption of the heart, brain, failure of the liver and kidneys up to their failure, hemorrhagic syndrome (increased bleeding) with hemorrhages and bleeding, aggravating the condition of patients, intravascular thrombosis, threatening a drop in blood pressure.
Causes
Experts consider the most common cause of acute blood transfusion complications to be the use of blood that is incompatible with the Rh factor (a special protein present or absent on the surface of red blood cells - erythrocytes), which does not correspond to the AB0 group (60% of all cases). Less commonly, a complication occurs when blood is incompatible for individual antigens.
Blood type compatibility - table
| Blood type | Can donate blood to groups | Can accept blood groups |
| I | I, II, III, IV | I |
| II | II, IV | I, II |
| III | III, IV | I, III |
| IV | IV | I, II, III, IV |
The blood transfusion procedure is medical, so the leading causative factors are:
- violation of the technique of blood transfusion;
- inconsistency with the methodology and errors in determining the blood group and Rh factor;
- incorrect execution of samples when checking for compatibility.
Risk factors that exacerbate the condition include:
- the use of bacteria-infected or poor-quality blood due to a violation of the temperature regime and shelf life;
- a large amount of incompatible blood transfused to the patient;
- the type and severity of the primary disease that required blood transfusion;
- condition and age of the patient;
- allergic predisposition.
Clinical aspects of transfusion shock - video
Symptoms and signs
The clinical picture in shock is accompanied by characteristic manifestations, but experts always take into account that there are also erased symptoms. Moreover, the brief improvement that occurs in many patients is suddenly replaced by a state with obvious and acute manifestations of severe renal and hepatic damage, which in 99% of cases is the main cause of death.
Therefore, both during and after blood transfusion, the patient should be under continuous observation.
Symptoms of transfusion shock - table
| By time of manifestation | Symptoms |
| Initial |
Lower back pain is a defining sign of the onset of shock during and after blood transfusion. It serves as a signal of catastrophic damage in the tissues of the kidneys. |
| As the condition progresses |
|
| Late | In the absence of medical assistance:
|
Features of the manifestations of the disease during general anesthesia
When incompatible blood is transfused into a patient who is under anesthesia during surgery, signs of shock are mild or absent.
The patient does not feel anything, does not complain, therefore, early diagnosis of the development of the pathology falls entirely on the doctors performing the operation.
Manifestations of jaundice during blood transfusion indicate the development of pathological processes in the liver
An abnormal blood transfusion reaction is indicated by:
- an increase or, conversely, a drop in blood pressure below normal levels;
- increase in heart rate;
- a sharp jump in temperature;
- blanching, cyanosis (blue) of the skin and mucous membranes;
- a noticeable increase in tissue bleeding in the area of the surgical wound;
- discharge of brown urine with inclusions resembling meat flakes in structure.
During surgical blood transfusion, a catheter must be inserted into the bladder: in this case, you can visually track the color and type of urine excreted.
The degree of shock reaction is determined by the doctor according to blood pressure.
Degrees of hemotransfusion shock - table
Diagnostics
Diagnosis is carried out on the basis of an analysis of the subjective sensations of the patient, special attention is paid to back pain - a specific symptom. Of the objective signs, a sharp drop in pressure, reddening of the urine, a decrease in diuresis, a rise in temperature and an increase in heart rate are of great importance.
The analysis is difficult, since in some cases the only sign of a complication is an increase in the temperature of the patient, so the change in this indicator is observed within 2 hours after the transfusion.
Since treatment for shock must be immediate and test results take time, experienced professionals resort to an old method of determining transfusion incompatibility, widely used in military hospitals under combat conditions - the Baxter test.
Baxter's test: after injecting about 70–75 ml of donor blood to the patient, 10 minutes later, a 10 ml sample is taken from another vein into a test tube. Then centrifugation is carried out to separate the liquid part - plasma, which normally has no color. Pink color indicates a high probability of developing transfusion shock as a result of incompatibility.
Laboratory tests reveal:
- Signs of hemolysis (destruction of red blood cells), which include:
- the appearance of free hemoglobin in the serum (hemoglobinemia reaches 2 grams per liter) already in the first hours;
- detection of free hemoglobin in the urine (hemoglobinuria) within 6-12 hours after the procedure;
- high content of indirect bilirubin (hyperbilirubinemia), which lasts up to 5 days, along with the appearance of urobilin in the urine and an increase in the content of stercobilin in the feces.
- A positive reaction with a direct antiglobulin test (Coombs test), which means the presence of antibodies to the Rh factor and specific globulin antibodies that are fixed on red blood cells.
- Detection of agglutination (gluing) of red blood cells when examining blood under a microscope (a sign of the presence of an antigen or antibody).
- Decrease in hematocrit (the volume of red blood cells in the blood).
- Decreased or absent serum haptoglobin (a protein that transports hemoglobin).
- Oliguria (reduced urine output) or anuria (urinary retention), indicating kidney dysfunction and failure.
Difficulties in differential diagnosis are associated with the frequent absence or blurring of clinical symptoms of reaction to blood transfusion. When studies that determine the development of acute hemolysis are not enough, additional serological tests are connected.
Hemolysis - the destruction of red blood cells and the release of free hemoglobin - the main laboratory indicator of the incompatibility of the blood transfused to the patient
Treatment
Treatment for transfusion shock is carried out in the intensive care unit and includes a set of measures.
Algorithm for emergency care
Emergency medical actions for blood transfusion complications are aimed at preventing coma, hemorrhagic syndrome and kidney failure.
Emergency care for shock during blood transfusion is aimed at stabilizing cardiac activity and vascular tone
When the first signs of shock appear:
- The transfusion procedure is urgently stopped and, without removing the needle from the vein, the dropper is blocked with a clamp. Further, massive infusion infusions will be carried out through the left needle.
- Change the disposable transfusion system to a sterile one.
- Enter subcutaneously (or intravenously) Adrenaline. If the blood pressure does not stabilize after 10–15 minutes, the procedure is repeated.
- Begin the introduction of Heparin (intravenously, intramuscularly, subcutaneously) to prevent the development of DIC, which is characterized by massive thrombus formation and bleeding.
- Conduct infusion therapy to stabilize blood pressure to a minimum normal rate of 90 mm Hg. Art. (systolic).
- A solution of calcium chloride is administered intravenously (reduces the permeability of the vascular wall and relieves an allergic reaction).
- A pararenal (perinephric) blockade is carried out - the introduction of Novocain solution into the perirenal tissue according to A.V. Vishnevsky to relieve vasospasm, edema, maintain blood circulation in tissues and relieve pain.
- Infused into a vein:
- means for maintaining the work of the heart - Cordiamin, Korglikon with a glucose solution;
- antishock drugs (Kontrykal, Trasilol);
- Morphine, Atropine.
With the development of hemorrhagic syndrome:
- they begin to transfuse the patient with freshly prepared blood (single group), plasma, platelet and erythrocyte mass, cryoprecipitate, which have an effective anti-shock effect that prevents kidney damage;
- epsilon-aminocaproic acid is administered intravenously as a hemostatic agent for bleeding associated with an increase in fibrinolysis (thrombus dissolution processes).
At the same time, instrumental measurements of blood pressure are carried out, bladder catheterization is performed to monitor kidney function and collect urine for hemolysis.
Medical treatment
If blood pressure can be stabilized, active drug therapy is carried out.
Use:
- diuretics intravenously (then intramuscularly for 2-3 days) to remove free hemoglobin, reduce the risk of developing acute kidney or liver failure or reduce its severity: Lasix, Mannitol. At the same time, Furosemide (Lasix) is combined with Eufillin according to the scheme.
Important! If there is no therapeutic effect during the infusion of Mannitol, its administration is stopped due to the threat of developing pulmonary edema, brain and simultaneous tissue dehydration.
- antihistamine (antiallergic) agents to suppress the rejection reaction of foreign blood components: Diphenhydramine, Suprastin, Diprazine;
- corticosteroids to stabilize the walls of blood vessels, relieve inflammatory edema, prevent acute pulmonary insufficiency: Prednisolone, Dexamethasone, Hydrocortisone with a gradual decrease in dose;
- as a means of improving microcirculation, preventing oxygen starvation of cells that have a hemostatic (hemostatic) effect:
Troxevasin, Cyto-Mac, ascorbic acid, Etamzilat; - antiplatelet agents that prevent the formation of blood clots: Pentoxifylline, Xanthinol nicotinate, Complamin;
- to relieve spasms of the bronchi and blood vessels: No-shpa, Euphyllin, Baralgin (permissible only with stable blood pressure indicators);
- analgesic and narcotic drugs for severe pain: Ketonal, Promedol, Omnopon.
- with bacterial contamination of the blood - broad-spectrum antimicrobials.
Drugs for the treatment of transfusion shock - photo gallery
Suprastin refers to antihistamines 
Prednisolone - a hormonal drug 
Etamzilat is used for increased bleeding 
Eufillin expands the lumen of blood vessels 
Ketonal is an effective pain reliever
Important! Do not prescribe antibiotics with nephrotoxic side effects, including sulfonamides, cephalosporins, tetracyclines, streptomycin.
Infusion therapy
The treatment regimen, the choice of medications and dosages are determined by the amount of diuresis (the volume of urine collected per unit of time).
Infusion therapy in the development of intravascular hemolysis - table
| Diuresis in ml per hour | |
| Over 30 | Less than 30 or anuria (lack of urination) |
| in 4–6 hours, at least 5–6 liters of solutions are administered | the amount of fluid administered is reduced to a volume calculated by the formula 600 ml + the volume of urine excreted |
|
|
| Stimulation of diuresis with infusion solutions begins only after the introduction of drugs for alkalinization of urine, in order to avoid damage to the renal tubules. | |
| Mannitol, Lasix to maintain the rate of diuresis 100 ml/hour or more | Lasix. Mannitol is canceled because when it is used against the background of anuria, hyperhydration occurs, which can lead to pulmonary and cerebral edema. |
| Diuresis is forced until the urine becomes clear and free hemoglobin in the blood and urine is eliminated. | If urine output does not increase within 20-40 minutes from the onset of hemolysis, renal blood flow may begin to be disturbed with the development of renal ischemia and nephronecrosis (death of organ cells). To remove toxins from the blood, free hemoglobin, plasmapheresis is performed, the question is raised about the need for hemodialysis, which can be performed only after the signs of hemolysis have been eliminated. |
| If a violation of the level of electrolytes is detected, potassium and sodium solutions are added. | |
| Treatment of DIC or acute coagulopathy (a dangerous condition of a sharp violation of blood clotting leading to the development of massive bleeding), if necessary, a blood transfusion is performed in the amount of blood loss. | |
Blood purification
If possible, and especially with the development of anuria, indicating acute destructive processes in the kidneys, blood purification is carried out outside the patient's body - plasmapheresis.
The procedure involves taking a certain amount of blood, removing the liquid part from it - plasma containing free hemoglobin, toxins, and decay products. Such purification of blood occurs when its liquid part passes through special filters and is then infused into another vein.
Plasmapheresis gives a quick therapeutic effect due to the active removal of aggressive antibodies, hemolysis products, and toxins. It is performed using the device with the complete elimination of the possibility of infection of the patient, lasts about 1-1.5 hours.
Stabilization of organs
To prevent the destruction of the tissue of the kidneys, liver, brain during hemotransfusion shock, measures are needed to maintain their functioning.
The rapid progression of respiratory failure, hypoxia (decrease in oxygen in the blood) and hypercapnia (increase in the amount of carbon dioxide) requires an emergency transfer of the patient to artificial respiration.
When symptoms of severe kidney failure (anuria, brown urine, back pain) appear, the patient is transferred to hemodialysis - a method based on extrarenal blood purification from toxins, allergens, hemolysis products using the "artificial kidney" apparatus. It is prescribed if renal failure is not amenable to drug treatment and threatens the death of the patient.
Prevention
Prevention of transfusion shock consists in following the principle: the medical approach to the procedure of blood transfusion should be as responsible as in organ transplantation, including limiting the indications for transfusion, competent conduct of tests and preliminary tests in accordance with the instructions.
Main indications for blood transfusion:
- Absolute indications for blood transfusion:
- acute blood loss (more than 21% of the volume of circulating blood);
- traumatic shock 2-3 tbsp;
- Relative indications for blood transfusion:
- anemia (hemoglobin level in the blood is less than 80 g/l);
- inflammatory diseases with severe intoxication;
- ongoing bleeding;
- violation of the blood coagulation system;
- decrease in the immune status of the body;
- long chronic inflammatory process (sepsis);
- some poisoning (snake venom, etc.).
To prevent the development of transfusion complications, it is necessary:
- eliminate errors in determining the patient's blood group and conducting tests for compatibility;
- conduct a control re-determination of the patient's blood group immediately before the hemotransfusion procedure;
- exclude the possibility of developing a Rh conflict, for which it is necessary to examine the patient's Rh affiliation and antibody titer, perform compatibility tests;
- eliminate the possibility of blood incompatibility for rare serological factors using Coombs' tests;
- use only disposable systems for blood transfusion;
- visually assess the type and volume of urine excreted by the patient during and immediately after transfusion (volume, color);
- monitor and analyze the symptoms of hemotransfusion shock, hemolysis;
- carefully monitor the patient for 3 hours after blood transfusion (measurement of temperature, pressure, pulse rate every hour).
The prognosis for transfusion shock depends on the timeliness of emergency care and further therapy. If active full-fledged treatment of pathology with manifestations of hemolysis, acute renal and respiratory failure, hemorrhagic syndrome is carried out in the first 6 hours after the onset of the disease, 75 out of 100 patients fully recover. In 25-30% of patients with severe complications, renal-hepatic dysfunction, cardiac, cerebral, and pulmonary vessels develop.
- a concept that combines a set of severe pathological reactions that develop as a result of transfusion of blood or its components and are accompanied by a violation of the function of vital organs. Post-transfusion complications may include air embolism and thromboembolism; hemotransfusion, citrate, bacterial shock; circulatory overload, infection with blood-borne infections, etc. They are recognized on the basis of symptoms that arose during blood transfusion or shortly after its completion. The development of post-transfusion complications requires the immediate cessation of blood transfusion and the provision of emergency care.
General information
Post-transfusion complications are severe, often threatening to the life of the patient, caused by blood transfusion therapy. About 10 million blood transfusions are performed annually in Russia, and the complication rate is 1 case per 190 blood transfusions. To a greater extent, post-transfusion complications are typical for urgent medicine (surgery, resuscitation, traumatology, obstetrics and gynecology), occur in situations requiring emergency blood transfusion, and in conditions of time pressure.
In hematology, it is customary to separate post-transfusion reactions and complications. Various kinds of reactive manifestations due to blood transfusions occur in 1-3% of patients. Post-transfusion reactions, as a rule, do not cause serious and long-term organ dysfunction, while complications can lead to irreversible changes in vital organs and death of patients.
Causes of post-transfusion complications
Blood transfusion is a serious procedure, which is the transplantation of living donor tissue. Therefore, it should be performed only after a balanced consideration of indications and contraindications, in conditions of strict observance of the requirements of technology and methods of blood transfusion. Such a serious approach will avoid the development of post-transfusion complications.
Absolute vital indications for blood transfusion are acute blood loss, hypovolemic shock, ongoing bleeding, severe posthemorrhagic anemia, DIC, etc. The main contraindications include decompensated heart failure, grade 3 hypertension, infective endocarditis, PE, pulmonary edema, stroke, liver failure, acute glomerulonephritis, systemic amyloidosis, allergic diseases, etc. However, if there are serious reasons, blood transfusions can be carried out, despite contraindications, under the guise of preventive measures. However, in this case, the risk of post-transfusion complications increases significantly.
Most often, complications develop with repeated and significant transfusion of the transfusion medium. The immediate causes of post-transfusion complications in most cases are iatrogenic in nature and may be associated with transfusion of blood that is incompatible with the ABO system and the Rh antigen; using blood of inadequate quality (hemolyzed, overheated, infected); violation of the terms and regime of storage, transportation of blood; transfusion of excessive doses of blood, technical errors during transfusion; underestimation of contraindications.
Classification of post-transfusion complications
The most complete and exhaustive classification of post-transfusion complications was proposed by A.N. Filatov, who divided them into three groups:
I. Post-transfusion complications due to errors in blood transfusion:
- circulatory overload (acute expansion of the heart)
- embolic syndrome (thrombosis, thromboembolism, air embolism)
- peripheral circulatory disorders due to intra-arterial blood transfusions
II. Reactive post-transfusion complications:
- bacterial shock
- pyrogenic reactions
III. Infection with bloodborne infections (serum hepatitis, herpes, syphilis, malaria, HIV infection, etc.).
Post-transfusion reactions in modern taxonomy, depending on the severity, are divided into mild, moderate and severe. Taking into account the etiological factor and clinical manifestations, they can be pyrogenic, allergic, anaphylactic.
Post-transfusion reactions
They can develop already in the first 20-30 minutes after the start of a blood transfusion or shortly after its completion and last for several hours. Pyrogenic reactions are characterized by sudden chills and fever up to 39-40°C. An increase in body temperature is accompanied by muscle pain, cephalgia, chest tightness, cyanosis of the lips, and pain in the lumbar region. Usually, all these manifestations subside after warming the patient, taking antipyretic, hyposensitizing drugs, or administering a lytic mixture.
At the first signs of thromboembolic post-transfusion complications, blood infusion should be immediately stopped, oxygen inhalations should be started, thrombolytic therapy (administration of heparin, fibrinolysin, streptokinase), if necessary, resuscitation. With the ineffectiveness of drug thrombolysis, thromboembolectomy from the pulmonary artery is indicated.
Citrate and potassium intoxication
Citrate intoxication is caused both by the direct toxic effect of the preservative - sodium citrate (sodium citrate), and by a change in the ratio of potassium and calcium ions in the blood. Sodium citrate binds calcium ions, causing hypocalcemia. Usually occurs at a high rate of administration of canned blood. The manifestations of this post-transfusion complication are arterial hypotension, increased CVP, convulsive muscle twitching, ECG changes (prolongation of the QT interval). With a high level of hypocalcemia, the development of clonic convulsions, bradycardia, asystole, and apnea is possible. To weaken or eliminate citrate intoxication, an infusion of 10% solution of calcium gluconate allows.
Potassium intoxication can occur with the rapid introduction of red blood cells or preserved blood stored for more than 14 days. In these transfusion media, potassium levels increase significantly. Typical signs of hyperkalemia are lethargy, drowsiness, bradycardia, arrhythmia. In severe cases, ventricular fibrillation and cardiac arrest may develop. Treatment of potassium intoxication involves intravenous administration of calcium gluconate or calcium chloride solution, the abolition of all potassium-containing and potassium-sparing drugs, intravenous infusions of saline, glucose with insulin.
Transfusion shock
The cause of this post-transfusion complication is most often the infusion of incompatible blood for AB0 or Rh factor, leading to the development of acute intravascular hemolysis. There are three degrees of hemotransfusion shock: with I st. systolic blood pressure drops to 90 mm Hg. Art.; at II stage - up to 80-70 mm Hg. Art.; III Art. - below 70 mm Hg. Art. In the development of post-transfusion complications, periods are distinguished: the actual hemotransfusion shock, acute renal failure and convalescence.
The first period begins either during the transfusion or immediately after it and lasts up to several hours. There is a short-term excitement, general anxiety, pain in the chest and lower back, shortness of breath. Circulatory disturbances develop (arterial hypotension, tachycardia, cardiac arrhythmia), reddening of the face, marbling of the skin. Signs of acute intravascular hemolysis are hepatomegaly, jaundice, hyperbilirubinemia, hemoglobinuria. Coagulation disorders include increased bleeding, DIC.
The period of acute renal failure lasts up to 8-15 days and includes the stages of oliguria (anuria), polyuria and restoration of kidney function. At the beginning of the second period, there is a decrease in diuresis, a decrease in the relative density of urine, after which urination may stop completely. Biochemical changes in the blood include an increase in the level of urea, residual nitrogen, bilirubin, and plasma potassium. In severe cases, uremia develops, leading to the death of the patient. In a favorable scenario, diuresis and kidney function are restored. During the period of convalescence, the functions of other internal organs, water-electrolyte balance and homeostasis are normalized.
At the first signs of transfusion shock, the transfusion should be stopped, while maintaining venous access. Infusion therapy begins immediately with blood-substituting, polyionic, alkaline solutions (rheopolyglucin, edible gelatin, sodium bicarbonate). Actually antishock therapy includes the introduction of prednisolone, aminophylline, furosemide. The use of narcotic analgesics and antihistamines is shown.
At the same time, drug correction of hemostasis, organ dysfunction (cardiac, respiratory failure), symptomatic therapy is carried out. In order to remove the products of acute intravascular hemolysis, it is used. With a tendency to develop uremia, hemodialysis is required.
Prevention of post-transfusion complications
The development of post-transfusion reactions and complications can be prevented. To do this, it is necessary to carefully weigh the indications and risks of blood transfusion, strictly follow the rules for the collection and storage of blood. Blood transfusions should be carried out under the supervision of a transfusiologist and an experienced nurse who has access to the procedure. Preliminary setting of control samples (determination of the patient's and donor's blood type, compatibility test, biological test) is mandatory. Hemotransfusion is preferably carried out by the drip method.
During the day after blood transfusion, the patient is subject to observation with control of body temperature, blood pressure, diuresis. The next day, the patient needs to examine the general analysis of urine and blood.
