Hemolytic shock during transfusion of blood that is incompatible by group affiliation and by the Rh factor. Blood transfusion shock: features of the pathological condition and methods of treatment Emergency care for transfusion complications
Transfusion shock is the result of errors made by medical personnel when transfusing blood or its components. Transfusion from the Latin transfusio - transfusion. Hemo - blood. So blood transfusion is a blood transfusion.
The procedure of transfusion (blood transfusion) is performed only in a hospital by trained doctors (in large centers there is a separate doctor - a transfusiologist). The preparation and conduct of the transfusion procedure requires a separate explanation.
In this article, we will focus only on the consequences of the mistakes made. It is believed that blood transfusion complications in the form of blood transfusion shock in 60 percent of cases occur precisely because of an error.
Transfusion shock is a consequence of immune and non-immune causes.
Immune causes include:
- Incompatibility of blood plasma;
- Incompatibility of the group and the Rh factor.
Non-immune causes are as follows:
- The entry into the blood of substances that increase body temperature;
- Transfusion of infected blood;
- Disruptions in blood circulation;
- Non-compliance with the rules of transfusion.
For reference. The main and most common cause of this complication is non-compliance with the technique of blood transfusion. The most common medical errors are incorrect blood typing and violations during compatibility tests.
How transfusion shock develops
Hemotransfusion shock is one of the most life-threatening condition of the victim, which manifests itself during or after blood transfusion.
After incompatible donor blood enters the recipient's body, an irreversible process of hemolysis begins, which manifests itself in the form of destruction of red blood cells - erythrocytes.
Ultimately, this leads to the appearance of free hemoglobin, resulting in impaired circulation, thrombohemorrhagic syndrome is observed, and the level of blood pressure is significantly reduced. Multiple dysfunctions of internal organs and oxygen starvation develop.
For reference. In a state of shock, the number of hemolysis components increases, which cause a pronounced spasm of the walls of blood vessels, and also cause an increase in the permeability of the vascular walls. Then the spasm turns into paretic expansion. Such a difference in the states of the circulatory system is the main cause of the development of hypoxia.
In the kidneys, the concentration of decay products of free hemoglobin and formed elements increases, which, together with the contraction of the walls of blood vessels, leads to the ontogenesis of renal failure.
As an indicator of the degree of shock, the level of blood pressure is used, which begins to fall as shock develops. It is believed that during the development of shock there are three degrees:
- first. Mild degree, at which the pressure drops to the level of 81 - 90 mm. rt. Art.
- second. The average degree at which the indicators reach 71 - 80 mm.
- third. Severe degree, in which the pressure drops below 70 mm.
The manifestation of a blood transfusion complication can also be divided into the following stages:
- The onset of a shock post-transfusion state;
- The occurrence of acute renal failure;
- Stabilization of the patient's condition.
Symptoms
Signs of the development of pathology can appear both immediately after the blood transfusion procedure, and in the following hours after
her. Initial symptoms include: - Short-term emotional arousal;
- Difficulty breathing, shortness of breath;
- The manifestation of cyanosis in the skin and mucous membranes;
- Fever due to chill;
- Muscular, lumbar and chest pains.
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Spasms in the lower back primarily signal the beginning of transformations in the kidneys. Ongoing changes in blood circulation are manifested in the form of a noticeable arrhythmia, blanching of the skin, sweating and a steady decrease in blood pressure levels.
If, at the first symptoms of hemotransfusion shock, the patient was not provided with medical assistance, then the following symptoms occur:
- Due to the uncontrolled growth of free hemoglobin, signs of hemolytic jaundice are born, characterized by yellowing of the skin and whites of the eyes;
- Actually, hemoglobinemia;
- The occurrence of acute renal failure.
Not so often, experts noticed the manifestation of such signs of hemotransfusion shock as hyperthermia, vomiting, numbness, uncontrolled muscle contraction in the limbs and involuntary bowel movements.
If a blood transfusion is performed to a recipient who is under anesthesia, then hemotransfusion shock is diagnosed by the following signs:
- Decreased blood pressure;
- Uncontrolled bleeding in the operated wound;
- Dark brown flakes are visible in the urinary catheter.
Important! The patient, who is under the influence of anesthesia, cannot report his state of health, therefore, the responsibility for the timely diagnosis of shock lies entirely with the medical staff.
First aid for shock
If during the transfusion procedure the patient has signs of shock, similar to the symptoms of hemotransfusion shock, then the procedure should be stopped immediately. The next step is to replace the transfusion system as soon as possible and connect a comfortable catheter in advance to the vein passing under the patient's collarbone. It is recommended in the near future to conduct a bilateral pararenal blockade with novocaine solution (0.5%) in a volume of 70-100 ml.In order to avoid the development of oxygen starvation, it is necessary to adjust the supply of humidified oxygen using a mask. The doctor should begin monitoring the volume of urine formed, and also urgently call laboratory assistants to take blood and urine for an early complete analysis, as a result of which the values \u200b\u200bof the content will be known. erythrocytes , free hemoglobin, fibrinogen.
For reference. If there are no reagents in the laboratory at the time of diagnosing post-transfusion shock to establish compatibility, then the proven Baxter method, which has been used in field hospital settings, can be used. It is necessary to inject 75 ml of donor material into the victim, and after 10 minutes to take blood from any other vein.
The test tube must be placed in a centrifuge, which, using centrifugal force, will separate the material into plasma and shaped elements. When incompatible, the plasma acquires a pink tint, while in the normal state it is a colorless liquid.
It is also desirable to immediately measure central venous pressure, acid-base balance and electrolyte levels, as well as conduct electrocardiography.
Operative anti-shock measures in most cases lead to an improvement in the patient's condition.
Treatment
Once the emergency response to shock has been taken, there is an urgent need to restore the main blood indicators.
Lecture 4
Complications in the transfusion of blood and its components
Blood transfusion complications are often encountered in clinical practice and are mainly due to violation of instructions for transfusion of blood and its components. According to statistics, complications during blood transfusion are observed in 0.01% of transfusions, and in 92% of cases they are associated with transfusion of incompatible blood according to the ABO system and the Rh factor, in 6.5% - with transfusion of poor-quality blood, in 1% with an underestimation of contraindications to blood transfusion, in 0.5% - with violation of transfusion technique.
Despite complex therapy and hemodialysis, mortality from blood transfusion complications remains high and reaches 25%.
The main causes of complications during blood transfusion are:
Incompatibility of the blood of the donor and the recipient (according to the ABO system, Rh factor, other factors)
Poor quality of the transfused blood (bacterial contamination, overheating, hemolysis, protein denaturation due to long periods of storage, violations of the temperature regime of storage, etc.).
Violations in the technique of transfusion (air and thromboembolism, acute expansion of the heart).
Underestimation of the state of the recipient's body before transfusion (presence of contraindications to blood transfusion, increased reactivity, sensitization).
Transfer of the causative agent of infectious diseases with transfused blood (syphilis, tuberculosis, AIDS, etc.).
As practice shows, the most common cause of blood transfusion complications is blood transfusion, incompatible with the ABO group factors and the Rh factor. Most of these complications are observed in obstetric-gynecological and surgical departments of medical institutions during blood transfusion for emergency indications (shock, acute blood loss, extensive trauma, surgical interventions, etc.).
Complications caused by transfusion of blood, erythrocyte mass, incompatible with the group and Rh factors of the ABO system.
The reason for such complications in the vast majority of cases is the failure to comply with the rules stipulated by the instructions for the technique of blood transfusion, according to the method for determining ABO blood groups and conducting compatibility tests.
Pathogenesis : massive intravascular destruction of transfused erythrocytes by natural agglutinins of the recipient with the release of destroyed erythrocytes and free hemoglobin with thromboplastin activity into the stromal plasma, includes the development of disseminated intravascular coagulation syndrome with severe disorders in the hemostasis and microcirculation system, followed by disorders of central hemodynamics and the development of hemotransfusion shock.
Transfusion shock. Transfusion shock may develop
1. when transfusing incompatible blood (errors in determining the blood type, Rh factor, incorrect selection of a donor in relation to other isohemagglutation and isoserological signs).
2. When transfusing compatible blood: a) due to insufficient consideration of the initial state of the patient; b). In connection with the introduction of poor-quality blood; V). due to individual incompatibility of donor and recipient proteins.
Hemolysis of donor erythrocytes in the bloodstream of the recipient is the main cause of developing hemodynamic and metabolic disorders that underlie blood transfusion shock.
The initial clinical signs of transfusion shock caused by transfusion of ABO-incompatible blood may appear immediately during blood transfusion or shortly after it and are characterized by short-term excitement, pain in the chest, abdomen, and lower back. In the future, circular disturbances characteristic of a state of shock (tachycardia, hypotension) gradually increase, a picture of massive intravascular hemolysis develops (hemoglobinemia, hemoglobinuria, bilirubinemia, jaundice) and acute impairment of kidney and liver functions. If shock develops during surgery under general anesthesia, then its clinical signs may be severe bleeding from the surgical wound, persistent hypotension, and in the presence of a urinary catheter, dark cherry or black urine.
The severity of the clinical course of shock largely depends on the volume of transfused incompatible erythrocytes, while the nature of the underlying disease and the patient's condition before blood transfusion play a significant role.
Depending on the level of blood pressure (maximum), there are three degrees of post-transfusion shock: shock of the 1st degree is characterized by a decrease in blood pressure to 90 mm Hg, shock of the 11th degree - within 80-70 mm Hg, shock of the 111th degree - below 70 mmHg The severity of the clinical course of shock, its duration and prognosis are not related to the dose of transfused blood and the cause of blood transfusion complications, as well as to the age of the patient, the state of anesthesia and the method of blood transfusion.
Treatment: stop transfusion of blood, erythrocyte mass that caused hemolysis; in the complex of therapeutic measures, simultaneously with the removal from shock, a massive (about 2-2.5 l.) plasmapheresis is shown to remove free hemoglobin, fibrinogen degradation products, with the replacement of the removed volumes with an appropriate amount of fresh frozen plasma or it in combination with colloidal plasma substitutes; to reduce the deposition of hemolysis products in the distal tubules of the nephron, it is necessary to maintain the patient's diuresis of at least 75-100 ml / hour with 20% mannitol (15-50 g) and furosemide 100 mg. Once, up to 1000 per day) correction of blood acid-base balance with 4% sodium bicarbonate solution; in order to maintain the volume of circulating blood and stabilize blood pressure, rheological solutions (rheopolyglucin, albumin) are used; if it is necessary to correct deep (at least 60 g / l) anemia - transfusion of individually selected washed erythrocytes; desensitizing therapy - antihistamines, corticosteroids, cardiovascular agents. The volume of transfusion-infusion therapy should be adequate to diuresis. The control is the normal level of central venous pressure (CVP). The dose of administered corticosteroids is adjusted depending on the stability of hemodynamics, but should not be less than 30 mg. For 10 kg. body weight per day.
It should be noted that osmotically active plasma substitutes should be used before the onset of anuria. With anuria, their appointment is fraught with the appearance of pulmonary or cerebral edema.
On the first day of the development of post-transfusion acute intravascular hemolysis, the appointment of heparin intravenously is indicated, up to 29 thousand units per day under the control of clotting time.
In cases where complex conservative therapy does not prevent the development of acute renal failure and uremia, the progression of creatininemia and hyperkalemia, the use of hemodialysis in specialized institutions is required. The issue of transportation is decided by the doctor of this institution.
Body reactions that develop according to the type of hemotransfusion shock, the causes of which are blood transfusions that are incompatible by Rh factors and other systems of erythrocyte antigens, develop somewhat less frequently than with transfusion of blood of different groups according to the ABO system.
Causes: These complications occur in patients sensitized to the Rh factor.
Isoimmunization with the Rh antigen can occur under the following conditions:
1. With repeated administration to Rh-negative recipients of Rh-positive blood;
2. During pregnancy of a Rh-negative woman with a Rh-positive fetus, from which the Rh factor enters the mother's blood, causing the formation of immune antibodies against the Rh factor in her blood.
The reason for such complications in the vast majority of cases is the underestimation of the obstetric and transfusion history, as well as the failure to comply with other rules that prevent incompatibility by the Rh factor.
Pathogenesis: massive intravascular hemolysis of transfused erythrocytes by immune antibodies (anti-D, anti-C, anti-E, etc.) formed in the course of previous sensitization of the recipient by repeated pregnancies or transfusions incompatible in antigen systems of erythrocytes (Rhesus, Call, Duffy, Kidd, Lewis and others).
Clinical manifestations This type of complications differ from the previous one by a later onset, less rapid course, delayed hemolysis, which depends on the type of immune antibodies and their titer.
The principles of therapy are the same as in the treatment of a post-transfusion type caused by blood transfusion (erythrocytes) incompatible with the group factors of the ABO system.
In addition to the group factors of the ABO system and the Rh factor Rh 0 (D), the cause of complications during blood transfusion, although less often, may be other antigens of the Rh system: ry 1 (C), rh 11 (E), hr 1 (c), hr (e) as well as antibodies from Duffy, Kell, Kidd, and other systems. It should be noted that the degree of their antigenicity is less, therefore, the value for the practice of blood transfusion of the Rh factor Rh 0 (D) is much lower. However, such complications do occur. They occur in both Rh-negative and Rh-positive individuals immunized through pregnancy or repeated blood transfusions.
The main measures to prevent transfusion complications associated with these antigens are taking into account the obstetric and transfusion history of the patient, as well as the fulfillment of all other requirements. It should be emphasized that a particularly sensitive test for compatibility, which allows to detect antibodies and, consequently, the incompatibility of the blood of the donor and recipient, is the indirect Coombs test. Therefore, an indirect Coombs test is recommended when selecting donor blood for patients with a history of post-transfusion reactions, as well as for sensitized individuals who are hypersensitive to the administration of erythrocytes, even if they are ABO and Rh compatible. The test for isoantigenic compatibility of transfused blood, as well as the test for compatibility by Rh factor-Rh 0 (D), is carried out separately from the test for compatibility by ABO blood groups and in no case replaces it.
The clinical manifestations of these complications are similar to those described above for the transfusion of Rh-incompatible blood, although they are much less common. The principles of therapy are the same.
Post-transfusion reactions and complications associated with the preservation and storage of blood, erythrocyte mass.
They arise as a result of the body's reaction to stabilizing solutions used in the conservation of blood and its components, to the metabolic products of blood cells resulting from its storage, to the temperature of the transfused transfusion medium.
Anaphylactic shock.
In clinical practice, reactions and complications of a non-hemolytic nature are quite common. They depend on the individual characteristics of the recipient, the functional state of the body, the characteristics of the donor, the nature of the transfusion medium, tactics and methods of blood transfusion. Freshly citrated blood is more reactogenic than canned blood. Transfusion of plasma (especially native) often gives reactions than the use of red blood cells. An allergic reaction occurs as a result of the interaction of allergic antibodies (reaginins) with allergens of transfused donor blood or plasma of the recipient. This reaction occurs more often in patients suffering from allergic diseases. Sensitization of the recipient may be due to allergens of various origins: food (strawberry, orange juice), drugs, inhalation, protein breakdown and denaturation products. Allergic reactions are usually mild and disappear after a few hours. They may occur at the time of blood transfusion, or 30 minutes or several hours after the transfusion.
Clinical manifestations are most often the development of urticaria, edema, pruritus, headache, nausea and fever, chills, and back pain. Anaphylactic shock rarely develops. The clinical manifestation of shock often occurs 15-30 minutes after transfusion and is characterized by fever, headache, chills, difficulty breathing due to bronchospasm. Then swelling of the face, urticaria all over the body, itching begins. Blood pressure drops, heart rate increases. The reaction can proceed violently, and then improvement occurs. In most observations, the phenomena of anaphylactic shock persist for the next day.
Treatment: stop blood transfusion, intravenous administration of antihistamines (diphenhydramine, suprastin, pipolfen, etc.), calcium chloride, adrenaline, corticosteroids, cardiovascular drugs, narcotic analgesics.
Mass Transfusion Syndrome. The syndrome is manifested by hemodynamic disturbances, the development of hepatic-renal and respiratory failure, phenomena of increased bleeding, metabolic changes. Most transfusiologists consider the introduction of more than 2500 ml of donor blood (40-50% of the circulating blood volume) into the patient's bloodstream at the same time within 24 hours as a massive blood transfusion.
The reason for the development of the syndrome of massive transfusion lies in the nominal conflict between the blood of the recipient and donors due to the presence of not only erythrocyte, but also leukocyte, platelet and protein antigens.
Complications that occur after massive blood transfusions are as follows:
1. Cardiovascular disorders (vascular collapse, asystole, bradycardia, cardiac arrest, ventricular fibrillation).
2. Blood changes (metabolic acidosis, hypocalcemia, hyperkalemia, increased blood viscosity, hypochromic anemia with leukopenia and thrombopenia: decreased levels of gamma globulin, albumin, citrate intoxication.
3. Violations of hemostasis (spasm of peripheral vessels, bleeding of wounds, fibrinogenopenia, hypothrombinemia, thrombopenia, increased fibrinolytic activity.
4. Changes in the internal organs (small punctate hemorrhages, less often bleeding from the kidneys, intestines, hepatic and renal failure - oliguria, anuria, jaundice, pulmonary hypertension with the development of metabolic acidosis and respiratory failure).
5. Decreased immunobiological activity of the recipient, characterized by divergence of the sutures of the surgical wound, poor wound healing, prolonged postoperative period.
The negative impact of massive whole blood transfusions is expressed in the development of disseminated intravascular coagulation syndrome. An autopsy reveals small hemorrhages in organs associated with micro thrombi, which consist of aggregates of erythrocytes and platelets. Violation of hypodynamics occurs in the systemic and pulmonary circulation, as well as at the level of capillary, organ blood flow.
The massive transfusion syndrome, with the exception of traumatic blood loss, is usually the result of whole blood transfusions with DIC that has already begun, when, first of all, it is necessary to transfuse large amounts of fresh frozen plasma (1-2 liters or more) with jet or frequent drops of its administration, but where transfusion of red blood cells (rather than whole blood) should be limited to vital signs.
In order to prevent and treat massive transfusion syndrome, it is necessary:
Transfuse strictly one-group canned whole blood with the shortest possible shelf life. Patients with the presence of isoimmune antibodies to conduct a special selection of blood. For patients with increased reactivity in the postoperative period, use a washed erythrocyte suspension.
Along with blood transfusion, use low-molecular blood substitutes (polyglucin, rheopolyglucin, hemodez, periston, rheomacrodex, etc.) to replenish blood loss. For every 1500-2000 ml of transfused blood, inject 500 ml of a plasma-substituting solution.
In operations with extracorporeal circulation, the method of controlled hemodilution (dilution or dilution of blood) with low molecular weight blood substitutes is used.
In case of violations of hemostasis in the immediate postoperative period, epsilonaminocaproic acid, fibrinogen, direct blood transfusion, platelet mass, concentrated solutions of dry plasma, albumin, gamma globulin, small doses of fresh erythrocyte mass, antihemophilic plasma are used.
In the postoperative period, osmotic diuretics are used to normalize diuresis.
Correction of violations of acid-base balance by introducing Tris-buffer into the bloodstream of the recipient.
Treatment of DIC - a syndrome caused by massive blood transfusion is based on a set of measures aimed at normalizing the hemostasis system and eliminating other leading manifestations of the syndrome, primarily shock, capillary stasis, acid-base, electrolyte and water balance disorders, damage to the lungs, kidneys, adrenal glands, anemia. It is advisable to use heparin (average dose of 24,000 units per day with continuous administration). The most important method of therapy is plasmapheresis (removal of at least one liter of plasma) by replacing fresh frozen donor plasma in a volume of at least 600 ml. The blockade of microcirculation by blood cell aggregants and vasospasm is eliminated by antiplatelet agents and other drugs (reopoliglyukin, intravenously, chimes 4-6 ml. 0.5% solution, eufilin 10 ml. 2.4% solution, trental 5 ml.). Protease inhibitors are also used - transilol, contrical in large doses - 80,000 - 100,000 units per intravenous injection. The need and volume of transfusion therapy is dictated by the severity of hemodynamic disorders. It should be remembered that whole blood in DIC cannot be used, and the washed erythrocyte mass should be transfused when the hemoglobin level drops to 70 g/l.
Citrate intoxication . With a rapid and massive transfusion of donor blood, a large amount of sodium citrate is introduced into the body of a patient with canned blood. The mechanism of action of citrate is a sudden decrease in the recipient's plasma concentration of ionized calcium due to its combination with the citrate ion. This leads during blood transfusion or at the end of it to severe circulatory disorders due to cardiac arrhythmias, up to ventricular fibrillation, spasm of the vessels of the pulmonary circulation, increased central venous pressure, hypotension, and convulsions.
hypocalcemia develops with transfusions of large doses of whole blood or plasma, especially at a high transfusion rate, prepared using sodium citrate, which, by binding free calcium in the bloodstream, causes hypocalcemia. Transfusion of blood or plasma prepared using sodium citrate at a rate of 150 ml/min. reduces the level of free calcium to a maximum of 0.6 mmol / l, and at a rate of 50 ml / min. the content of free calcium in the plasma of the recipient changes slightly. The level of ionized calcium returns to normal immediately after the cessation of the transfusion, which is explained by the rapid mobilization of calcium from endogenous depots and the metabolism of citrate in the liver.
In the absence of any clinical manifestations of temporary hypocalcemia, the standard prescription of calcium supplements (to "neutralize" citrate) is unjustified, since it can cause arrhythmias in patients with cardiac pathology. It is necessary to remember about the category of patients who have initial hypocalcemia, or about the possibility of its occurrence during various medical procedures (therapeutic plasmapheresis with compensation of the exfused plasma volume), as well as during surgical interventions. Particular attention should be paid to patients with the following comorbidities: hypoparothyroidism, D-avitaminosis, chronic renal failure, liver cirrhosis and active hepatitis, congenital hypocalcemia in children, pancreatitis, toxic-infectious shock, thrombophilic conditions, postresuscitation conditions, long-term therapy with corticosteroid hormones and cytostatics.
Clinic, prevention and treatment of hypocalcemia: a decrease in the level of free calcium in the blood leads to arterial hypotension, increased pressure in the pulmonary artery and central venous pressure, prolongation of the Q-T interval on the ECG, the appearance of convulsive twitching of the muscles of the lower leg, face, respiratory rhythm disturbance with the transition to apnea with a high degree of hypocalcemia. Subjectively, the increase in hypocalcemia is perceived by patients at first as unpleasant sensations behind the sternum that interfere with inhalation, an unpleasant taste of metal appears in the mouth, convulsive twitches of the muscles of the tongue and lips are noted, with a further increase in hypocalcemia, the appearance of clonic convulsions, respiratory failure until it stops, heart rhythm disturbances - bradycardia, up to asystole.
Prevention consists in identifying patients with potential hypocalcemia (a tendency to convulsions), injecting plasma at a rate not exceeding 40-60 ml / min, prophylactic administration of a 10% calcium gluconate solution - 10 ml for every 0.5 l of plasma.
When clinical symptoms of hypocalcemia appear, it is necessary to stop the administration of plasma, intravenously inject 10-20 ml of calcium gluconate or 10 ml of calcium chloride, ECG monitoring.
Hyperkalemia the recipient may experience rapid transfusion (about 120 ml/min) of long-term stored canned blood or red blood cells (with a shelf life of more than 14 days, the potassium level in these transfusion media can reach 32 mmol/l). The main clinical manifestation of hyperkalemia is the development of bradycardia.
Prevention: when using blood or erythrocyte mass for more than 15 days of storage, transfusions should be made drip (50-70 ml / min), it is better to use washed erythrocytes.
The group of complications associated with violation of transfusion technique blood include air and thromboembolism, acute expansion of the heart.
Air embolism occurs when the system is not properly filled, as a result of which air bubbles enter the patient's vein. Therefore, it is strictly forbidden to use any injection equipment for transfusion of blood and its components. When an air embolism occurs, patients develop shortness of breath, shortness of breath, pain and a feeling of pressure behind the sternum, cyanosis of the face, and tychocardia. Massive air embolism with the development of clinical death requires immediate resuscitation - indirect heart massage, mouth-to-mouth artificial respiration, calling the resuscitation team.
Prevention of this complication lies in the exact observance of all the rules of transfusion, installation of systems and equipment. It is necessary to carefully fill all tubes and parts of the equipment with transfusion medium, following the removal of air bubbles from the tubes. Observation of the patient during transfusion should be constant until its completion.
Thromboembolism- embolism with blood clots that occurs when clots of various sizes enter the patient's vein, formed in the transfused blood (erythrocyte mass) or, which is less common, brought with the blood flow from the patient's thrombosed veins. The cause of an embolism may be an incorrect transfusion technique, when clots in the transfused blood enter the vein, or thrombi formed in the patient's vein near the tip of the needle become emboli. The formation of microclots in canned blood begins from the first day of its storage. The formed microaggregates, getting into the blood, linger in the pulmonary capillaries and, as a rule, undergo lysis. When a large number of blood clots are ingested, a clinical picture of thromboembolism of the pulmonary artery branches develops: sudden pain in the chest, a sharp increase or occurrence of shortness of breath, coughing, sometimes hemoptysis, pallor of the skin, cyanosis, in some cases, collapse develops - cold sweat, drop in blood pressure , rapid pulse. At the same time, the electrocardiogram shows signs of a load on the right atrium and a displacement of the electrical axis to the right is possible.
Treatment of this complication requires the use of fibrinolysis activators - streptase (streptodecase, urokinase), which is inserted through a catheter, preferably, if there are conditions for its installation, in the pulmonary artery. With a local effect on a thrombus in a daily dose of 150,000 IU (50,000 IU 3 times). With intravenous administration, the daily dose of streptase is 500,000 - 750,000 IU. Intravenous administration of heparin is shown (24,000 - 40,000 units per day), immediate jet injection of at least 600 ml. fresh frozen plasma under coagulation control.
Prevention of pulmonary embolism consists in the correct technique of harvesting and transfusion of blood, which excludes the ingress of blood clots into the patient's vein, the use of filters and microfilters during hemotransfusion, especially with massive and jet transfusions. In case of needle thrombosis, it is necessary to re-puncture the vein with another needle, in no case trying to restore the patency of the thrombosed needle in various ways.
Acute dilatation of the heart occurs when the right heart is overloaded with an excessively large amount of blood quickly poured into the venous bed.
Infectious diseases, which are the result of blood transfusion, clinically proceed in the same way as in the usual route of infection.
Serum hepatitis- one of the most severe complications that occur in the recipient when transfusing blood or its components, prepared from a donor who is either a virus carrier or was in the incubation period of the disease. Serum hepatitis is characterized by a severe course with a possible outcome in liver dystrophy, chronic hepatitis and cirrhosis of the liver.
The specific causative agent of post-transfusion hepatitis is considered to be the B-1 virus, discovered as an Australian antigen. The incubation period is from 50 to 180 days.
The main measure for the prevention of hepatitis is the careful selection of donors and the identification of potential sources of infection among them.
Transfusion of blood and its components is widely used in clinical practice. A prerequisite for blood transfusion is strict adherence to instructions. After transfusion of incompatible blood, various reactions (pyrogenic, allergic, anaphylactic) and hemotransfusion shock can be observed.
pyrogenic reactions are manifested by an increase in body temperature, sometimes chills, pain in the lower back and bones. In these cases, the use of antipyretics and cardiac therapy is indicated.
With an allergic reaction to increase the temperature, the body is joined by shortness of breath, nausea, vomiting. In these cases, in addition to antipyretics, antihistamines (diphenhydramine, suprastin), corticosteroids, cardiac and desensitizing agents are used.
The most severe reaction is anaphylactic shock., which is characterized by vasomotor disorders, skin flushing, cyanosis, cold sweat. The pulse is frequent, thready. Arterial pressure is reduced. Heart sounds are muffled. Pulmonary edema and urticaria may develop.
Complications after blood transfusion are associated with incompatibility of the blood of the donor and the recipient, bacterial contamination of the blood, violation of the technique of blood transfusion. (air embolism, thromboembolism), circulatory overload, massive blood transfusion, underestimation of contraindications to blood transfusion. Most often, the occurrence of hemotransfusion shock is caused by the transfusion of completely or partially incompatible blood.
Transfusion shock develops during transfusion, incompatible with the group or Rh factor of blood. Currently, many agglutinogens are known that are present in human blood. Determination of blood groups and Rh affiliation does not always make blood transfusion completely safe. More often post-transfusion shock occurs in case of incompatibility of the blood of the recipient and the donor according to the AB0 system. Immunological conflict in transfusion shock can also be due to isoimmunization, different Rh-affiliation of the patient and the donor. Blood transfusion is the introduction of a foreign protein, and therefore it is necessary to establish strict indications. Blood transfusion should not be performed in cases where it can be dispensed with. Only a doctor should perform a blood transfusion. Careful observation of the patient allows you to notice the initial violations, indicating a dangerous pathology. Sometimes the first signs of a post-hemorrhagic reaction are the patient's anxiety, back pain, chills. In such cases, blood transfusion should be stopped immediately.
Clinical picture, which develops during the transfusion of incompatible blood, can be very diverse. When transfusing blood that is group-incompatible, clinical signs of complications appear after the introduction of small amounts of blood (25 - 75 ml). The patient becomes restless, complains of feeling unwell, then back pain caused by spasm of the renal vessels, chest tightness, fever. If blood transfusion does not stop, then blood pressure decreases, pallor of the skin appears, and sometimes vomiting. Hemoglobinuria develops rather quickly (urine acquires the color of dark beer). If the transfusion is stopped on time, these symptoms may disappear without a trace. However, strict medical supervision is necessary, since severe renal dysfunction may occur later, up to the development of acute renal failure.
9. Indications and contraindications for blood transfusion!
Indications for blood transfusion!
A) Absolute - acute blood loss (15% BCC); traumatic shock; severe operations, accompanied by extensive tissue damage and bleeding.
B) Relative p- anemia, inflammatory diseases with severe intoxication, ongoing bleeding, disorders of the coagulation system, a decrease in the body's immune status, long-term chronic inflammatory processes with a decrease in regeneration and reactivity, some poisoning.
Contraindications to blood transfusion! can be divided into two groups:
Absolute:
acute septic endocarditis;
fresh thromboses and embolisms;
· pulmonary edema;
severe disorders of cerebral circulation;
Heart defects, myocarditis and myocardiosclerosis of various types with a violation of the general circulation of the II-III degree;
· hypertension degree ΙΙΙ with severe atherosclerosis of cerebral vessels, nephrosclerosis.
Relative:
subacute septic endocarditis without progressive development of diffuse glomerulonephritis and disorders of the general circulation.
heart defects with circulatory failure IIb degree;
Pronounced amyloidosis;
acute tuberculosis.
Importance of nurse competence when working with blood.
A physician should be one who puts the life and health of the patient above personal interests. The motto of medicine, proposed by the 17th-century Dutch physician Van Tulpius - aliis inserviendo consumer (lat.) - serving others, I burn myself.
In the complex of medical measures, professional competence in all matters is of great importance, especially when it comes to the transfusion of blood and its components. The most effective medicines, skillfully performed surgeries, etc., sometimes cannot ensure recovery, unless systematic transfusion of blood, its components and blood substitutes is carried out.
Therefore, the most characteristic feature for a nurse should be - awareness of their responsibility in the performance of immediate duties, which must be carried out not only correctly, but also in a timely manner. It is necessary to know the effect of blood, its antigenic structure, the effect of IV procedures on the patient. If, instead of a useful action, a complication arises, you must immediately stop the procedure. You can not blindly and mechanically carry out assignments. If an intravenous infusion of blood or its components shows an unusual effect, then an observant, attentive and medically educated nurse will invite a doctor who will decide what to do. From the foregoing, we can conclude that the competence of a nurse is very important. If earlier she was only an assistant, then in our time the specialty “nurse” is distinguished into a new independent discipline due to changes in environmental conditions, society, attitudes and scientific discoveries.
LECTURE.
Topic: Blood transfusion and blood substitutes .
The role of knowledge about transfusiology in the work of a nurse.
Blood transfusion is a serious operation for the transplantation of human living tissue. This method of treatment is widely used in clinical practice. Blood transfusion is used by a nurse of various specialties: departments of surgery, gynecology, traumatology, etc. The achievements of modern science, in particular transfusiology, make it possible to prevent complications during blood transfusion. The cause of complications are errors in blood transfusion, which are due to or insufficient knowledge of the basics of transfusiology, violation of the rules and techniques of blood transfusion at various stages. Scrupulous, competent implementation of the rules and reasonable consistent actions of the nurse during blood transfusion determine its successful implementation. In the healthcare system, this important role belongs to the category of paramedical workers, on whose highest knowledge, qualifications and personal qualities not only the success of the treatment, but also the quality of life of the patient depends. A professional nurse must know a lot: i.e. a nurse involved in preparing the patient and transfusing blood, blood components and blood substitutes must know and be able to do a lot, and in practice apply all the baggage of knowledge, be next to the patient at the first call and help him cope with the situation that has arisen.
1. The concept of blood transfusion of its components and blood substitutes.
Blood transfusion (haemotransfusio, transfusio sanguinis; synonym: blood transfusion, blood transfusion) therapeutic method, which consists in introducing into the bloodstream of the patient (recipient) whole blood or its components prepared from a donor or the recipient himself, as well as blood that has poured into the body cavity during injuries and operations.
Blood transfusion - This is a method of transfusion therapy, this is an intervention, as a result of which transplantation (transplantation) of allogeneic or autogenous tissue is carried out. The term "blood transfusion" combines the transfusion to the patient of both whole blood and its cellular components and plasma protein preparations.
In clinical practice, the following main types of L. to. are used: indirect, direct, exchange, autohemotransfusion. The most common method is indirect transfusion of whole blood and its components (erythrocyte, platelet or leukocyte mass, fresh frozen plasma). Blood and its components are usually administered intravenously using a disposable blood transfusion system, to which a vial or plastic container with transfusion medium is connected. There are other ways of introducing blood and erythrocyte mass - intra-arterial, intra-aortic, intraosseous.
2. History of the development of transfusiology.
There are 2 periods in the history of blood transfusion. 1st period - from ancient times to the discovery of the laws of isohemagglutination and blood group factors (erythrocyte antigens). This period lasted from ancient times to the discovery of blood circulation by W. Harvey (628) and continued until the discovery of blood group factors by K. Landsteiner. The first successful blood transfusion took place in 1667, when the French explorers Denis and Emmerez transfused the blood of an animal (lamb) into a human. But the 4th transfusion to another patient ended in death. Human blood transfusions have been discontinued for almost 100 years.
In the Russian Fatherland in 1832. G. Wolf transfused blood to a woman who was dying after childbirth from uterine bleeding, which led to the recovery of the woman in labor. In 1847, the dissector of Moscow University I. M. Sokolov for the first time transfused human blood serum to a patient with cholera.
In Russia, the first fundamental work on blood transfusion was the book by A. M. Filomafitsky "Treatise on blood transfusion ...".
In the 60-80s. 19th century in Russia, 3 important discoveries were made in blood transfusion; S. P. Kolomnin introduced the method of intra-arterial transfusion, V. V. Sutugin - the method of chemical stabilization of blood. N. I. Pirogov emphasized the benefits of blood transfusion for some wounds in the field.
1900-1925 were associated with the development of the doctrine of immunity - the immunity of the human body to infectious and non-infectious agents and substances with alien antigenic properties.
For a long time, immunity meant the immunity of the body only to infectious diseases. I. I. Mechnikov (1903) also shared this opinion. He wrote: "Under the immunity to infectious diseases one should understand the general system of phenomena due to which the body can withstand the attacks of pathogenic microbes." In the future, the concept of "immunity" has received a broader interpretation.
In 1901 K. Landsteiner discovered blood groups, there were 3 of them. In 1907, Ya. Jansky singled out the 4th blood group.
Blood transfusion in the USSR was quickly introduced into medical practice. In 1919, V. N. Shamov, N. N. Elansky, and I. R. Petrov were the first to obtain standard sera for determining the blood group and, taking them into account, performed a blood transfusion. In 1926, N. N. Elansky's monograph "Blood Transfusion" was published. Institutes began to open (1926) and blood transfusion stations. Our country has taken one of the leading places in the development of blood transfusion.
The theory of blood clotting belongs to the physiologist A. A. Schmidt - 2nd half of the 19th century. Rosengardt and Yurevich proposed sodium citrate (citrate) as a blood stabilizer. It played a huge role in the case of indirect blood transfusion, called "citrate".
In recent years, indications for blood transfusion have been revised. Currently, new principles of transfusion tactics have been introduced into practice, this is component and infusion-transfusion hemotherapy, the essence of which is the differentiated or complex use of transfusion of blood and its components, drugs, saline solutions and blood substitutes.
3. Ways and methods of introducing blood transfusion media.
This reaction is the most serious among transfusion reactions, as it often ends in death. It can almost always be avoided.The reaction of incompatibility is often accompanied by hyperthermia, so the temperature increase during transfusion should always be taken seriously, without immediately classifying it as a banal pyrogenic reaction. It is possible to reliably assess the febrile reaction only by measuring the body temperature in advance, before the transfusion. The clinical picture of the incompatibility reaction depends on the administered dose of the antigen and on the nature of the antibodies acting on it. If the patient complains of "hot flush", back pain, weakness, nausea, headache, chest tightness, if there is chills and body temperature above 38.3 0C, the transfusion should be stopped immediately. Collapse or the appearance of free hemoglobin in the urine are ominous signs that require immediate treatment to save the patient's life or prevent irreversible kidney damage.
Sometimes, depending on the group affiliation of incompatible blood, the first symptoms of the reaction are not so pronounced, since the destruction of red blood cells does not occur in the bloodstream, but outside the vessels, in the reticuloendothelial system. The amount of free hemoglobin in the plasma is minimal, the destruction of red blood cells is detected in this case by an increase in the level of bilirubin in the plasma, often so pronounced that a few hours after the transfusion, the patient develops jaundice. Sometimes the only sign of blood incompatibility is the absence of an increase in hemoglobin levels after a blood transfusion.
With a significant destruction of erythrocytes, substances are released that activate coagulation processes with subsequent consumption of fibrinogen. This condition can cause hemorrhagic syndrome with bleeding from the surgical site and mucous membranes. During anesthesia and after the introduction of large doses of sedatives, the clinical symptoms of an incompatibility reaction may be suppressed, so the first sign of a transfusion of incompatible blood may be sudden diffuse bleeding. In patients, the level of fibrinogen decreases and the total clotting time of whole blood increases.
Treatment. If an incompatibility reaction is suspected, blood transfusion is stopped, treatment is started immediately and the search for the causes of incompatibility is started. Circulatory collapse is treated as outlined in the Resuscitation chapter. If the patient develops anuria, treat acute renal failure, notify the nearest hemodialysis center and consult with its specialists. If there is diffuse bleeding, then the patient is transfused with fresh frozen plasma and, possibly, platelet concentrate.
A complete examination of the patient is usually carried out by a hematologist. Since he is involved to a certain extent in blood transfusion, he should be called immediately as soon as an incompatibility reaction is detected. For hematological examination, rowing:
1) a sample of the recipient's blood before transfusion (it is usually already in the laboratory);
2) samples of donor blood from the test container and from the amount remaining in the ampoule;
3) a sample of the recipient's blood after transfusion in a test tube with an anticoagulant, for example, citrate;
4) sample of coagulated blood of the recipient after transfusion (10-20 ml);
5) a sample of urine isolated during or after a blood transfusion.
Every patient receiving a blood transfusion should have diuresis measured within 48 hours after the transfusion. Low urine output combined with a relative urine gravity below 1010 indicates renal failure.
In the treatment of acute hypovolaemia, the hematologist must provide compatible blood to continue the transfusion, so the sooner these tests are obtained, the better.
Part of the work to identify the causes of incompatibility should be done by the attending physician to make sure that all the necessary precautions for transfusion are observed, the blood is not mixed up, and there are no organizational errors. If it turns out that the patient has been transfused with blood of another group by mistake, this will reduce the time to obtain compatible blood. The error may come from the center that prepared the blood, so usually the hematologist notifies the management of the blood transfusion center about the reaction and sometimes uses the help of the center when examining the patient.
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.
