輸血風(fēng)險(xiǎn)非感染性課件

1、TRANSFUSION RISKS(NON-INFECTIOUS)Hua Shan, M.D., Ph.DJohns Hopkins Medical InstitutionsBaltimore, Maryland, USATRANSFUSION RISKS(NON-INFECTI輸血風(fēng)險(xiǎn)（非感染性）華山 M.D.，Ph.D約翰 霍伯金斯醫(yī)學(xué)院美國(guó)，馬里蘭州，巴爾的摩輸血風(fēng)險(xiǎn)（非感染性）華山 M.D.，Ph.D輸血風(fēng)險(xiǎn)非感染性課件危 險(xiǎn) 肝炎 同種致敏作用 循環(huán)超負(fù)荷 過(guò)敏反應(yīng) 敗血癥危 險(xiǎn) 肝炎輸血風(fēng)險(xiǎn)非感染性課件輸血風(fēng)險(xiǎn)非感染性課件Risks of Transfusion: infectio

2、us vs. non-infectiousInfectionsUSA Non-infectiousUSAHIV1/ 1.9 millionDeath:acute hemolytic1:600,000(New York 1990-1991)HCV1/ 1.8 millionHBV1/ 205,000Risks of Transfusion:Infection輸血風(fēng)險(xiǎn)：感染性對(duì)比非感染性感染性USA 非感染性USAHIV1/190萬(wàn)死亡：急性溶血1:600,000(New York 1990-1991)HCV1/180萬(wàn)HBV1/ 205,000輸血風(fēng)險(xiǎn)：感染性對(duì)比非感染性感染性USA 非感染性U

3、SA1:Transfusion ReactionsPotentially severe TR:Hemolytic TRAnaphylactic TRTransfusion-related Acute Lung Injury Circulatory overloadSeptic TRTransfusion-associated Graft-vs-Host Disease Transfusion ReactionsPotential輸血反應(yīng)(TR)潛在的嚴(yán)重輸血反應(yīng)：溶血輸血反應(yīng)過(guò)敏性輸血反應(yīng)輸血相關(guān)性急性肺損傷 循環(huán)超負(fù)荷敗血癥輸血相關(guān)性移植物抗宿主病輸血反應(yīng)(TR)潛在的嚴(yán)重輸血反應(yīng)：Tran

4、sfusion ReactionsCommon and usually mild:Febrile nonhemolytic TRMild allergic TR(Circulatory overload) Acute pain TRTransfusion ReactionsCommon a輸 血 反 應(yīng) 常見(jiàn)的，通常輕度的輸血反應(yīng)：非溶血性發(fā)熱輸血反應(yīng)輕度過(guò)敏輸血反應(yīng)（循環(huán)超負(fù)荷）急性疼痛輸 血 反 應(yīng) 常見(jiàn)的，通常輕度的輸血反應(yīng)：Hemolytic TRCause:Immunological incompatibility between donor and recipient ABO, R

5、h, other RBC alloantigens Mechanism:Antibody mediated destruction of RBC (Non-immune-mediated hemolysis: Wrong infusion fluid, wrong needle size, or incorrect use of blood warmer, etc)Hemolytic TRCause:溶血性輸血反應(yīng)原因： 捐獻(xiàn)者和受者之間的免疫不相容性，ABO，Rh和其它紅細(xì)胞血型同種抗原機(jī)制： 抗體介導(dǎo)的紅細(xì)胞破壞非免疫介導(dǎo)的溶血： 輸液錯(cuò)誤、針的大小錯(cuò)誤或血液不當(dāng)預(yù)熱等等）溶血性輸血反應(yīng)原

6、因：Subtypes of Hemolytic TRAcute (AHTR) vs. Delayed (DHTR) TimeHemolysis Antibody Acute: 24hr Extravascular Rh/others(IgG)Subtypes of Hemolytic TRAcute溶血性輸血反應(yīng) 急性溶血性輸血反應(yīng)對(duì)比遲發(fā)性溶血性輸血反應(yīng) 時(shí)間 溶血 抗體 急性 24hr 血管外 IgG類抗體溶血性輸血反應(yīng) 急性溶血性輸血反應(yīng)對(duì)比遲發(fā)性溶血性輸血ANTIBODY-MEDIATED HEMOLYSISIgM antibodies are typically naturally

7、occurring, best example is the ABO system IgG antibodies are typically alloantibodies induced by pregnancy or transfusions; best example is the Rh system.ANTIBODY-MEDIATED HEMOLYSIS抗體介導(dǎo)的溶血 IgM抗體是典型的天然存在的血型抗體，最好的例子是ABO血型系統(tǒng) IgG抗體是典型的同種抗體，由懷孕或輸血誘導(dǎo)產(chǎn)生的；最好的例子是Rh血型系統(tǒng)抗體介導(dǎo)的溶血ABO Antigens Critical Role in Tra

8、nsfusion High antigen density on red cellsReciprocal arrangement whereby patients who are group A have naturally occurring anti-B in their serum. ABO antibodies are high titer IgM antibodies which produce intravascular hemolysisGroup O is universal donor; group AB is universal recipientABO Antigens

9、Critical Role inABO抗原 輸血中的重要角色紅細(xì)胞上的高密度抗原有A抗原的病人的血清中天然存在抗-BABO抗體是高滴度的IgM抗體，它們會(huì)造成血管內(nèi)溶血O型血是萬(wàn)能獻(xiàn)血者，AB型是萬(wàn)能受血者ABO抗原 輸血中的重要角色紅細(xì)胞上的高密度抗原Rh BLOOD GROUP1939- Levine and Stetson report case of mother of a stillborn who suffered severe HTR after transfusion of husbands blood.1940- Landsteiner and Wiener immunize

10、d rabbits with rhesus cells and found sera that agglutinated cells from 85% of NYC donors 1941- Levine confirmed association between Rh incompatibility and HDNRh BLOOD GROUP1939- Levine andRh血型1939年 Levine和Stetson報(bào)道了一例出現(xiàn)死胎的母親在輸注了丈夫的血液后發(fā)生嚴(yán)重溶血性輸血反應(yīng)1940年 Landsteiner和Wiener用恒河猴的細(xì)胞免疫兔子，發(fā)現(xiàn)其血清能與85% 的紐約市獻(xiàn)血者

11、血液發(fā)生凝集 1941年 Levine證實(shí) Rh不相容性和新生兒溶血病之間存在聯(lián)系Rh血型1939年 Levine和Stetson報(bào)Rh Antigens Clinical ImportanceImmunogenicity: strongHigh frequency of incompatibilityRhD: 85% positive, 15% negative (USA). D c EMajor problem in US for transfusion recipientsPrior to RhIg, major cause of hemolytic disease of the new

12、bornRh Antigens Clinical ImportanRh抗原 臨床重要性免疫原性：強(qiáng)RhD： 85% 陽(yáng)性，15%陰性（美國(guó)）D c E 成為美國(guó)受血者的主要問(wèn)題在RhIg之前是新生兒溶血病的主要原因Rh抗原 臨床重要性免疫原性：強(qiáng)Other Red Cell AntigensAt least 300 blood groups have been described.Many antibodies are clinically significant, causing hemolysis and transfusion reactions.Other antibodies can

13、 cause serologic incompatibility but do not affect red cell survival clinically insignificantAntibodies causing transfusion reactions vary among populations depending upon antigen frequenciesOther Red Cell AntigensAt leas其他紅細(xì)胞抗原已報(bào)道至少有300種血型抗原很多抗體具有臨床意義，會(huì)造成溶血和輸血反應(yīng)其他抗體可能造成血清學(xué)不相容性，但不會(huì)影響紅細(xì)胞存活無(wú)臨床意義 抗體造成的

14、輸血反應(yīng)在不同人群中不同，其主要依賴于抗原頻率其他紅細(xì)胞抗原已報(bào)道至少有300種血型抗原Prevention of Hemolytic TRAt sample collection: Correct patient and sample identificationPre-transfusion TestingABO/RH antigen and antibodyUnexpected antibodiesBefore transfusion: correct patient and unit identificationDuring and after transfusion: close m

15、onitoring of patientsPrevention of Hemolytic TRAt s溶血輸血反應(yīng)的預(yù)防標(biāo)本的采集： 確認(rèn)病人和標(biāo)本正確無(wú)誤輸血前實(shí)驗(yàn)室檢查-ABO/Rh抗原和抗體-不規(guī)則抗體輸血前：確認(rèn)病人和輸血量的正確無(wú)誤 輸血中和輸血后：密切觀察病人溶血輸血反應(yīng)的預(yù)防標(biāo)本的采集： 確認(rèn)病人和標(biāo)本正確無(wú)誤PRETRANSFUSION TESTINGVerify patient identityDetermine ABO and RhPerform antibody screen (to detect unexpected antibodies)Perform compati

16、bility test-final verificationPRETRANSFUSION TESTINGVerify p輸血前實(shí)驗(yàn)核實(shí)病人身份確定ABO和Rh血型進(jìn)行抗體篩查（檢測(cè)不規(guī)則抗體）相容性試驗(yàn)最后確認(rèn)輸血前實(shí)驗(yàn)核實(shí)病人身份輸血風(fēng)險(xiǎn)非感染性課件輸血風(fēng)險(xiǎn)非感染性課件輸血風(fēng)險(xiǎn)非感染性課件表1 標(biāo)本貼簽要求和拒絕標(biāo)準(zhǔn) 要求 手寫標(biāo)簽符合申請(qǐng)表資料 病人全名 病人住院的身份號(hào) 絕對(duì)拒絕 有證據(jù)顯示貼標(biāo)簽不是在床邊完成 打印或自動(dòng)生成的標(biāo)簽 名字錯(cuò)誤或沒(méi)有 姓錯(cuò)誤或沒(méi)有 沒(méi)有病人的住院身份號(hào) 身份號(hào)超過(guò)1個(gè)數(shù)字有誤，除非只有2 位數(shù)，數(shù)字順序顛倒 臍帶樣本沒(méi)有標(biāo)明“臍帶”或“嬰兒”或“男孩/女孩

17、”難以執(zhí)行 只有首寫字母，罕見(jiàn)的姓氏 手寫標(biāo)簽在自動(dòng)標(biāo)簽上 樣本標(biāo)簽符合臂章，但與申請(qǐng)表的資料不符可接受 名字錯(cuò)誤但可以理解，或者兩個(gè)名字 姓有細(xì)微的拼寫錯(cuò)誤 病人身份號(hào)的一個(gè)數(shù)字錯(cuò)誤或兩個(gè)數(shù)字顛倒；罕見(jiàn)名字 抽取血標(biāo)本的病人的住院病房、床號(hào)和日期必須寫在標(biāo)本的標(biāo)簽上或是輸血申請(qǐng)單上 不良事件的報(bào)告和咨詢表1 標(biāo)本貼簽要求和拒絕標(biāo)準(zhǔn)輸血風(fēng)險(xiǎn)非感染性課件表2：ABO和/或Rh血型錯(cuò)誤的頻率 標(biāo)本 標(biāo)本分型 錯(cuò)誤 百分比正確標(biāo)簽 40,274 14 0.035錯(cuò)誤標(biāo)簽（拒絕） 496 7 1.4表2：ABO和/或Rh血型錯(cuò)誤的頻率Elements of a Compatibility Testin

18、g SystemElements of a Compatibility Testing System Patient identification Sample identification ABO/Rh/Ab screen Records check Unit selection Crossmatching Labeling Recipient identification Patient identification Sample identification ABO/Rh/Ab screen Records check Unit selection Crossmatching Label

19、ing Recipient identification 1/2,900 samples contains blood from the wrong patient1/2,900 samples contains blood from the wrong patient Lumadue JA et al. Transfusion 1997;37:1169-72.Lumadue JA et al. Transfusion 1997;37:1169-72.Elements of a Compatibility Te相容性試驗(yàn)的組成元素確認(rèn)病人確認(rèn)標(biāo)本 抽錯(cuò)血標(biāo)本的幾率是1/2900確認(rèn)受者相容性試

20、驗(yàn)的組成元素確認(rèn)病人輸血風(fēng)險(xiǎn)非感染性課件輸血風(fēng)險(xiǎn)非感染性課件輸血風(fēng)險(xiǎn)非感染性課件輸血風(fēng)險(xiǎn)非感染性課件Acute Hemolytic ReactionsSigns and SymptomsFever and chills81%RigorsAnxiety, feeling of doomFacial flushingAbdominal, back, or flank painNausea and vomiting 12%Dyspnea 7%Hypotension/tachycardia 12%Pain at infusion site 16%Oliguria/anuria 36%Diffuse b

21、leeding (DIC) 8%Acute Hemolytic ReactionsSign急性溶血反應(yīng)體征和癥狀發(fā)熱發(fā)寒 僵直焦急、感覺(jué)不幸臉發(fā)紅腹、背或腰疼頭暈、惡心 呼吸困難 低血壓/心動(dòng)過(guò)速 輸血部位疼痛 尿少/無(wú)尿 彌漫性出血(DIC) 81%12%7%12%16%36%8%急性溶血反應(yīng)體征和癥狀發(fā)熱發(fā)寒 81% 溶血性輸血反應(yīng)的治療1、停止輸血2、維持靜脈通路3、開(kāi)始利尿4、輸液5、維持血壓6、監(jiān)測(cè)腎功能 7、監(jiān)測(cè)凝血狀態(tài) 8、避免輸注抗原陽(yáng)性血 溶血性輸血反應(yīng)的治療1、停止輸血輸血風(fēng)險(xiǎn)非感染性課件溶血性輸血反應(yīng)的調(diào)查 1、停止輸血2、取血樣3、檢查是否有筆誤4、進(jìn)行直接抗球蛋白試驗(yàn)

22、 5、觀察血漿的溶血狀況或黃疸6、如果懷疑溶血反應(yīng) ，重復(fù)相容性實(shí)驗(yàn)溶血性輸血反應(yīng)的調(diào)查 1、停止輸血Laboratory InvestigationsBlood ProductConfirm ABO, Rh Confirm other antigensBlood Bank LaboratoryDirect antiglobulin testConfirm ABO, A/S, patient IDLook for hemolysisClinical LaboratoryComplete blood countBilirubin, creatinineDIC evaluationLaborato

23、ry InvestigationsBlood實(shí)驗(yàn)室調(diào)查血液制品確認(rèn)ABO，Rh血型確認(rèn)其他血型抗原血庫(kù)實(shí)驗(yàn)室直接抗球蛋白試驗(yàn)確認(rèn)ABO，A/S，病人身份尋找溶血癥臨床實(shí)驗(yàn)室全血計(jì)數(shù)膽紅素，肌酐，彌漫性血管內(nèi)凝血評(píng)估實(shí)驗(yàn)室調(diào)查血液制品確認(rèn)ABO，Rh血型血庫(kù)實(shí)驗(yàn)室直接抗球蛋白TherapyGeneralRenalPulmonaryDICVenous accessMaintain BP and urine outputMonitorPulmonaryFunctionConsider HeparinVital signsDiureticsOxygenPlateletsICU DopamineVent

24、ilatorFFPPulmonaryArtery cathDialysisTherapyGeneralRenalPulmonaryDI治 療總的腎的肺的彌漫性血管內(nèi)凝血靜脈途徑維持血壓和排尿監(jiān)測(cè)肺功能考慮肝素重要信號(hào)利尿劑氧血小板重癥監(jiān)護(hù)多巴胺呼吸器新鮮冰凍血漿肺動(dòng)脈導(dǎo)管 透析治 療總的腎的肺的彌漫性靜脈途徑維持血壓和排尿監(jiān)測(cè)肺AHTRSUMMARYABO Incompatible blood is the most common causeIntravascular hemolysis can lead to fever, shock, renal failure, DIC. Clerica

25、l errors and wrong blood in tube are the major cause: (51% of 355 reported deaths in 100 million units 1976-1985)AHTRSUMMARYABO Incompatible b急性溶血性輸血反應(yīng)小結(jié)ABO不相容是溶血最常見(jiàn)的原因血管內(nèi)溶血會(huì)導(dǎo)致發(fā)熱、休克、腎衰、彌漫性血管內(nèi)凝血書寫錯(cuò)誤和血標(biāo)本錯(cuò)誤是主要原因：（1976-1985年間，1億單位輸血量355例死亡報(bào)導(dǎo)中51%是由此造成）急性溶血性輸血反應(yīng)小結(jié)ABO不相容是溶血最常見(jiàn)的原因輸血風(fēng)險(xiǎn)非感染性課件輸血風(fēng)險(xiǎn)非感染性課件Hemoglo

26、bin Level Change During DHTRHemoglobin Level Change DuringHemoglobin Level Change During DHTRHemoglobin Level Change During*Many patients may be asymptomatic*Many patients may be asymptom血管外溶血性輸血反應(yīng) 癥狀：虛弱不舒服頭疼體征紅細(xì)胞壓積降低黃疸（高膽紅素血癥）發(fā)熱直抗試驗(yàn)陽(yáng)性*很多病人可能沒(méi)有癥狀血管外溶血性輸血反應(yīng) 癥狀：DHTR- Criteria Pre-transfusion:Negative

27、pretransfusion antibody screenNegative crossmatchPost-transfusion:Crossmatch with post-transfusion serum becomes positiveAlloantibody detectedClinical and laboratory evidence of hemolysis Past history of pregnancy or transfusionsDHTR- Criteria Pre-transfus延遲性溶血性輸血反應(yīng)診斷標(biāo)準(zhǔn)輸血前：輸血前抗體篩查陰性交叉配血試驗(yàn)陰性輸血后：用輸血后的

28、血清進(jìn)行交叉配血試驗(yàn)呈陽(yáng)性檢測(cè)到同種抗體 臨床和實(shí)驗(yàn)室證明溶血 既往有懷孕或輸血史延遲性溶血性輸血反應(yīng)診斷標(biāo)準(zhǔn)輸血前：DHTR- Laboratory FindingsUnexplained anemiaPositive direct antiglobulin test (DAT)Antibody in posttransfusion RBC eluate: Non-ABO RBC alloantibodiesDHTR- Laboratory FindingsUnexp延遲性溶血性輸血反應(yīng)實(shí)驗(yàn)室發(fā)現(xiàn)無(wú)法解釋的貧血直抗陽(yáng)性輸血后紅細(xì)胞洗出液存在抗體： 非-ABO紅細(xì)胞同種抗體延遲性溶血性輸血反應(yīng)

29、實(shí)驗(yàn)室發(fā)現(xiàn)無(wú)法解釋的貧血Antibodies Implicated in DHTRJohns Hopkins seriesAnti-E 47%Anti-Jka 23% ( clinically important)Anti K 15% Antibodies Implicated in DHTR延遲性溶血性輸血反應(yīng)中的抗體霍普金斯醫(yī)院資料抗-E 47%抗-Jka 23%（臨床意義）抗-K 15% 延遲性溶血性輸血反應(yīng)中的抗體霍普金斯醫(yī)院資料抗-E DHTR TimelineTIME (DAYS)EVENTCAUSE0Negative testsAntibody not detectable1RB

30、Cs given3-10Clinical hemolysisAccelerated RBC destruction10-21Positive DAT and A/S detectedAntibody titer increases and sensitizes cells21DAT negativeSensitized donor cells clearedDHTR TimelineTIME (DAYS)EVENTC延遲性溶血性輸血反應(yīng)時(shí)間表天事件原因0 試驗(yàn)陰性抗體不可被檢測(cè)1RBCs given3-10臨床溶血紅細(xì)胞破壞加速 10-21直抗陽(yáng)性，監(jiān)測(cè)到A/S抗體滴度增加，細(xì)胞致敏21直抗陰

31、性捐獻(xiàn)者致敏細(xì)胞被清除延遲性溶血性輸血反應(yīng)時(shí)間表天事件原因0 試驗(yàn)陰性抗體不可被檢DHTR PreventionImproved patient care by developing mechanism to identify patients, counsel them about future transfusions, provide early warnings to health care providers.Prevention with careful transfusion history, registries of alloimmunized patientsDHTR Pr

32、eventionImproved patien延遲性溶血性輸血反應(yīng)的預(yù)防通過(guò)對(duì)病人身份鑒定、 和他們商討未來(lái)的的輸血，對(duì)健康看護(hù)者提供早期警告來(lái)改進(jìn)對(duì)病人的照顧對(duì)同種免疫的病人備案，仔細(xì)詢問(wèn)既往輸血史 預(yù)防延遲性溶血性輸血反應(yīng)延遲性溶血性輸血反應(yīng)的預(yù)防通過(guò)對(duì)病人身份鑒定、 和他們商討未Typical sequence of chest X-rays changes:Left: Normal CXR prior to transfusionMiddle:2 hrs posttransfusion, showing bilateral pulmonary infiltrates c/w pulmo

33、nary edemaRight:48 hours posttransfusion, showing clearing of pulmonary infiltratesChest X-ray in a post-transfusion patientTypical sequence of chest X-ra一名病人輸血后的胸片典型的胸片改變左圖輸血前正常胸片中圖輸血后2小時(shí)顯示肺兩側(cè)有浸潤(rùn)，肺水腫右圖輸血后48小時(shí)顯示肺浸潤(rùn)清除一名病人輸血后的胸片典型的胸片改變Transfusion Related Acute Lung Injury (TRALI)Acute Lung Injury (ALI

34、)Acute onset of hypoxiaBilateral infiltrates on chest X-rayFever, mild hypotensionHappens within 6 hours of transfusionPlasma containing product (FFP, Plt, RBC)Rule out other reasons for ALISepsis, pneumonia, DIC, aspiration etcTRALI can cause patient deathThe #1 cause for transfusion related dealth

35、 in USA in 2001-2003Transfusion Related Acute Lung輸血相關(guān)性急性肺損傷急性肺損傷組織缺氧急性發(fā)作透雙側(cè)浸潤(rùn)發(fā)熱、輕度低血壓輸血后6小時(shí)內(nèi)發(fā)生 血漿含有血制品（新鮮冰凍血漿、血小板、紅細(xì)胞）排除其他急性肺損傷原因敗血癥、肺炎、彌漫性血管內(nèi)凝血、吸入等輸血相關(guān)急性肺損傷可使病人死亡是2001-2003年美國(guó)輸血相關(guān)死亡的首位原因。輸血相關(guān)性急性肺損傷急性肺損傷TRALI-Differential DiagnosisAnaphylactic Transfusion ReactionCirculatory OverloadBacterial conta

36、minationTRALI-Differential DiagnosisAnTRALI的鑒別診斷過(guò)敏性輸血反應(yīng)循環(huán)量超負(fù)荷細(xì)菌污染TRALI的鑒別診斷過(guò)敏性輸血反應(yīng)TRALI-Mechanism Immunological reactionAntibodies to white cellsanti-HLA or granulocyte specific Usually in donorsLess often in recipientsTRALI-Mechanism Immunological TRALI發(fā)生機(jī)制免疫學(xué)反應(yīng)白細(xì)胞的抗體抗- HLA或粒細(xì)胞特異性抗體通常在獻(xiàn)血者中在受血者中不常見(jiàn)T

37、RALI發(fā)生機(jī)制免疫學(xué)反應(yīng)TRALI-Prevention Prevention:Exclude multiparous donors from plasma donoation (UK)Minimize the use of high-plasm-volume products from leukocyte-alloimmunized donors (US)TRALI-Prevention Prevention:TRALI預(yù)防預(yù)防：不用經(jīng)產(chǎn)婦血漿（英國(guó)）最小限度地使用白細(xì)胞同種免疫的捐獻(xiàn)者的高血漿量的血制品TRALI預(yù)防預(yù)防：TRALI-Treatment Respiratory suppo

38、rt:Oxygen supplementationIntubation / mechanical ventilationMost patients improve clinically within 48-96 hrs if treated promptlyTRALI-Treatment Respiratory suTRALI治療呼吸支持：補(bǔ)充氧插管法/機(jī)械換氣大部分病人如果治療迅速在 48-96小時(shí)內(nèi)臨床緩解TRALI治療呼吸支持：TRALI Summary Pulmonary leukoagglutination syndromeReaction to donor antibodies a

39、gainst recipient white cellsRespiratory distress, hypoxia, pulmonary edema, 5 to 8 % mortalityIntubation, 100% O2, defer donors Reactions more likely with larger quantities of plasma from multiparous donorsTRALI Summary Pulmonary leukoaTRALI小結(jié)肺白細(xì)胞凝集綜合癥受者白細(xì)胞對(duì)捐獻(xiàn)者抗體的反應(yīng)呼吸困難、組織缺氧、肺水腫 、5-8%死亡率插管法、100% O2、

40、捐獻(xiàn)者延期獻(xiàn)血反應(yīng)大多是由于輸注大量經(jīng)產(chǎn)婦獻(xiàn)血者的血漿造成TRALI小結(jié)肺白細(xì)胞凝集綜合癥Transfusion Associated Circulatory Overload (TACO)Congestive heart failure cause by transfusionDiminished cardiac reservePre-transfusion fluid overloadIV infusion, chronic anemia etcEspecially in old or very young patientsRapid infusion or massive transfu

41、sionSymptoms caused by acute pulmonary edema:Dyspnea, tachycardia, orthopenea, BP increase, cyanosis, pulmonery/pedal edemaTransfusion Associated Circula輸血相關(guān)性循環(huán)超負(fù)荷輸血造成的充血性心衰 心力儲(chǔ)備降低輸血前輸液過(guò)量靜脈注射、慢性貧血等 特別是老年人和小年齡病人快速或大量輸血急性肺水腫造成的癥狀：呼吸困難、心動(dòng)過(guò)速、端坐呼吸、血壓增高、紫紺、肺/ 下肢水腫輸血相關(guān)性循環(huán)超負(fù)荷輸血造成的充血性心衰TACO-Differential diag

42、nosisTRALI Hypotension Pulmonary wedge pressure normal or low Chest x-ray Anaphylaxis Rapid onset (seconds to minutes) Erythmatous confluent rashSevere hypotensionNo pulmonary edemaBacterial contamination Fever HypotensionTACO-Differential diagnosisTRA循環(huán)超負(fù)荷鑒別診斷急性輸血相關(guān)性肺損傷 低血壓 肺楔壓正?；蚱?胸透過(guò)敏反應(yīng)快速發(fā)作紅斑綜合性

43、皮疹嚴(yán)重的低血壓無(wú)肺水腫細(xì)菌污染發(fā)熱 低血壓循環(huán)超負(fù)荷鑒別診斷急性輸血相關(guān)性肺損傷TACO-PreventionIdentify susceptible patients:Old, young, history of heart disease, fluid overload, chronic anemia etcSlow infusion: 1 ml/kg body weight/hour Concentrate componentsSplit a component Close monitoring of symptomsTACO-PreventionIdentify suscep循環(huán)超負(fù)

44、荷預(yù)防確定易感者：年老、小病人、有心臟病史、輸液過(guò)量、慢性貧血等輸血速度減慢每公斤體重每小時(shí)輸1ml血 濃縮成份分離血液成份密切監(jiān)測(cè)癥狀 循環(huán)超負(fù)荷預(yù)防確定易感者：SEPTIC REACTIONSMicrobial contaminationFever (hours), shock, hypotensionGram stain, bacterial culturePlatelets (room temp storage) Red cell reactions less common but often due to Yersinia infectionSEPTIC REACTIONSMicro

45、bial cont敗 血 癥微生物污染發(fā)熱、休克、低血壓革蘭氏染色、細(xì)菌培養(yǎng)血小板（室溫保存）紅細(xì)胞反應(yīng)少見(jiàn)，但經(jīng)常是由于耶爾森氏菌感染敗 血 癥微生物污染Transfusion-Associated GVHDClassic GVHD symptoms: diarrhea, skin rash, hepatitisBone marrow failure -aplastic anemia common with TA-GVHDDeath (infection) 2 to 3 weeks post transfusionTransfusion-Associated GVHDCla輸血相關(guān)的移植物抗

46、宿主病經(jīng)典的癥狀：痢疾、皮疹、肝炎骨髓衰竭再生障礙性貧血常見(jiàn)于是輸血相關(guān)的移植物抗宿主病輸血后2-3周死亡（死于感染）輸血相關(guān)的移植物抗宿主病經(jīng)典的癥狀：痢疾、皮疹、肝炎PATIENTS AT RISK for TA-GVHDIn-utero transfusionsYoung childrenPatients with congenital immunedeficiencyPatients with acquired immunosuppressionCancerImmunesuppressive therapy Recipients of related donor bloodPATIEN

47、TS AT RISK for TA-GVHDIn存在有輸血相關(guān)的移植物抗宿主病風(fēng)險(xiǎn)的病人 子宮內(nèi)的輸血 年幼兒童 有先天免疫缺陷的病人 有獲得性免疫抑制、癌癥、接受免疫抑制治療的病人 親緣性輸血的受血者存在有輸血相關(guān)的移植物抗宿主病風(fēng)險(xiǎn)的病人 子宮內(nèi)的輸Prevention of TA-GVHD: IRRADIATED BLOODIrradiation at the correct dose destroys lymphocytes ability to reproduce, therefore eliminate risk of TA-GVHDLuokoreduction is NOT su

48、fficient, because a very small number of live lymphocytes can still cause TA-GVHDPrevention of TA-GVHD: IRRADITA-GVHD預(yù)防 血液輻照適當(dāng)劑量的輻照損壞白細(xì)胞的再生能力，因此可減少輸血相關(guān)移植物抗宿主病的風(fēng)險(xiǎn)去白是不夠的，因?yàn)榉浅Ｉ倭康幕畹陌准?xì)胞仍舊可以造成輸血相關(guān)移植物抗宿主病TA-GVHD預(yù)防 血液輻照適當(dāng)劑量的輻照損壞白細(xì)胞的再生FEBRILE, NON-HEMOLYTIC REACTIONSTemperature elevation 1 CWBC antibodies in

49、 patient serum reacting with donor WBC or plateletsCytokines generated by stored WBCMust be distinguished from hemolytic and septic reactionsFEBRILE, NON-HEMOLYTIC REACTIO非溶血的發(fā)熱反應(yīng) 溫度升高1C 病人血清中的白細(xì)胞抗體與捐獻(xiàn)者的白 細(xì)胞或血小板反應(yīng) 儲(chǔ)存的白細(xì)胞產(chǎn)生細(xì)胞因子 必須與溶血反應(yīng)和敗血癥區(qū)別非溶血的發(fā)熱反應(yīng) 溫度升高1CFEBRILE, NON-HEMOLYTIC REACTIONSPreventable b

50、y use of leukoreduced blood componentsMay be applied for selected patients with previous reactions or universally to prevent reactions in all patientsPre-medication: TylenolWashing components may also help to remove cytokines or white cells from blood componentsFEBRILE, NON-HEMOLYTIC REACTIO非溶血性發(fā)熱反應(yīng)

51、通過(guò)使用去白血液制品可以預(yù)防去白血制品可用于以前有反應(yīng)的病人或者普遍用于 預(yù)防輸血反應(yīng)輸前用藥：羥苯基乙酰胺血液成份洗滌也可有助于去除細(xì)胞因子或白細(xì)胞非溶血性發(fā)熱反應(yīng)通過(guò)使用去白血液制品可以預(yù)防輸血風(fēng)險(xiǎn)非感染性課件病理免疫介導(dǎo)的組胺的釋放處理抗組胺劑類固醇（嚴(yán)重）腎上腺素（嚴(yán)重）洗滌紅細(xì)胞（抗-IgA）過(guò) 敏 反 應(yīng)病理過(guò) 敏 反 應(yīng)ALLERGIC REACTIONSHypersensitivity (IgE) response to donor plasma proteins; hives, flushing, tachycardia are most common signs and s

52、ymptomsBronchospasm or anaphylaxis can occur, often with IgA deficiencyBenadryl, corticosteroids, concentrated or washed productsMost common cause of transfusion reaction, particularly with products containing plasmaALLERGIC REACTIONS過(guò)敏反應(yīng)對(duì)捐獻(xiàn)者的血漿蛋白超敏反應(yīng)（IgE），麻疹、臉紅、心動(dòng)過(guò)速都是常見(jiàn)的體征和癥狀 會(huì)發(fā)生支氣管痙攣或過(guò)敏反應(yīng)，常常IgA缺乏二

53、苯醇胺、皮質(zhì)類固醇，濃縮或洗滌血液產(chǎn)品是最普遍的輸血反應(yīng)的原因，特別是含血漿的血制品過(guò)敏反應(yīng)Massive TransfusionDefinition:Receiving 10 units of blood (replacing one blood volume) in 24 hours:Replacing 50% of the circulating blood volume in 10U血液：在3小時(shí)內(nèi)置換了50%循環(huán)血量通常發(fā)生在：外傷、主動(dòng)脈瘤破裂、嚴(yán)重的出血（胃腸道、外科手術(shù)中等）大 量 輸 血定義Massive Transfusion-ComplicationsHypothermiaHemostatic abnormalities Dilutional coagulopathyDICMetab