... konulu sunumlar: "KAN TRANSFÜZYONLARI VE KOMPLİKASYONLARI"— Sunum transkripti:
1 KAN TRANSFÜZYONLARI VE KOMPLİKASYONLARI DOÇ.DR SUAT BİÇERYEDİTEPE ÜNİVERSİTESİ TIP FAKÜLTESİÇOCUK SAĞLIĞI VE HASTALIKLARI AD
2 Transfüze edilen kan ürünleri Eritrosit (RBC)Trombosit (PLT)Granülosit (Nötrofil)Plazma
3 Eritrosit (RBC) Transfüzyonu Amaç:Kanın oksijen taşıma kapasitesini artırmakDoku oksijenasyonunu devam ettirmekRed blood cells (RBCs) are transfused to increase the oxygen-carrying capacity of the blood and, in turn, to maintain satisfactory tissue oxygenation. However, transfusions may be given more stringently to children, because normal hemoglobin levels are lower in healthy children than in adults and, often, children do not have the underlying multiorgan, cardiorespiratory, and vascular diseases that develop with aging in adults. Thus, children often compensate better for RBC loss and, as is true for patients of all ages, there is increasing enthusiasm for conservative practices (i.e., low pre-transfusion hematocrit values).BibliographyBell EF, Strauss RG, Widness JA, et al: Randomized trial of liberal versus restrictive guidelines for red blood cell transfusion in preterm infants. Pediatrics 2005; 115:Centers for Disease Control and Prevention : HIV transmission through transfusion—Missouri and Colorado, 2008. MMWR 2010; 59(41):Eder AF, Hillyer CD, Dy BA, et al: Adverse reactions to allogeneic whole blood donation by 16- and 17-year olds. JAMA 2008; 299:Guay J, de Moerloose P, Lasne D: Minimizing perioperative blood loss and transfusions in children. Can J Anaesth 2006; 53:Hebert PC, McDonald BJ, Tinmouth A: Clinical consequences of anemia and red cell transfusion in the critically ill. Crit Care Clin 2004; 20:Kirpalani H, Whyte RK, Andersen C, et al: The premature infants in need of transfusion (PINT) study: a randomized, controlled trial of a restrictive (low) versus liberal (high) transfusion threshold for extremely low birth weight infants. J Pediatr 2006; 149:Kuehn BM: CDC launches surveillance system to improve blood transfusion safety. JAMA 2010; 303:1467.Lacroix J, Hébert PC, Hutchison JS, et al: Transfusion strategies for patients in pediatric intensive care units. N Engl J Med 2007; 356:The Lancet: Improving blood safety worldwide : Lancet 2007; 370:361.Lee JS, Gladwin MT: The risks of red cell storage. Nat Med 2010; 16:Morley SL: Red blood cell transfusions in acute paediatrics. Arch Dis Child Educ Pract Ed 2009; 94:65-73.Ross SD, Allen IE, Henry DH, et al: Clinical benefits and risks associated with epoetin and darbepoetin in patients with chemotherapy-induced anemia: a systematic review of the literature. Clin Ther 2006; 28:Stramer SL, Wend U, Candotti D, et al: Nucleic acid testing to detect HBV infection in blood donors. N Engl J Med 2011; 364(3):Strauss RG: Commentary: is it safe to limit allogeneic red blood cell transfusions to neonates?. Neonatology 2008; 93:Strauss RG: Controversies in the management of the anemia of prematurity using single-donor red blood cell transfusion and/or recombinant human erythropoietin. Transfus Med Rev 2006; 20:34-44.Strauss RG: How I transfuse red blood cells and platelets to infants. Transfusion 2008; 48:Vamvakas EC, Strauss RG: Meta-analysis of controlled clinical trials studying the efficacy of recombinant human erythropoietin in reducing blood transfusions in the anemia of prematurity. Transfusion 2001; 41:406.
4 ÇOCUK VE ADOLESAN (>1 YAŞ) Akut kan kaybı (>%25)Hb < 8 g/dL (Perioperatif dönemde)Hb < 13 g/dl ve ağır kardiyopulmoner yetersizlik varsaHb < 8 g/dL ve semptomatik kronik anemi varsaHb < 8 g/dL ve kemik iliği yetersizliği varsaBEBEK (≤ 4 AY)Hb < 13 g/dl ve ağır pulmoner hastalık varsaHb < 13 g/dl ve ağır kardiyak hastalık varsaHb < 10 g/dl ve orta derecede pulmoner hastalık varsaHb < 10 g/dL ve major cerrahi geçirecekseHb < 8 g/dL ve semptomatik anemi varsaGUIDELINES FOR PEDIATRIC RED BLOOD CELL TRANSFUSIONS*[†]CHILDREN AND ADOLESCENTSAcute loss of > 25% of circulating blood volumeHemoglobin < 8.0 g/dL[†] in the perioperative periodHemoglobin < 13.0 g/dL and severe cardiopulmonary diseaseHemoglobin < 8.0 g/dL and symptomatic chronic anemiaHemoglobin < 8.0 g/dL and marrow failureINFANTS ≤ 4 MO OLDHemoglobin < 13.0 g/dL and severe pulmonary diseaseHemoglobin < 10.0 g/dL and moderate pulmonary diseaseHemoglobin < 13.0 g/dL and severe cardiac diseaseHemoglobin < 10.0 g/dL and major surgeryHemoglobin < 8.0 g/dL and symptomatic anemia
5 Postoperatif dönem Akut hemoraji Devam eden kan kaybı + hemodinamik instabilite TransfüzyonAkut hemorajiKanamanın durdurulması + Perfüzyonun sağlanması (kristalloid/kolloid)Kan kaybı > kan hacminin %25’i (>17 ml/kg) ve instabil hastaTransfüzyonIn the perioperative period, it is unnecessary for most children to maintain hemoglobin levels of 8 g/dL or greater, a level frequently desired for adults. There should be a compelling reason to prescribe any postoperative RBC transfusion, such as continued bleeding with hemodynamic instability, because most children (without continued bleeding) can, over time, restore their RBC mass with iron therapy. The most important measures in the treatments of acute hemorrhage are to control the hemorrhage and to restore the circulating blood volume and tissue perfusion with crystalloid and/or colloid solutions. If the estimated blood loss is > 25% of the circulating blood volume (>17 mL/kg) and the patient's condition remains unstable, RBC transfusions may be indicated along with plasma transfusions at a 1 : 1 ratio of RBC : plasma volumes. In acutely ill children with severe pulmonary disease requiring assisted ventilation, it is common practice to maintain the hemoglobin level close to the normal range, although the efficacy of this practice has not been documented by controlled scientific studies.
6 Ağır pulmoner hastalık Ventilasyon desteği gerektiren ağır akciğer hastalığında Hb normal düzeylerde tutulmalıdır.The pre-transfusion blood hemoglobin level or hematocrit that should prompt a RBC transfusion is controversial (i.e., restricted or a low pre-transfusion level vs liberal or a high pre-transfusion level) despite a substantial amount of published information, including randomized clinical trials. Some physicians in critical care settings prefer to transfuse RBCs quite conservatively (i.e., restricted guidelines) and to permit modest anemia, because patients with levels close to the normal range (i.e., liberal guidelines) have poorer outcomes. Studies in critically ill adults demonstrated better outcomes when the hemoglobin level was maintained at 7-9 g/dL than at 10-12 g/dL. However, anemic adults with significant cardiac disease did better with hemoglobin levels maintained at 13 g/dL than at 10 g/dL. Similar studies in children admitted to intensive care units found no inferiority when RBC transfusions were given by restricted guidelines (transfusion threshold of 7 g/dL), although the patients were in stable clinical status and needed few transfusions. In contrast, unstable critically ill children may need more liberal RBC transfusions.
7 AnemiDemir eksikliği anemisi genelde iyi kompanse edilir ve oral demir tedavisine iyi yanıt alınır. (Hb>5 g/dL).Transfüzyon kararı:Çocuğun semptomları, bulguları, kompansasyon kapasitesine,Kardiyorespiratuar, vasküler ve merkezi sinir sistemi hastalığı olup olmamasına,Aneminin nedenine ve izlemine göre verilir.Alternatif tedaviler (Eritropoetin-KBY)Orak hücreli anemi ve talasemi majorThe pre-transfusion blood hemoglobin level or hematocrit that should prompt a RBC transfusion is controversial (i.e., restricted or a low pre-transfusion level vs liberal or a high pre-transfusion level) despite a substantial amount of published information, including randomized clinical trials. Some physicians in critical care settings prefer to transfuse RBCs quite conservatively (i.e., restricted guidelines) and to permit modest anemia, because patients with levels close to the normal range (i.e., liberal guidelines) have poorer outcomes. Studies in critically ill adults demonstrated better outcomes when the hemoglobin level was maintained at 7-9 g/dL than at 10-12 g/dL. However, anemic adults with significant cardiac disease did better with hemoglobin levels maintained at 13 g/dL than at 10 g/dL. Similar studies in children admitted to intensive care units found no inferiority when RBC transfusions were given by restricted guidelines (transfusion threshold of 7 g/dL), although the patients were in stable clinical status and needed few transfusions. In contrast, unstable critically ill children may need more liberal RBC transfusions.may need more liberal RBC transfusions.With chronic anemia, the decision to transfuse RBCs should not be based solely on blood hemoglobin levels, because children compensate well and may be asymptomatic despite low hemoglobin levels. Patients with iron deficiency anemia are often treated successfully with oral iron alone, even at hemoglobin levels < 5 g/dL. Factors other than hemoglobin concentration to be considered in the decision to transfuse RBCs include: (1) the patient's symptoms, signs, and compensatory capacities; (2) the presence of cardiorespiratory, vascular, and central nervous system disease; (3) the cause and anticipated course of the anemia; and (4) alternative therapies, such as recombinant human erythropoietin (EPO) therapy, which is known to reduce the need for RBC transfusions and to improve the overall condition of children with chronic renal insufficiency (Chapter 529.2). In anemias that are likely to be permanent, it is also important to balance the detrimental effects of anemia on growth and development against the potential toxicity associated with repeated transfusions.
8 YenidoğanFötal Hb var. Oksijen tutma kapasitesi yüksek. 2-3 difosfogliseratla ilişkisi zayıf.Kalp, akciğer ve damarların anemiyi kompanse etme yeteneği zayıf.Renal, hepatik ve nörolojik fonksiyonlar henüz tam gelişmemiş.Siyanotik konjenital kalp hastalıklı yenidoğanda Hb>13 g/dL (Hct>%40) düzeyde tutulmalıdır.Major cerrahi geçirecek olan yenidoğanda Hb>10 g/dL, Hct>%30 olmalıdır.Semptomatik anemide: Taşipne, dispne, taşikardi, apne, bradikardi, beslenmede güçlük, letarjiLow plasma EPO levels provide a rationale for the use of recombinant EPO in the treatment of anemia of prematurity. Proper doses of EPO and iron effectively stimulate neonatal erythropoiesis. However, the efficacy of EPO therapy to substantially diminish the need for RBC transfusions has not been convincingly demonstrated, particularly for sick, extremely premature neonates, and recombinant EPO has not been widely accepted as a treatment for anemia of prematurity (Chapter 97.1). In rare cases, some preparations of EPO have been associated with the development of anti-EPO antibodies in adults that have produced severe anemia.Because of the controversies over recombinant EPO therapy, many low birthweight preterm infants need RBC transfusions (see Table 464-1). In neonatal patients with severe respiratory disease, defined as requiring relatively large quantities of oxygen and ventilator support, it has been customary to maintain blood hemoglobin at > 13 g/dL (hematocrit > 40%). Proponents believe that transfused RBCs containing adult hemoglobin, with their superior interaction with 2,3-diphosphoglycerate and leading to better oxygen offloading than that of fetal hemoglobin, are likely to provide optimal oxygen delivery throughout the period of diminished pulmonary function. Although this practice is widely recommended, little evidence is available to firmly establish its efficacy or to define its optimal use (the best hemoglobin level for each degree of pulmonary dysfunction), and as mentioned earlier, more restricted guidelines have been suggested. Infants with less severe cardiopulmonary disease may require less vigorous support; hence, a lower hemoglobin level is suggested for those with only moderate disease. Consistent with the rationale for oxygen delivery in neonates with severe respiratory disease, it seems appropriate to keep the hemoglobin value > 13 g/dL (hematocrit > 40%) in neonates with severe cardiac disease leading to either cyanosis or congestive heart failure.The optimal hemoglobin level for neonates facing major surgery has not been established by definitive studies. However, it seems reasonable to maintain the hemoglobin level at > 10 g/dL (hematocrit > 30%) because of the limited ability of a neonate's heart, lungs, and vasculature to compensate for anemia; the inferior off-loading of oxygen because of the diminished interaction between fetal hemoglobin and 2,3-diphosphoglycerate; and the developmental impairment of neonatal renal, hepatic, and neurologic function. This transfusion guideline must be applied with flexibility to individual infants facing different kinds of surgery.Stable neonates do not require RBC transfusion, regardless of their blood hemoglobin levels, unless they exhibit clinical problems attributable to anemia. Proponents of RBC transfusions for symptomatic anemia believe that the low RBC mass contributes to tachypnea, dyspnea, tachycardia, apnea and bradycardia, feeding difficulties, and lethargy, which can be alleviated by transfusion of RBCs. However, anemia is only one of several possible causes of these problems, and RBC transfusions should only be given when clinical problems are attributable to the anemia.
9 Eritrosit suspansiyonu Tam kandan sentifugasyonla ayrılır.Antikoagülan ve koruyucu eklenerek, %60 Hct (%70-90) düzeyiyle kan bankasında 42 güne dek saklanabilir.10-15 ml/kg dozda, 2-4 saat sürede verilir.Hiperpotasemi !! (50 mEq/L) (Özellikle yüksek volümde (>25 ml/kg) transfüzyonda riskli)Taze eritrosit suspansiyonuThe RBC product of choice for children and adolescents is the standard suspension of RBCs separated from whole blood by centrifugation and resuspended in an anticoagulant/preservative storage solution at a hematocrit value of approximately 60% for storage up to 42 days, per U.S. Food and Drug Administration (FDA) approval. The usual dose is 10-15 mL/kg, but transfusion volumes vary greatly, depending on clinical circumstances (continued vs arrested bleeding, hemolysis). For neonates, many centers transfuse the same RBC product as selected for older children, whereas others prefer a packed RBC concentrate (hematocrit 70-90%). Either is infused slowly (over 2-4 hr) at a dose of approximately 15 mL/kg. Because of the small quantity of extracellular fluid given at these relatively high hematocrit values and the slow rate of transfusion, the type of RBC anticoagulant/preservative solution used does not pose risks for premature infants. Packing RBCs by centrifugation at the time the aliquot is issued for transfusion ensures that a consistent RBC dose is infused with each transfusion but is not mandatory and is impractical for some blood banks.Depolama süresi <7 günHiperpotasemi riski düşükYenidoğanlarda daha çok tercih edilir.
10 TROMBOSİT (PLT) TRANSFÜZYONU Trombositopeni (< 50 × 109/L) + kanama riski- Major cerrahi- Trombositopeni + kanamaGuidelines for platelet (PLT) support of children and adolescents with quantitative and qualitative PLT disorders are similar to those for adults (see Table on the Nelson Textbook of Pediatrics website at ), in whom the risk of life-threatening bleeding after injury or occurring spontaneously can be related to the severity of thrombocytopenia. PLT transfusions should be given to patients with PLT counts < 50 × 109/L when they are bleeding or are scheduled for an invasive procedure, and the PLT count should be maintained > 50 × 109/L until bleeding ceases or the patient is stable after the procedure.
11 PLT transfüzyonu endikasyonları Çocuk ve adolesan: PLT < 50 × 109/L ve kanama var,PLT < 50 × 109/L ve invazif prosedür uygulanacak,PLT < 20 × 109/L ve kemik iliği yetersizliği ve kanama riski var enfeksiyon, organ yetersizliği, pıhtılaşma bozukluğu, mukozal lezyonlar, ağır graft versus host hastalığı, anemi),PLT < 10 × 109/L ve kemik iliği yetersizliği var,Trombositler herhangi bir sayıda, trombosit disfonksiyonu var ve kanama var veya invazif prosedür geçirecek.CHILDREN AND ADOLESCENTSPLT count < 50 × 109/L and bleedingPLT count < 50 × 109/L and an invasive procedurePLT count < 20 × 109/L and marrow failure with hemorrhagic risk factorsPLT count < 10 × 109/L and marrow failure without hemorrhagic risk factorsPLT count at any level, but with PLT dysfunction plus bleeding or an invasive procedureINFANTS ≤ 4 MO OLDPLT count < 100 × 109/L and bleeding or during extracorporeal membrane oxygenationPLT count < 20 × 109/L and clinically stablePLT count < 50 × 109/L and clinically unstable
12 PLT transfüzyonu endikasyonları < 4 ay: PLT < 100 × 109/L ve kanama var ya da ECMO uygulanıyor,PLT < 50 × 109/L ve invazif prosedür uygulanacak,PLT < 50 × 109/L ve klinik anstabil,PLT < 20 × 109/L ve klinik stabil,Trombositler herhangi bir sayıda, trombosit disfonksiyonu var ve kanama var veya invazif prosedür geçirecek.PLT count < 100 × 109/L and bleeding or during extracorporeal membrane oxygenationPLT count < 50 × 109/L and an invasive procedurePLT count < 20 × 109/L and clinically stablePLT count < 50 × 109/L and clinically unstablePLT count at any level, but with PLT dysfunction plus bleeding or an invasive procedure
13 Trombositopeni ve risk faktörleri Ateş,Antimikrobiyal tedavi,Aktif kanama,İnvazif prosedür gereksinimi olması,Yaygın damar içi pıhtılaşma (DIC),Pıhtılaşma sorunu olan hastada karaciğer-böbrek bozukluğu olması.Hedef PLT > 50 × 109/LStudies of patients with thrombocytopenia resulting from bone marrow failure indicate that the risk of spontaneous bleeding increases markedly when PLT levels fall to < 20 × 109/L, and hemorrhagic risk factors (infection, organ failure, clotting abnormalities, mucosal lesions, severe graft versus host disease, or anemia) are present. In this high-risk setting, prophylactic PLT transfusions are given to maintain a PLT count > 20 × 109/L. This threshold has been challenged by studies of adult patients, who in many instances were selected to be in relatively good clinical condition without hemorrhagic risk factors. Consequently, a lower PLT transfusion trigger of 5-10 × 109/L is recommended for stable (i.e., low-risk) patients. In practice, however, severe thrombocytopenia is commonly associated with the development/occurrence of risk factors, including fever, antimicrobial therapy, active bleeding, need for an invasive procedure, disseminated intravascular coagulation, and liver or kidney dysfunction with clotting abnormalities. In these situations, PLT transfusions are given to maintain relatively high PLT counts. Despite the desire by some physicians to elevate the blood PLT count to 80 × 109/L or 100 × 109/L or even higher, there are no definitive data to justify a true benefit of PLT transfusions given at a PLT count > 50 × 109/L, unless bleeding is active with a PLT count between 50 and 100 × 109/L and thrombocytopenia seems to be the only cause.
14 Kalitatif trombosit fonksiyon bozuklukları Kalıtımsal ya da edinsel (karaciğer-böbrek fonksiyon bozukluğu ya da ECMO, kardiyak by-pass)Ömür boyu sürebilir (kalıtsal)Tekrarlanan PLT transfüzyonları alloimmunizasyon ve duyarsızlık oluşturur.Sadece kanama varsa ya da invazif prosedür gereksinimi varsa PLT transfüze edilmeli.Kanama zamanı>x2Desmopressin asetat??Antiplatelet etkili ilaçlar (ör: NSAID) verilmemeli!Qualitative PLT disorders may be inherited or acquired (in advanced hepatic or renal insufficiency or when blood flows through an extracorporeal circuit, such as during extracorporeal membrane oxygenation [ECMO] or cardiopulmonary bypass). In patients with such disorders, PLT transfusions are justified only if the risk of significant bleeding is quite high or actually occurs. Because inherited PLT dysfunction often is lifelong and repeated transfusions may lead to alloimmunization and refractoriness (i.e., poor response to PLT transfusions), prophylactic PLT transfusions are rarely justified, unless an invasive procedure is planned. In these cases, an abnormal result with the use of a modern PLT function device or, historically, a bleeding time more than twice the upper limit of laboratory normal may be taken as diagnostic evidence of PLT dysfunction. However, an abnormal bleeding time or any other abnormal laboratory test result is poorly predictive of hemorrhagic risk or the need to transfuse PLTs. Alternative therapies, particularly desmopressin acetate, should be considered to avoid PLT transfusions. Antiplatelet medications (nonsteroidal anti-inflammatory drugs) should be avoided in these patients.
15 Yenidoğan Kanama ve tromboz için risk faktörleri fazla Trombosit yıkımı yüksekTrombosit yapımı düşükKemik iliğinde megakaryosit progenitörlerinin sayısı düşük- Trombopoetin yanıtı düşükTrombosit disfonksiyonu ve kanama ya da kanama riski yoksa >100 × 109/L
17 GRANÜLOSİT (NÖTROFİL) TRANSFÜZYONU Nötropenik hastalar antibiyotiklerin ve granülosit koloni stimülan faktörlerin etkin kullanımına rağmen progressif bakteriyel ve fungal enfeksiyonlara karşı risk altındadırlar . Özellikle hematopoetik progenitör hücre tedavisi alanlarda risk büyüktür.
18 Granülosit transfüzyon endikasyonları: Çocuk ve adolesanda:Ağır nötropeni (kan nötrofil sayısı <0.5 × 109/L) ve antimikrobiyal tedaviye rağmen devam eden bakteriyel ya da fungal enfeksiyon,Kalitatif nötrofil defekti ve antimikrobiyal tedaviye rağmen devam eden bakteriyel ya da fungal enfeksiyon olması.≤4 aylık bebeklerde:* İlk 1 haftalık yenidoğanda kan nötrofil sayısı <3.0 × 109/L ya da >1 haftada kan nötrofil sayısı <1.0 × 109/L olması ve fulminan bakteriyel enfeksiyon olmasıTable 466-1 -- GUIDELINES FOR PEDIATRIC GRANULOCYTE TRANSFUSIONS*CHILDREN AND ADOLESCENTSSevere neutropenia (blood neutrophil count <0.5 × 109/L) and infection (bacterial, yeast, or fungal) unresponsive or progressive despite appropriate antimicrobial therapy.Qualitative neutrophil defect and infection (bacterial or fungal) unresponsive to appropriate antimicrobial therapyINFANTS ≤4 MO OLDBlood neutrophil count <3.0 × 109/L in 1st wk of life or <1.0 × 109/L thereafter and fulminant bacterial infection*Words in italics must be defined for local transfusion guidelines.
19 Doz < 10 kg: 1-2 × 109/kg nötrofil / granülosit solüsyonu Adolesan: 5-8 × 1010 nötrofil / granülosit solüsyonuİstenilen nötrofil düzeyi: Birkaç gün süreyle 1.0 × 109/LOnce the decision to provide GTX has been made, an adequate dose of fresh leukapheresis cells must be transfused. Neonates and infants weighing < 10 kg should receive 1-2 × 109/kg neutrophils per GTX. Larger infants and children should receive a total dose of at least 1 × 1010 neutrophils per GTX; the preferred dose for adolescents is 5-8 × 1010 per GTX, a dose requiring donors to be stimulated with G-CSF plus dexamethasone. GTX should be given daily until either the infection resolves or the blood neutrophil count is sustained above 1.0 × 109/L for a few days.BibliographyPrice TH: Granulocyte transfusion therapy. J Clin Apheresis 2006; 21:65-71.Strauss RG: Neutrophil collection and transfusion. In: Simon TL, Snyder EL, Solheim BG, et al ed. Rossi's principles of transfusion medicine, ed 4. Bethesda, MD: AABB & Blackwell Publishing Ltd; 2009:
20 PLAZMA TRANSFÜZYONUPlazma proteinlerinin (özellikle pıhtılaşma faktörlerinin) replasmanı amacıyla uygulanır.İki tip plazma ürünü vardır1- Taze donmuş plazma (ilk 8 saatte hazırlanmış)2- 24 saatlik plazma (Faktör V ve VIII düzeyleri daha düşük)Doz: 15 ml/kgPlasma is transfused to replace clinically significant deficiencies of plasma proteins (nearly always clotting proteins) for which more highly purified concentrates are not available. Two interchangeable plasma products are available for transfusion, plasma frozen within 8 hr of collection (fresh frozen plasma) and plasma frozen within 24 hr of collection. Although levels of factors V and VIII are lower in the latter plasma product, they are equally efficacious for literally all indications for plasma transfusions (see Table 467-1). Requirements for plasma vary with the specific protein being replaced, but a starting dose of 15 mL/kg is usually satisfactory.
21 Plazma endikasyonları (Bebek, çocuk ve adolesan) Pıhtılaşma faktörlerinde ağır düzeyde eksiklik ve kanama,Pıhtılaşma faktörlerinde ağır düzeyde eksiklik ve invazif prosedür uygulanacak olması,Warfarin etkisinin acil olarak giderilme gereksinimi,Dilüsyonal koagülopati ve kanama (ör, masif transfüzyon),Antikoagülan protein (antitrombin III, protein C ve S) replasmanı,Plazma değişiminde replasman sıvısı olarak (ör: trombotik trombositopenik purpura), kanama riski taşıyan pıhtılaşma faktörlerinde eksiklik(ler), karaciğer yetersizliği). GUIDELINES FOR PEDIATRIC PLASMA TRANSFUSIONS*INFANTS, CHILDREN, AND ADOLESCENTSSevere clotting factor deficiency AND bleedingSevere clotting factor deficiency and an invasive procedureEmergency reversal of warfarin effectsDilutional coagulopathy and bleeding (e.g., massive transfusion)Anticoagulant protein (antithrombin III, proteins C and S) replacementPlasma exchange replacement fluid for thrombotic thrombocytopenic purpura or for disorders in which there is risk of bleeding due to clotting protein abnormalities (e.g., liver failure)
22 Faktör II, V, X, XI eksikliğinde plazma tam tedavi sağlar. Faktör XIII ve fibrinojen eksikliği: Kriyopresipitat,Faktör VII, VIII (hemofili A), IX eksikliklerinde (hemofili B) ve von Willebrand hastalığında spesifik faktörler verilmelidir.Hafif-orta şiddette hemofili A ve von Willebrand hastalığında desmopressin yararlı olabilir.Aktif kanama ya da acil cerrahi operasyon öncesi gibi warfarin etkisinin acil olarak giderilmesi gereken durumlarda ve faktör II, VII, IX ve X eksikliklerinde K vitamini yeterli olmaz, TDP gerekir.Transfusion of plasma is efficacious for the treatment of deficiencies of clotting factors II, V, X, and XI. Deficiencies of factor XIII and fibrinogen are treated with cryoprecipitate. Transfusion of plasma is not recommended for the treatment of patients with severe hemophilia A or B, von Willebrand disease, or factor VII deficiency, because safer factor VII, VIII, and IX concentrates are available. Moreover, mild to moderate hemophilia A and certain types of von Willebrand disease can be treated with desmopressin (Chapter 471). An important use of plasma is for rapid reversal of the effects of warfarin in patients who are actively bleeding or who require emergency surgery (in whom functional deficiencies of factors II, VII, IX, and X cannot be rapidly reversed by vitamin K). Results of screening coagulation tests (prothrombin, activated partial thromboplastin, and thrombin times) should not be assumed by themselves to reflect the integrity of the coagulation system or regarded as indications for plasma transfusions. To justify plasma transfusion, coagulation test results must be related to the patient's clinical condition. Transfusion of plasma in patients with chronic liver disease and prolonged clotting times is not recommended unless bleeding is present or an invasive procedure is planned, because correction of the clotting factor deficiencies is brief.
23 Tromboz eğilimiPlazmada antikoagülan etkili antitrombin III, protein C ve protein S de var.TTPPlasma also contains several anticoagulant proteins (antithrombin III, protein C, and protein S) whose deficiencies have been associated with thrombosis. In selected situations, plasma may be appropriate as replacement therapy, along with anticoagulant treatment, in patients with these disorders. However, when available, purified concentrates are preferred. Other indications for plasma include replacement fluid during plasma exchange in patients with thrombotic thrombocytopenic purpura (i.e., thrombotic microangiopathies) or other disorders for which plasma is likely to be beneficial (plasma exchange in a patient with bleeding and severe coagulopathy). Plasma is not indicated for correction of hypovolemia or as immunoglobulin replacement therapy, because safer alternatives exist (albumin or crystalloid solutions and IV immunoglobulin, respectively).
25 TRANSFÜZYONLARDA KOMPLİKASYON VE RİSKLER HIV (1/ )Hepatit C (1/ – )
26 Ürtiker ya da diğer deri reaksiyonları 1/50-100 TAHMİNİ RISKFebril reaksiyon1/300Ürtiker ya da diğer deri reaksiyonları1/50-100Eritrosit alloimmunizasyonu1/100Yanlış tranfüzyon1/14,000-19,000Hemolitik reaksiyon1/6,000Fatal hemoliz1/1,000,000Transfüzyonla ilişkili akciğer hasarı1/5,000HIV1 ve HIV21/2,000, ,000,000Hepatit B1/100, ,000Hepatit C1/1,000, ,000,000Human T-cell lenfotropik virüs (HTLV) I ve II1/641,000Bakteriyel kontaminasyon1/5,000,000Malarya1/4,000,000Anaflaksi1/20,000-50,000Graft versus host hastalığıSık değilİmmünmodulasyon?ESTIMATED RISKS IN TRANSFUSION PER UNIT TRANSFUSED IN THE USAESTIMATED RISKFebrile reaction1/300Urticaria or other cutaneous reaction1/50-100Red blood cell alloimmunization1/100Mistranfusion1/14,000-19,000Hemolytic reaction1/6,000Fatal hemolysis1/1,000,000Transfusion-associated lung injury1/5,000HIV1 and HIV21/2,000,000-3,000,000Hepatitis B1/100, ,000Hepatitis C1/1,000,000-2,000,000Human T-cell lymphotrophic virus (HTLV) I and II1/641,000Bacterial contamination1/5,000,000Malaria1/4,000,000Anaphylaxis1/20,000-50,000Graft versus host diseaseUncommonImmunomodulationUnknownFrom Klein HG, Spahn DR, Carson JL: Red blood cell transfusion in clinical practice, Lancet 370:415–426, 2007.
27 Enfeksiyöz riskler: HIV, hepatit C, CMV Hepatitis (A, B, E) ve retrovirüsler (human T-cell lenfotropik virüs tip I ve II ve HIV-2), sifilis, parvovirüs B19, Epstein-Barr virus, human herpesvirüs 8, Batı Nil virüsü, sarı humma aşı virüsü, malarya, babesiyoz, Anaplasma phagocytophilum ve Chagas hastalığı.Varyant Creutzfeldt-Jacob hastalığıTransfusion-associated cytomegalovirus (CMV) can be nearly eliminated by transfusion of leukocyte reduced cellular blood products or by selection of blood from donors who are seronegative for antibody to cytomegalovirus. Although it is logical to hypothesize that first collecting blood components from CMV-seronegative donors and then removing the white blood cells (WBCs) might improve safety, no data are available to document the efficacy of this combined approach. Moreover, findings from one study suggest that this combined approach, surprisingly, may be incorrect. Large quantities of CMV are present “free” in the plasma of healthy-appearing donors during primary infection (while CMV antibodies are either still absent or are newly emerging), rather than being leukocyte associated as they are during latent infection, when substantial quantities of antibodies are present. Thus, virus will not be removed by leukocyte reduction, and donors will be misclassified as CMV seronegative because antibody is below the limits of detection in window-phase or early infection. Because nearly all plasma CMV disappears after donors are seropositive for CMV antibody for several months and the virus is almost exclusively leukocyte associated at this time, the best method to reduce CMV risk may be to effectively perform leukocyte reduction of blood from donors known to be CMV seropositive for at least 1 year.Additional infectious risks include other types of hepatitis (A, B, E) and retroviruses (human T-cell lymphotropic virus types I and II and HIV-2), syphilis, parvovirus B19, Epstein-Barr virus, human herpesvirus 8, West Nile virus, yellow fever vaccine virus, malaria, babesiosis, Anaplasma phagocytophilum, and Chagas disease. Variant Creutzfeldt-Jacob disease has also been transmitted by blood transfusions in humans.
28 Enfeksiyon dışı riskler: Hemolitik ve non-hemolitik reaksiyonlar,Sıvı yüklenmesi,GVH hastalığı,Elektrolit ve asit-baz denge bozuklukları,Demir yüklenmesi,Oksidan hasara karşı yatkınlık artışı,Hemoliz,Post-transfüzyon purpura,Akut akciğer hasarı,İmmunsupresyon,Alloimmunizasyon.Transfusion-associated risks of a noninfectious nature that may occur include hemolytic and nonhemolytic transfusion reactions, fluid overload, graft versus host disease, electrolyte and acid-base imbalances, iron overload if repeated transfusions are needed long term, increased susceptibility to oxidant damage, exposure to plasticizers, hemolysis with T-antigen activation of red blood cells, post-transfusion purpura, acute lung injury, immunosuppression, and alloimmunization (see Table 468-1). Immunomodulation may be reduced by leukocyte reduction. Transfusion reactions and alloimmunization to red blood cell and leukocyte antigens seem to be uncommon in infants. Adverse effects are seen primarily in massive transfusion settings, such as exchange transfusions and trauma or surgery, in which relatively large quantities of blood are needed, but are rare with the small-volume transfusions usually given.
29 GVH önlemi için irradyasyon Prematürebebeklerde immun olgunlaşma yetersizliği Post-transfüzyon graft versus host hastalığı gelişim riskinde artış?Bebeğin postnatal yaşı,Transfüze edilen üründeki immunocompetan lenfosit sayısı,Donör ve alıcı arasındaki HLA uyumluluğu,Birçok yerde prematürelere kan ürünleri gama ışınlanmış (γ-irradiated) olarak verilmektedir.İntrauterin ve kan değişiminde kullanılan lökosit içeren kan ürünlerine,- Ağır kombine immun yetersizliği olanlara verilecek olan kan ürünlerine,Kalp cerrahisi uygulanacak olan Di George sendromlulara verilecek kan ürünlerine,Hematopoietic progenitor hücre transplantlarına gama ışınlama yapılmalıdır .Premature infants are known to have immune dysfunction, but their relative risk of post-transfusion graft versus host disease is controversial. The postnatal age of the infant, the number of immunocompetent lymphocytes in the transfusion product, the degree of human leukocyte antigen compatibility between donor and recipient, and other poorly described phenomena determine which infants are truly at risk for graft versus host disease. Regardless, many centers caring for preterm infants transfuse exclusively γ-irradiated cellular products. Directed donations with blood drawn from blood relatives must always be irradiated because of the risk of engraftment with transfused HLA-homozygous, haploidentical lymphocytes. Cellular blood products given as intrauterine and exchange transfusions should be γ-irradiated, as are transfusions for patients with severe congenital immunodeficiency disorders (severe combined immunodeficiency syndrome and DiGeorge syndrome requiring heart surgery) and transfusions for recipients of hematopoietic progenitor cell transplants. Other groups who are potentially at risk but for whom no conclusive data are available include patients given T-cell antibody therapy (antithymocyte globulin or OKT3), those with organ allografts, those receiving immunosuppressive drug regimens, and those infected with HIV.
30 γ-ışınlama ?T-hücre antikor tedavisi (antitimosit globulin ya da OKT3),Organ nakilleri,İmmunsupresif tedavi alanlar,HIVOther groups who are potentially at risk but for whom no conclusive data are available include patients given T-cell antibody therapy (antithymocyte globulin or OKT3), those with organ allografts, those receiving immunosuppressive drug regimens, and those infected with HIV.
31 Gama (γ) ışınlama:Sezyum, kobalt ya da lineer akselerasyonla cGy dozda; minimum doz 2500 cGy.Hücresel komponenti olan tüm kan ürünleri ışınlanmalıdır.Plazma ve kriyopresipitat gibi dondurulmuş plazma ürünlerinin ışınlanmasına gerek yoktur.Lökositi azaltılmış kan ürünlerinin kullanılması durumunda da ışınlama yapılmalıdır.Current practice uses γ-irradiation from a cesium, cobalt, or linear acceleration source at doses ranging from 2,500 to 5,000 cGy; a minimum dose of 2,500 cGy is required. All cellular blood components should be irradiated, but frozen “acellular” products, such as plasma and cryoprecipitate, do not require it. Leukocyte reduction cannot be substituted for γ-irradiation to prevent graft versus host disease.BibliographyAlter HJ, Kein HG: The hazards of blood transfusion in historical perspective. Blood 2008; 112:Centers for Disease Control and Prevention : Anaplasma phagocytophilum transmitted through blood transfusion—Minnesota, 2007. MMWR Morbid Mortal Wkly Rep 2008; 57:Centers for Disease Control and Prevention : Transfusion-related transmission of yellow fever vaccine virus—California, 2009. MMWR Morbid Mortal Wkly Rep 2010; 59:34-36.Centers for Disease Control and Prevention : West Nile virus transmission via organ transplantation and blood transfusion—Louisiana, 2008. MMWR Morbid Mortal Wkly Rep 2009; 58:Centers for Disease Control and Prevention : Blood donor screening for Chagas disease—United States, 2006–2007. MMWR Morbid Mortal Wkly Rep 2007; 56:Hladik W, Dollard SC, Mermin J, et al: Transmission of human herpesvirus 8 by blood transfusion. N Engl J Med 2006; 355:Klein HG, Spahn DR, Carson JL: Red blood cell transfusion in clinical practice. Lancet 2007; 370:Strauss RG: Data-driven blood banking practices for neonatal RBC transfusions. Transfusion 2000; 40:Zieman M, Krueger S, Maier AB, et al: High prevalence of cytomegalovirus DNA in plasma samples of blood donors in connection with seroconversion. Transfusion 2007; 47: (plus Editorial, pages 1955–1958)