Wide use of hemotransfusion is characteristic of modern surgery. Hemotransfusion is an operation of transplantation of fabric (blood) from the healthy person (donor) to sick (recipient) with the medical purpose. Hemotransfusion without deadly complications became possible after opening of blood groups (1901 Landshteyner, 1906 of Yanovsky) and a Rhesus factor (1940 Landshteyner and Winer).
There are 4 main blood groups: 1-2-3-4. They differ in the maintenance of aglyutinogen And yes In both agglutinins and and b.
Agglutinogens, or antigens A and B, are in erythrocytes.
Agglutinins, or antibodies and and b are in a blood plasma.
At a meeting the agglutinum of a gene And with agglutinin and, and also agglutinogen B happens to agglutinin b reaction of isohemagglutination of o it is pasting of erythrocytes of one person at their mixing with serum of other person.
Blood groups have the following structure:
1. group: There are no agglutinogens, there are agglutinins and and b (a Ь)
2. group: Agglutinogen A, agglutinin b (Ab);
3. group: Agglutinogen B, agglutinin and (Wa);
4. group: Agglutinogens A and B, agglutinins are not present (AB)
Adhered earlier to the law of Ottenberg according to which erythrocytes of the transfused donor blood stick together. According to this law the recipient with the first group was allowed to transfuse donor blood only of 1 group, to the recipient with the second group donor blood 2 and 1 of groups, to the recipient with the third group o donor blood 3 and 1 of groups, to the recipient with the 4th group o donor blood of all 4 groups. However in recent years it is proved that each group is strictly individual. So, agglutinogen A has 2 subgroups: 1 and A2, thus, the II group can be Alb or A2b, the IV group A1vo or A2vo. Besides there was known the return law of Ottenberg: at large volumes of hemotransfusion pasting of erythrocytes of the recipient is possible. Therefore now it is allowed to transfuse only odnogruppny blood.
Blood of any group can be either Rh-positive, or negative, depending on presence of a Rhesus factor (Rh-factor). About 85% of people have this factor, or a Rhesus factor - are positive, 15% have no it, or a Rhesus factor - are negative. But in recent years it became known that there are 5 main (Д, With, with, E, e) and a set of nonbasic subgroups of a Rhesus factor. The subgroup D meets in 85%, the others in the decreasing order with> E> With> е. Therefore definition of blood groups and a Rhesus factor is of great importance.
with use of standard serums: serum of 1 group contains agglutinins and and; group o serum 2 agglutinin £, group o serum 3 agglutinin and; serum 4 groups (control) does not contain agglutinins. The blood group is defined in 2 series, apply serums which mix with the studied blood.
0 (ab) - - - -
A(b) + - + -
B(a) + + - -
AB(0) + + + -
: with use of standard erythrocytes
0 (ab) - + + +
A(b) - - + +
B(a) - + - +
AB(0) - - - -
combination of 1 and 2 methods.
with use of tsoliklon
2 tsoliklon are known: anti-And yes Anti-B
0 (ab) - -
A(b) + -
B(a) - +
AB(0) + +
Definition of a Rhesus factor:
1. in the water bath: In Petri's cup apply standard antirezusny serum, mix with erythrocytes of the studied blood. The cup of a petra is placed in the water bath for 7-10 minutes at a temperature of 45-48 degrees. If there is an agglutination, then blood a Rhesus factor - is positive.
2. Express method: On a bottom of a test tube bring 1 drop of antirezusny serum and 1 drop of the studied blood, mix them, overturn a test tube so that contents spread on a wall. 3 min. later look behind agglutination existence, for an exception of false aggregation эритр tsit need to be added 2-Z ml of normal saline solution. Agglutination existence blood a Rhesus factor - is positive.
3. Laboratory methods: it is gelatinous test, indirect test of Koombs, definition of a Rhesus factor in the presence of Polyglucinum, albumine, etc.
Effect of the transfused blood:
1. Replaceable action of o in cases of massive blood loss, chronic anemia. In these cases the medical effect is connected with increase in OTsK, increase in a respiratory surface of erythrocytes, improvement of oxygen exchange.
2. haemo static action of o due to injection with blood of blood-coagulation factors, especially at direct hemotransfusion or transfusion of svezhezagotovlenny blood.
3. Disintoxication action of o due to injection with blood of the proteins of plasma absorbing toxic substances.
4. Immunobiological effect of o at the expense of the content in blood of antibodies.
5. the promoting effect of o at the expense of proteins of plasma, amplifies a metabolism, the angenesis is stimulated.
Indications to hemotransfusion
1. Acute blood loss.
2. Shock - hemorrhagic, traumatic, burn
3. Chronic anemia.
4. Big traumatic operative measures.
5. Acute intoxications.
6. Disturbances of coagulant system of blood.
7. Oppression of immune forces of an organism.
8. Disturbances of a trophicity and angenesis.
Contraindications to hemotransfusion
1. circulatory unefficiency of the II-III St.
2. Thromboembolic defeats.
3. Acute disorders of cerebral circulation.
4. Fluid lungs.
5. Liver failure.
6. Allergic diseases.
Basic principles of modern transfusiology
1. Transfusion of whole blood since o hemotransfusion it as it is told above, operation o fabric transplantation is considered wrong. At hemotransfusion the organism sensitization, posttransfusion complications are possible. Therefore it is put forward new tactics: a component hematotherapy, i.e. transfusion only of those components of blood which are necessary in each case. Transfusion of whole blood is justified only in cases of massive blood losses.
2. The principle - one donor of one recipient, i.e. for treatment of the patient it is necessary to use blood components from 1 or the minimum number of donors that reduces probability of transfusion complications.
3. Transfusion of odnogruppny blood, i.e. blood of the same group and the same Rhesus factor is transfused to the patient. Only in exceptional cases the Rh-negative blood of 1 group can be transfused to the patient with any blood group in quantity to 500 ml.
4. Hemotransfusion is carried out only by the doctor: the attending physician, the doctor on duty, the doctor of department of transfusion, and during operation o by the anesthesiologist or surgeon, not participating in an anesthesia or operation.
5. The transfused blood has to be surely investigated on AIDS, hepatitis, syphilis.
Criteria of the validity of blood to transfusion
1. existence on a label bottle with complete data about the donor.
2. Period of storage: at a temperature of +4 degrees stored blood is stored in the refrigerator 21 days. The period of storage can be extended when using new preservatives, freezing blood etc.
3. Macroscopically: blood has to be 3-layer: erythrocytes, a layer of leukocytes, plasma, in plasma there should not be flakes, fibrin threads. There should not be a hemolysis, i.e. red coloring of plasma. At accidental mixing of 3 layers it is necessary to settle blood.
4. preservation of tightness of a bottle. A crack in a bottle, the bottles opened earlier, hemotransfusion from 1 bottle to several patients are not allowed.
1. indirect hemotransfusion: injection of stored blood, most often intravenously. O vnutriarterialno, vnutrikostno, vnutriaortalno is more rare.
2. Direct hemotransfusion: directly from the donor to the patient, now because of danger of infection with AIDS, hepatitis it is almost forbidden. Only in extreme situations, especially at the IDCS, carrying out direct transfusion about in advance inspected reserve donor is possible.
3. exchange transfusion: partial or full removal of blood of the patient with substitution by its donor blood. At acute otravleninkh poisons - mushrooms, salts of heavy metals), at hemotransfusionic shock.
4. the return transfusion of own blood, in 2 types.
o o Autohemotrasfusion when blood undertakes at the most sick before operation, and is poured to it in time or after operation.
o o Reinfusion transfusion to the patient of the blood which streamed in serous cavities of an organism owing to wounds or during operation.
Condition for reinfusion lack of damage and opening of a gleam of digestive tract.
5. O plasma exchange withdrawal from blood of the patient of plasma with substitution of its volume plasma substituting solutions and donor plasma. Together with plasma at the same time toxic substances, antibodies, etc. are removed.
1. Blood typing and a Rhesus factor of the patient and donor blood, despite marks in the passport and a case history at the patient and on the label of donor blood.
2. Test on group compatibility: apply 2-3 drops of blood serum of sick (recipient) on a cup of a petra, add a small drop of blood of the donor, mix them and observe result within 5 min. Agglutination of erythrocytes should not be. If the gglyutination appeared, this blood is incompatible.
3. The Poliglyukinovy method o bring 2 drops of serum of the patient, 1 drop of blood of the donor and 1 drop of 33% of solution of Polyglucinum in a test tube. Contents are mixed, the test tube is turned so that contents spread on walls. In 5 min. in a test tube pour 3-4 ml of physical solution. Agglutination should not appear.
4. Test on a Rhesus factor compatibility.
5. The bioassey, is carried out at the patient's bed. Connect system, enter struyno 10-15 ml of blood, then within 5 minutes watch a condition of the patient. In the absence of signs of reactions such procedure is repeated by 2 more times. Absence реак forms AI after triple check the basis for transfusion of other dose of donor blood.
Execution of documentation at hemotransfusion
1. Before each hemotransfusion the doctor writes down in a case history a predt-ransfuzionny epicrisis (indications to transfusion, the poured environment, its dose and a way of injection).
2. The transfusion registers in the izhurnal of registration of transfusion of transfusion environments!, and in the history of o disease in the form of the protocol of hemotransfusion, or in "A leaf of registration of transfusion of transfusion means.
3. After a hemotransfusion observation of the patient, 3-fold thermometry in each hour is made, macroscopic assessment of color and amount of urine, these data are brought in a case history in the diary of observation.
4. Next day after a hemotransfusion undertake the general blood test and urine.
COMPONENTS OF BLOOD AND BLOOD SUBSTITUTES. POST-HEMOTRANSFUSIONIC COMPLICATIONS
Treat components of blood: a packed red cells, the washed erythrocytes, plasma, a concentrate of thrombocytes, лейковзвесь.
O packed red cells the main component of blood which is received from stored blood by department of plasma from it. Contains erythrocytes in the basic that causes its smaller reactogenicity. Sharply increases the oxygen capacity of blood.
Indications to use:
1. Acute o blood losses about 30% and more OTsK;
2. The severe forms of an iron deficiency anemia which are not giving in to treatment by iron preparations;
3. The blood diseases which are followed by suppression of an erythrogenesis (a leukosis, aplastic anemia, an iyelomny disease, etc.).
4. Intoxications (poisonings, burns, it is purulent - septic states).
Period of storage 21 days at a temperature of +4 degrees.
The washed erythrocytes of o receive from whole blood or erythroweight by their washing in isotonic solution or special environments. At the same time leukocytes, proteins of plasma, thrombocytes, the destroyed cells therefore the washed erythrocytes are ареакто the unlimited transfusion environment are removed. Therefore the washed erythrocytes are shown to patients with the complicated transfusion anamnesis sick with various allergic states, at hemotransfusionic shock. A period of storage 24 hours at a temperature of +4 degrees.
Platelet concentrate of o receive by department of thrombocytes from whole blood.
The indication to transfusion тм are:
1. thrombocytopenic bleeding;
2. an IDCS in a hypocoagulation phase;
Лейкоезвесь (leukocytic weight) o receive from 5-8 l of blood with use of a separator of blood for transfusion by the patient, for compensation of deficit of leukocytes.
2. sepsis, resistant to treatment
3. decrease in a leukopoiesis owing to chemotherapy
Plasma - a liquid part of blood which part biologically active agents are: proteins, lipids, carbohydrates, enzymes, etc.
Types: native, freshly frozen, dry, anti-hemophilic. freshly frozen plasma in view of full preservation of biological functions is most effective.
1. a burn disease in any stage
2. it is purulent - septic processes
3. at bleedings with blood coagulation disturbance, especially in obstetric practice
4. at gemofilichesky bleedings.
Blood preparations: are made of blood.
1. proteinaceous drugs of complex action
2. Proofreaders of coagulant system
o cryoprecipitate for the purpose of a hemostasis
o fibrinolysin for dissolution of blood clots
o local drugs: fibrinous film, absorbable gelatin sponge, dry thrombin
3. drugs of immunological action: these are immunoglobulins (antitetanic, anti-influenza, protivokorevy, anti-staphylococcal), gamma-globulin, etc.
Blood substitutes (KZ)
These are drugs which at intravenous administration can replace medical effect of donor blood or its components in a certain measure.
Distinguish 6 KZ groups:
1. Hemodynamic (antishock) o are intended for treatment and prevention of shock of various origin,
o Polyglucinum of o colloidal solution with high osmotic activity at the expense of what attracts and holds liquid in a circulatory bed,
o Reopoliglyukin of o a low-molecular dextran, quickly raises the ABP, improves rheological properties of blood and microcirculation,
o o Gelatinolum solution of partially split gelatin, with firmness raises the ABP, long keeps in a circulatory bed.
2. KZ of disintoxication action: enter at burns, sepsis, intoxications of various genesis.
o Haemodesum - low-molecular solution, connects and brings toxins out of an organism, improves microcirculation, strengthens a renal blood stream, increases a diuresis,
3. KZ of parenteral food,
o Proteinaceous hydrolyzates (Hydrolysinum, casein hydrolyzate, Amincrovinum, Aminopeptidum).
o Solutions of mix of amino acids (альвезин, polyamine, левамин);
o Carbohydrates: 5-10-20-40% glucose solutions;
o Fats: lipofundinum, интралипид, fatty emulsion.
4. Electrolytic (crystalloid) solutions. Improvements of rheological properties of blood are used for regulation of a water-salt and acid-base state, for elimination of deficit of liquid, for desintoxication,
o Physical. solution o of isotonic 0, 9% sodium chloride solution
o Solution Ringer-Locke;
o the combined (multisalt) solutions: disalt, трисоль, Acesolum, лактосол, the polarizing mix
5. The multifunctional KZ o having a number of properties: hemodynamic, disintoxication, alimentary actions.
6. KZ haemo proofreaders of o is almost artificial blood (at a development stage).
1. Air embolism;
3. thrombophlebitises of veins;
4. Serumal hepatitis;
5. Infection with syphilis, AIDS;
6. The pyrogenic reactions;
7. Allergic reactions.
1. hemotransfusionic shock of o arises at hemotransfusion, a packed red cells, incompatible on the AVO group system.
The reason in most cases o failure to follow rules of hemotransfusion at one of stages.
Pathogeny: intravascular destruction of erythrocytes of donor blood leads to an exit in blood of free hemoglobin, active thromboplastin that leads to the IDCS, disturbance of microcirculation, TsNS, shock.
Initial signs of hemotransfusionic shock can appear during hemotransfusion or soon after it: this excitement of patients, stethalgia, waist. Then pallor of integuments, tachycardia, cold sweat, permanent falling of the ABP develop. the haemoglobinaemia, hemolitic jaundice, опн, an acute liver failure develop in later terms. If shock develops in operation time, under anesthetic, that its signs are permanent falling of the ABP, the raised bleeding from operation oh of a wound, emergence of urine of color .myasny помоевп (therefore in hemotransfusion cases during operation bladder catheterization is obligatory),
treatment: at emergence of signs of hemotransfusionic shock it is necessary to stop hemotransfusion at once, to begin antishock therapy: Polyglucinum, narcotic analgetics, heparin, antihistaminic drugs, corticosteroid hormones, then необхо имо carrying out an artificial diuresis, plasma exchange, according to indications of o a hemodialysis, at o anemia transfusion of individually picked up washed erythrocytes.
2. Rhesus factor conflict: arises at incompatibility on a Rhesus factor. Can occur in 2 cases:
o At repeated transfusion of a Rh-positive blood to the Rh-negative recipient;
o At repeated pregnancy of the Rh-negative woman a Rh-positive fruit
At incompatibility on a Rhesus factor clinical manifestations differ from hemotransfusionic shock in later beginning, less rapid current delayed .gemolizy. The principles the same treatments that at hemotransfusionic shock.
3. not hemolitic posttransfusion complications of o at the expense of the patient's sensitization to antigens of leukocytes, thrombocytes and blood proteins as a result of the hemotransfusions which are carried out earlier. Are shown usually in 30 minutes after hemotransfusions in the form of a hyperthermia fever, a headache, back pains, urticaria, a skin itch, an asthma, suffocation, a Quincke's edema. Treatment of o in/in adrenaline, antihistaminic drugs, corticosteroids, calcium chloride, narcotic analgetics, disintoxication therapy.
4. The syndrome of massive transfusions (a syndrome of homologous blood) of o develops" at introduction to the patient for short term to 3 l of whole blood (i.e. to 40-50% of OTsK) from many donors.
The leading manifestation of a syndrome of massive transfusions is the IDCS, bleeding of wounds, hemorrhages, falling of the ABP, an asystolia, bradycardia, fibrillation of ventricles up to a cardiac standstill. Treatment: antishock therapy, elimination of a staz of blood, disturbances of electrolytic balance, fight with опн and anemia, use of heparin to 24 thousand. Piece a day, a plasma exchange with substitution by freshly frozen plasma, use of a reopoliglshchkin, Euphyllinum, trental, Contrykal or Trasylolum on 80-100 thousand. Pieces.
5. The hypocalcemia (citrate intoxication) of o develops at bystry transfusion of stored blood, owing to binding of calcium of the patient with sodium citrate of donor blood,
The hypocalcemia leads to falling of the ABP, increase in TsVD, appear twitchings of muscles, disturbances of a respiratory rhythm, difficulty of a breath are convulsive, in a mouth smack of metal appears. Further increase of a hypocalcemia leads to tonic spasms, disturbances of breath up to an apnoea, bradycardia up to an asystolia. For prevention on each 500 ml of stored blood enter 10 ml of 10% of a gluconate of calcium.