Early symptoms of incompatible blood transfusion. Post-transfusion complications. Transfusion procedure algorithm

Blood transfusion shock is a collective concept that unites a number of similar clinical conditions that arise in response to extremely strong effects on the body of various factors, with hypotension, a critical decrease in blood flow in tissues, the development of tissue hypoxia and hypothermia.

When giving blood transfusions, you should consider possible development this most difficult condition.

Etiology

This transfusion complication occurs due to violation of the rules for manipulating blood or its components, errors in determining the blood group and the compatibility of the recipient’s and donor’s blood components.

The main factors leading to the development state of shock, are: the ABO antigenic system and the Rh factor system. There are also a huge number of other antigenic systems, but they rarely give such a complication.

Pathogenesis

Shock is an allergic reaction of type II - cytotoxic. It develops immediately during the transfusion or after a certain time after the procedure.

The development of hemolysis inside the vessels during blood infusion is possible if red blood cells begin to be destroyed due to incompatibility with the antigenic profile of the recipient's plasma.

The basis for the development of a shock state is the breakdown of red blood cells. This process leads to the release of specific substances that provoke spasm of blood vessels, and then their pathological dilation. The permeability of the vessel wall increases, which leads to the release of plasma into the tissue and thickening of the blood.

Out into the blood large number substances that promote the formation of blood clots, leading to the development of disseminated intravascular coagulation syndrome. Its pathogenesis is characterized by an initial increase in blood clotting with the formation of many small blood clots.

After consumption, when the blood can no longer clot, massive bleeding occurs. There is a disruption of blood flow in small vessels, which leads to insufficient oxygen supply to the internal organs, and, consequently, to their damage.

All organs suffer, including the kidneys. The breakdown products of hemoglobin accumulate in their glomeruli, which leads to a drop in the rate of blood filling and the development of kidney failure.

Shock Clinic

There are 3 stages that appear in case of incompatibility:

Actually a shock.
Pathology of the kidneys, which is expressed by acute failure.
Recovery period.

The state of shock can last from several minutes to a couple of hours. It is possible to trace a clear relationship between the appearance of symptoms of transfusion shock and the transfusion

The patient's condition is initially characterized by a feeling of anxiety, causeless agitation, pain in the chest, abdominal and lumbar pain, chills, difficulty breathing, blueness skin.

Low back pain is one of the most characteristic features development of this complication. Subsequently, vascular disorders begin to appear.

Characteristic symptoms:

Tachycardia.
A sharp decrease in blood pressure.
Appearance of signs acute failure hearts.

A common manifestation is changes in the patient’s facial skin (redness followed by pallor), skin spotting, dyspeptic disorders, increased body temperature, and inability to control urination.

Symptoms of blood transfusion shock - which develops inside the vessels, and. Its manifestations:

Free hemoglobin to the blood.
Hemoglobin in urine.
Hyperbilirubinemia.
Jaundice.
Hepatomegaly.
The color of urine changes: a brownish tint appears (in urine analysis - proteinuria and altered red blood cells).

As a result of hemolysis and the development of disseminated intravascular coagulation syndrome, a disruption of the blood coagulation system occurs, which is expressed by increased bleeding and the occurrence of hemorrhagic diathesis.

When blood is infused during surgical interventions carried out using general anesthesia, symptoms may be erased. Surgeons may notice abnormal bleeding from the wound and urine the color of meat slop.

Anesthesiologists focus on sharp drop pressure. Duration and severity pathological processes depends on the number of incompatible red blood cells injected, the characteristics of the pathological process in the patient and his state of health before the transfusion.

Degrees

There are 3 degrees of shock, the definition of which is based on systolic pressure:

I Art. — SBP above 90 mm Hg. Art.
II Art. — SBP ranges from 71 to 90 mm Hg. Art.
III Art. — SBP below 70 mmHg. Art.

The possible outcome of shock is directly proportional to the course and duration of the reduced pressure. Most often, anti-shock measures help reverse changes in blood vessels and prevent complications of this condition.

Associated symptoms

After a while, the temperature may rise and a yellow color may appear. eyeballs, constant headaches. This indicates the development of acute renal failure(OPN). It manifests itself in the form of three subsequent phases: oligo- or anuria, polyuria and the recovery phase.

Against the background of unchanged hemodynamic conditions, it is observed a sharp decline the amount of urine excreted, initial signs of hydration of the body are observed, the level of creatinine, urea and potassium in the plasma increases (oliguria phase).

After some time, diuresis is restored. Despite this, high content microelements in the blood may persist (polyuria phase). In the future, with a favorable outcome, the filtration capacity of the kidneys is restored.

This ends pathological condition restoration of all pathological processes in the body (convalescence period).

Blood transfusion shock is a condition when it is required urgent Care. The algorithm of actions in this situation can be presented as follows:

Removing the patient from a state of shock.
Prevention measures pathological changes in important organs and their correction.
Relief of developing DIC syndrome.
Prevention of development of acute renal failure.

If adverse symptoms appear, the first action of the nurse or doctor is to stop the transfusion procedure and replace the system with saline solutions.

The most important factor is time: the faster medical interventions are performed, the better the prognosis for the patient.

Infusion therapy

All shock treatment regimens begin with infusions.

First of all, it is necessary to replenish the circulating blood volume (CBV) and restore hemostatic function (dextrans with a molecular weight of 40-70 thousand units are used - rheopolyglucin, gelatinol).

Early infusion of a 4% solution of sodium bicarbonate or lactosol is also indicated. In this way, compensation for metabolic acidification of the blood is ensured, and the synthesis of hematin hydrochloride does not occur.

Subsequently, a crystalloid infusion is performed (with a solution of 0.9% sodium chloride or Ringer's solution) to reduce the amount of free Hb and prevent the destruction of fibrinogen. The amount of infused drugs must be controlled by the volume of diuresis and pressure values.

Drug therapy

Needs to be raised arterial pressure patient, as well as ensure normal renal blood flow. A triad of standard antishock drugs: prednisolone (a glucocorticosteroid to increase blood pressure), furosemide (a diuretic) and aminophylline (a phosphodiesterase inhibitor). Antihistamines and opioid painkillers (fentanyl) are also used.

Efferent methods

An effective method of anti-shock therapy is plasmapheresis - removal of about 2 liters of plasma followed by infusion of fresh frozen plasma and colloid solutions. Symptomatic correction of work disorders internal organs.

If necessary, medications are prescribed that stimulate the activity of important body systems. When symptoms characteristic of a decrease in respiratory function lungs, it is possible to transfer the patient to a ventilator. At severe anemia(hemoglobin concentration less than 70 g/l) it is possible to transfuse washed red blood cells that are compatible in blood type with the patient’s red blood cells.

Correction of the hemostatic system

Anticoagulants are used, transfusions of fresh frozen plasma and antienzyme drugs (Gordox) are performed to inhibit fibrinolysis.

Since the development of acute renal failure is possible in the future, treatment of transfusion shock is also aimed at correcting functional state kidney Furosemide and mannitol are used and correction is performed with crystalloid solutions.

If there is no effect, hemodialysis may be used. During the recovery period, specific symptoms are treated.

Prevention

To avoid the development of shock during transfusion, you need to follow some rules (this is a kind of prevention):

Before a blood infusion, you need to collect a detailed history, in which it is important to focus on previous transfusions or infusions.
Comply with all rules for conducting compatibility tests (if there are errors or inaccuracies, repeat the procedure).

Indications for blood transfusion

In addition to the development of a state of shock, other complications associated with the infusion of blood components are also possible. These may be pyrogenic or allergic reactions, thrombosis or acute aneurysm. Therefore, it is important to treat it carefully and use it only for certain indications.

Absolute readings:

Massive blood loss (more than 15% of blood volume).
Shock states.
Severe traumatic operations with heavy bleeding.

Relative readings:

Anemia.
Severe intoxication.
Disturbance of the hemostasis system.

Contraindications

There are also a number of prohibitions. Absolute contraindications:

Acute heart failure.
Myocardial infarction.

Relative contraindications:

Heart defects.
The presence of blood clots or emboli in the vascular bloodstream.
Violations cerebral circulation.
Tuberculosis.
Kidney or liver failure.

It is important to know that if there are absolute indications, then blood or its components are transfused in any case. Even if there are contraindications.

Conclusion

Transfusion shock is a serious and not the only complication that occurs during transfusions, therefore, even in an emergency, all necessary tests should be carefully carried out and the rules of blood transfusions should be followed.

If signs of transfusion shock are observed, it is important to begin treatment as quickly as possible, which will improve the prognosis for the patient.

Post-transfusion reactions during blood transfusion, their prevention and treatment.

Blood products, indications for their use

Blood components, indications for their use.

Erythrocyte mass (red blood cells and a small amount of preservative and stabilizer);

Erythrocyte suspension (erythrocyte mass in a resuspending solution - erythronaf or erythrocyphonitis);

Thawed and washed red blood cells;

Plasma (native, dry, fresh frozen);

Platelet mass;

Leukocyte mass.

Increased oncotic blood pressure;

2. Increase in BCC;

3. Increase in protein content in the blood;

4. Detoxification effect;

5. Stimulation of diuresis.

In order to prevent pyrogenic and allergic reactions in patients with isosensitivity to HLA antigens, leukocyte or platelet antigens, it is necessary to use washed donor red blood cells, platelet concentrates, and leukocyte mass, selected taking into account the specificity of the antibodies in the recipient. Patients sensitized by multiple blood transfusions are recommended to undergo medicinal antihistamine premedication with drugs that prevent the manifestation of allergic reactions before transfusion.

Prevention of blood transfusion reactions includes:

Before transfusion:

1) strict compliance with all requirements and conditions for the procurement, storage and transfusion of canned blood, its components and preparations;

2) use of disposable systems;

3) careful collection of transfusion and obstetric history:

Number of previous transfusions;

The interval between them;

Portability;

Type of transfusion solution;

How long after the transfusion did the reaction occur and its nature (temperature increase by 0.5-2.0 °C, muscle pain, suffocation, swelling, skin rash, shortness of breath);

Signs of post-transfusion hemolytic complications (yellowness of the skin and mucous membranes, dark color urine, pain in the lower back, abdomen, behind the sternum);

Number of pregnancies, births, early miscarriages, antenatal fetal death, hemolytic disease of the newborn;

4) determination of group and Rh affiliation by a doctor and in the laboratory. Antibody screening in the laboratory;

5) determination of indications for the use of donor blood and its components;

6) conducting control studies of the patient’s and donor’s blood groups. Testing for compatibility.

During transfusion:.

1) transfusions (except for emergencies) should be carried out using the drip method or at a rate of 500 ml/h;

2) biological sample;

3) during blood transfusion, the patient is monitored by a doctor or nursing staff for timely detection clinical manifestations post-transfusion reactions or complications.

After transfusion:.

1) monitoring the patient for 24 hours after transfusion:

During the first 2 hours after the end of the transfusion, body temperature and blood pressure are recorded;

Every hour: volume, color of the first portion of urine, daily diuresis. The doctor records any post-transfusion reaction or complication in the medical/delivery history;

2) a bag or bottle with the remainder (at least 10 ml) of a blood transfusion medium with a label is stored for 48 hours, and a test tube with the patient’s blood taken before transfusion is stored for 7 days in the refrigerator at +2-6 °C;

3) each transfusion is recorded in:

Journal of registration of transfusion of transfusion media, form 009/u (order of the USSR Ministry of Health No. 1030 dated 10/04/80);

Medical history/birth history in the form of a protocol or in the transfusion media transfusion registration sheet, form 005/u (order of the USSR Ministry of Health No. 1030 dated 10/04/80).

Post-transfusion reactions. Transfusion therapy in the vast majority of cases is not accompanied by reactions. However, some patients develop reactive manifestations during or shortly after transfusion, which, unlike complications, are not accompanied by serious and long-term dysfunction of organs and systems; they occur in 1-3% of patients. If reactions and complications occur, the doctor performing the blood transfusion must immediately stop the transfusion without removing the needle from the vein.

Patients who experience post-transfusion reactions must be observed by a doctor and paramedic and treated promptly. Depending on the cause and clinical manifestations, pyrogenic, allergic and anaphylactic reactions are distinguished.

Pyrogenic reactions. Such reactions usually begin 20 to 30 minutes after transfusion and last from several minutes to several hours. They are manifested mainly by general malaise, fever and chills. In severe reactions, body temperature rises by more than 2 °C, stunning chills, cyanosis of the lips, severe headache.

Mild reactions usually go away without treatment. In case of moderate and severe reactions, the patient must be warmed up by covering him with a warm blanket, putting a heating pad under his feet, and giving him a strong drink. hot tea or coffee. In case of high hyperthermia, hyposensitizing, antipyretic drugs, lytic mixtures, and promedol are administered.

Allergic reactions. These reactions appear a few minutes after the start of the transfusion. The clinical picture is dominated by allergic symptoms: shortness of breath, suffocation, nausea, vomiting. Skin itching, urticaria, and Quincke's edema appear. Leukocytosis with eosinophilia is detected in the blood. Symptoms mentioned can be combined with common features feverish condition.

For treatment, antihistamines, hyposensitizing agents are used, and, if necessary, promedol, glucocorticoids, and cardiovascular drugs.

Anaphylactic reactions. In rare cases, blood transfusions can cause anaphylactic reactions. Clinical picture characterized by acute vasomotor disorders: patient anxiety, facial redness, cyanosis, suffocation, erythematous rash; pulse quickens, blood pressure decreases. Often reactive manifestations quickly stop.

Sometimes it can develop severe complication- anaphylactic shock requiring immediate intensive care. The course of anaphylactic shock is acute. It develops during transfusion or in the first minutes after it. Patients are restless and complain of difficulty breathing. The skin is usually hyperemic. Cyanosis of the mucous membranes, acrocyanosis, and cold sweat appear. Breathing is noisy, wheezing, audible at a distance (bronchospasm). Blood pressure is very low or cannot be determined by auscultation, heart sounds are muffled, and a boxy percussion tone is heard during percussion of the lungs, and whistling dry rales are heard during auscultation. Pulmonary edema may develop with bubbling breathing, coughing with the release of foamy pink sputum. In this case, moist rales of various sizes are heard over the entire surface of the lungs.

Complete antishock therapy is carried out. Intravenous corticosteroids, rheopolyglucin, cardiovascular, and antihistamines are used to relieve broncho- and laryngospasm. Acute laryngeal edema with asphyxia is an indication for urgent tracheostomy. As the process increases and respiratory failure progresses, the patient is transferred to artificial pulmonary ventilation (ALV). For convulsions it is carried out anticonvulsant therapy. Correct water and electrolyte disturbances and stimulate diuresis. If necessary, carry out resuscitation measures in full.

Post-transfusion complications. In contrast to post-transfusion reactions, post-transfusion complications pose a danger to the patient’s life, since vital activity is disrupted. important organs and systems. Complications may be associated with incompatibility according to the AB0 system or the Rh factor, poor quality of transfused blood components, the state of the recipient's body, unaccounted contraindications for blood transfusion, and technical errors when performing blood transfusion. In the prevention of post-transfusion complications, the leading role belongs to organizational measures and careful compliance with relevant instructions and orders.

Complications associated with transfusion incompatible components blood. Most often, the first and most serious sign of a complication is blood transfusion shock. It can develop already during a biological test, during a transfusion, or in the next minutes and hours after it. The earliest and most characteristic sign of transfusion shock is an acute circulatory and respiratory disorder. In contrast to ABO incompatibility, Rh incompatibility is characterized by a late onset of symptoms and a blurred clinical picture of shock. Also, reactive manifestations and symptoms of shock are slightly expressed during transfusion incompatible blood patients under anesthesia receiving glucocorticoid hormones or radiation therapy.

The duration of shock in most cases exceeds 1 hour. Often in the first hours or even days after transfusion, the only symptom of incompatibility of transfused blood is acute intravascular hemolysis, which manifests itself as symptoms of hemolytic jaundice and lasts on average 1 - 2 days, in severe cases up to 3 -6 days . the degree of hemolysis increases with increasing dose of transfused incompatible blood.

Hemolysis is especially pronounced during transfusion of Rh-incompatible blood.

Along with symptoms of shock and acute hemolysis, characteristic features Blood transfusion complications include a serious disorder in the blood coagulation system - disseminated intravascular coagulation syndrome.

Shock, acute hemolysis, and renal ischemia resulting from transfusion of incompatible blood lead to the development of acute renal failure. If the phenomena of blood transfusion shock are stopped, after a short period of relatively calm state In the patient, from the 1st to 2nd day of the disease, renal dysfunction is already detected. The oliguric and then the anuric period of acute renal failure begins. The duration of the oligoanuric period varies from 3 to 30 days or more, most often 9-15 days. Then, within 2 - 3 weeks, diuresis is restored.

Treatment of transfusion shock begins immediately after diagnosis. It should be aimed at solving two problems: 1) therapy of blood transfusion shock; 2) therapy and prevention of organ damage, primarily kidneys and DIC syndrome.

The infusion system is completely changed. The order of administration, choice and dosage of medications depend on the severity of shock and are described in special guidelines.

Emergency plasmapheresis is very effective, removing at least 1.3-1.8 liters of plasma containing pathological substances. If necessary, plasmapheresis is repeated after 8-12 hours. Replacement of the volume of removed plasma is carried out by transfusions of albumin, fresh frozen plasma and crystalloid solutions.

Prevention and treatment of blood clotting disorders and acute renal failure are carried out.

Post-transfusion complications caused by poor quality of transfused blood. Bacterial contamination. Infection of a blood component can occur at any stage of the technological process, as well as in medical institution in case of violation of aseptic and antiseptic requirements.

When an infected blood component is transfused, bacterial shock develops and is quickly fatal. In other cases, phenomena of severe toxicosis are observed. Bacterial shock is manifested by the development of severe chills, high fever, tachycardia, severe hypotension, cyanosis, and convulsions in the patient. Excitement, blackouts, vomiting, and involuntary bowel movements are noted.

This complication is possible only in case of gross violations of the organization of blood transfusion in the department and the rules for storing blood components. All patients develop shock and acute intravascular hemolysis. Subsequently, toxic hepatitis and acute renal failure occur.

Violation temperature regime storage of blood components. Transfusion of overheated blood components occurs most often as a result of the use of wrong methods warming blood components before transfusion, thawing plasma, as well as in case of non-compliance with the temperature regime for storing blood components. In this case, protein denaturation and hemolysis of red blood cells are observed. Shock develops with symptoms of severe intoxication, development of disseminated intravascular coagulation syndrome and acute renal failure.

Transfusion of “frozen” red blood cells can occur if there is a gross violation of the storage temperature regime. When frozen, hemolysis of red blood cells occurs. The patient develops acute intravascular hemolysis, disseminated intravascular coagulation syndrome and acute renal failure.

Complications associated with technical errors when performing blood transfusion. Air embolism. As a result of air (2-3 ml is enough) entering the patient’s vein due to technical errors in performing blood transfusion, an air embolism occurs. Air entering the central veins through a catheter is especially dangerous. The reasons for this may be improper filling of the transfusion system with blood, a defect in the system (leaks leading to “leakage” of air into the line), or the entry of air at the end of the transfusion due to untimely shutdown of the system.

Thromboembolism. Due to the detachment of a venous thrombus and its entry into the arterial bed (brain, lungs, kidneys), thromboembolism occurs. Blood clots can enter a patient's vein due to transfusion through an unfiltered system. Acute cardiac disorders. With rapid infusion of large volumes of fluids against a background of cardiac weakness, symptoms may appear. acute disorders cardiac activity. They are evidenced by symptoms of acute heart failure - cardiac asthma, pulmonary edema, myocardial infarction.

Potassium and citrate intoxication. When transfusing large volumes of whole canned blood stabilized with nitrate hemopreservatives, potassium and citrate intoxication occurs. For prevention, it is enough to administer 10 ml of 10% CaC12 solution for every 500 ml of preserved blood.

Transfusion shock is the result of errors made by medical personnel during the transfusion of blood or its components. Transfusion from the Latin transfusio - transfusion. Hemo is blood. This means a blood transfusion is a blood transfusion.

The transfusion (blood transfusion) procedure 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 material we will focus only on the consequences of 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.

Blood transfusion shock is a consequence of immune and non-immune causes.

Immune causes include:

Blood plasma incompatibility;
Incompatibility of group and Rh factor.

Non-immune causes are as follows:

Substances that increase body temperature enter the blood;
Transfusion of infected blood;
Disruptions in blood circulation;
Failure to comply with transfusion rules.

For reference. The main and most common cause The occurrence of this complication is non-compliance with blood transfusion techniques. The most common medical errors are incorrect identification of blood type and violations during compatibility tests.

How does transfusion shock develop?

Transfusion shock is one of the most life-threatening conditions of the victim, which manifests itself during or after a blood transfusion.

After incompatible donor blood enters the recipient’s body, the 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, which results in impaired circulation, thrombohemorrhagic syndrome is observed, and blood pressure levels are 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 causes a pronounced spasm of the vascular walls, and also causes an increase in the permeability of the vascular walls. Then the spasm turns into paretic expansion. This difference in the state of the circulatory system is the main reason for the development of hypoxia.

In the kidneys, the concentration of decomposition 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.

The level of blood pressure is used as an indicator of the degree of shock, which begins to fall as shock develops. It is believed that during the development of shock there are three degrees:

first. Mild degree, in 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 blood transfusion complications 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 pathology development can appear both immediately after the blood transfusion procedure and in the subsequent hours after

her. Initial symptoms include:

Short-term emotional arousal;
Difficulty breathing, shortness of breath;
Manifestation of cyanosis in the skin and mucous membranes;
Fever due to chills;
Muscle, lumbar and chest pain.

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Spasms in the lower back primarily signal the beginning of transformations in the kidneys. Continued changes in blood circulation are manifested in the form of noticeable arrhythmias, pale skin, sweating and a steady decrease in blood pressure levels.

If at the first symptoms of transfusion 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 arise, characterized by yellowing of the skin and white membranes of the eyes;
Actually, hemoglobinemia;
The occurrence of acute renal failure.

Not so often, experts noticed the manifestation of such signs of transfusion shock as hyperthermia, vomiting syndrome, numbness, uncontrolled muscle contraction in the limbs and involuntary bowel movements.

If a blood transfusion is performed on a recipient who is under anesthesia, then blood transfusion shock is diagnosed based on the following criteria:

Decreased blood pressure;
Uncontrolled bleeding in the operated wound;
Dark brown flakes are visible in the urinary drainage catheter.

Important! A patient who is under the influence of anesthesia cannot report how he is feeling, so 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 experiences signs of shock similar to the symptoms of transfusion shock, then the procedure should be stopped immediately. Next, you should replace the transfusion system as soon as possible and pre-connect a convenient catheter into the vein running under the patient’s collarbone. It is recommended to carry out a perirenal bilateral blockade with novocaine solution (0.5%) in a volume of 70-100 ml in the near future.

To avoid development oxygen starvation, you should establish a supply of humidified oxygen using a mask. The doctor should begin monitoring the volume of urine produced, and also urgently call laboratory technicians to collect blood and urine for an ambulance. full analysis, as a result of which the content values will become known red blood cells , free hemoglobin, fibrinogen.

For reference. If, when diagnosing post-transfusion shock, the laboratory does not have reagents to establish compatibility, then you can use the proven Baxter method, which was used in field hospitals. It is necessary to inject 75 ml of donor material into the victim, and after 10 minutes, 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 formed elements. If incompatible, the plasma acquires a pink tint, whereas in its normal state it is a colorless liquid.

It is also advisable to immediately measure central venous pressure, acid-base balance and electrolyte levels, as well as conduct electrocardiography.

Prompt implementation of anti-shock measures in most cases leads to an improvement in the patient's condition.

Treatment

After emergency anti-shock actions have been carried out, there is a need for urgent restoration of basic blood indicators.

Blood transfusion is safe method therapy, subject to certain conditions, their violation provokes complications and post-transfusion reactions. The following errors lead to them: non-compliance with the rules of blood conservation, incorrect determination of blood group, incorrect technique, failure to take into account contraindications for transfusion. Thus, in order to prevent complications and reactions during blood transfusion, a certain set of rules should be strictly followed.

Indications for blood transfusion

Indications for this manipulation are determined by the goal that needs to be achieved: increasing the activity of blood clotting in case of blood loss, replenishing the missing K vital signs relate:

acute bleeding;
severe anemia;
traumatic surgical interventions.

Other indications include:

intoxication;
blood pathology;
purulent-inflammatory processes.

Contraindications

Among the contraindications are the following ailments:

septic endocarditis;
third stage hypertension;
pulmonary edema;
glomerulonephritis in acute form;
cardiac dysfunction;
general amyloidosis;
bronchial asthma;
cerebrovascular accident;
allergy;
severe renal failure;
thromboembolic disease.

Analyzing contraindications, Special attention it is necessary to pay attention to allergy and transfusiological anamnesis. However, if there are vital (absolute) indications for transfusion, blood is transfused, despite the presence of contraindications.

Transfusion procedure algorithm

In order to avoid mistakes and complications during blood transfusion, the following sequence of actions should be followed during this procedure:

Preparing the patient for it involves determining the blood type and Rh factor, as well as identifying contraindications.
They charge for two days general analysis blood.
Immediately before the transfusion, the individual should urinate and have a bowel movement.
Carry out the procedure on an empty stomach or after a light breakfast.
Select the transfusion method and transfusion medium.
The suitability of blood and its components is determined. Check the expiration date, integrity of packaging, storage conditions.
The blood group of the donor and recipient is determined, which is called control.
Check for compatibility.
If necessary, determine compatibility by Rh factor.
Prepare a disposable transfusion system.
A transfusion is carried out, after administering 20 ml, the transfusion is stopped and a sample is taken for biological compatibility.
Observe the transfusion.
After completion of the procedure, an entry is made in the medical documents.

Classification of complications during blood transfusion

According to the systematization developed by the Institute of Hematology and Blood Transfusion, all complications are divided into groups, depending on the factors that provoked them:

blood transfusion incompatible with Rh factor and group;
massive blood transfusions;
errors in transfusion technique;
transmission of infectious agents;
post-transfusion metabolic disorders;
transfusion of low-quality blood and its components.

Classification of post-transfusion complications

Post-transfusion complications associated with blood transfusion include the following:

Transfusion shock caused by transfusion of inappropriate blood. This is very dangerous complication and the severity is mild, moderate severity, heavy. The rate of administration and the amount of incompatible blood transfused are of decisive importance.
Post-transfusion shock - occurs when transfusion of group-compatible blood.
Transfer of infection along with donor blood.
Complications arising from errors made in blood transfusion techniques.

Currently, the risk of developing blood transfusion and post-transfusion shock has been almost reduced to zero. We managed to achieve this proper organization process during transfusion.

Symptoms of post-transfusion shock

Symptoms of complications after blood transfusion appear after the administration of 30-50 ml. The clinical picture looks like this:

tinnitus;
decreased blood pressure;
discomfort in the lumbar region;
tightness in the chest;
headache;
dyspnea;
severe pain in the abdomen and increasing pain in the lumbar region spine;
the patient screams in pain;
loss of consciousness with involuntary defecation and urination;
cyanosis of the lips;
rapid pulse;
sharp redness, and then paleness of the face.

In rare cases, ten to twenty minutes after a blood transfusion, a complication of this nature may occur. death. Often the pain subsides, cardiac function improves, and consciousness returns. In the next period of shock there is:

leukopenia, which gives way to leukocytosis;
jaundice is mild or may be absent;
temperature rise to 40 degrees or above;
hemoglobinemia;
kidney dysfunction that progresses;
oliguria gives way to anuria and in the absence of timely measures, death occurs.

This period is characterized by slowly occurring oliguria and pronounced changes in urine - the appearance of protein, an increase specific gravity, cylinder and red blood cells. A mild degree of post-transfusion shock differs from the previous ones in its slow course and rather late onset of symptoms.

Therapy at the first signs of transfusion shock

cardiovascular - "Ouabain", "Korglikon";
"Norepinephrine" to increase blood pressure;
antihistamines - "Suprastin" or "Diphenhydramine", among corticosteroids, "Hydrocortisone" or "Prednisolone" is preferable.

The above agents slow down the rate of antigen-antibody reaction and stimulate vascular activity. The movement of blood through the vessels, as well as microcirculation, is restored with blood substitutes, saline solutions, "Reopoliglyukin".

With the help of drugs “Sodium lactate” or “Sodium bicarbonate”, the products of destruction of red blood cells are removed. Diuresis is supported with Furosemide and Mannitol. In order to relieve spasm of the renal vessels, a perinephric bilateral blockade with Novocaine is performed. In case of respiratory failure, the individual is connected to a ventilator.

If there is no effect from the pharmacotherapy of acute renal failure, as well as an increase in autointoxication (uremia), hemosorption (removal from the bloodstream) is indicated. toxic substances), hemodialysis.

Bacterial toxic shock

This complication during blood and blood substitute transfusions is quite rare. Its provocateur is blood infected during the procurement and storage process. The complication appears during the transfusion or thirty to sixty minutes after it. Symptoms:

severe chills;
a sharp drop in pressure;
excitation;
temperature increase;
loss of consciousness;
thready pulse;
incontinence of feces and urine.

Blood that did not have time to be transfused is sent for background testing, and when the diagnosis is confirmed, therapy is started. For this purpose, drugs are used that have detoxification, anti-shock and antibacterial effects. In addition, cephalosporins and aminoglycosides are used antibacterial agents, blood substitutes, electrolytes, analgesics, detoxifiers, anticoagulants and vasoconstrictor medications.

Thromboembolism

This complication after a blood transfusion is caused by blood clots that have broken off from the affected vein as a result of the transfusion or blood clots blood resulting from improper storage. Blood clots, clogging blood vessels, provoke infarction (ischemia) of the lung. The individual appears:

chest pain;
A dry cough later turns into a wet cough with the release of bloody sputum.

On x-ray focal inflammation of the lungs is visible. When initial signs appear:

the procedure is stopped;
connect oxygen;
Cardiovascular drugs, fibrinolytics: “Streptokinase”, “Fibrinolysin”, anticoagulants “Heparin” are administered.

Massive blood transfusion

If two or three liters of blood is infused over a short period (less than 24 hours), then such manipulation is called massive blood transfusion. In this case, blood from different donors is used, which, together with its long storage period, provokes the occurrence of massive blood transfusion syndrome. In addition, other reasons influence the occurrence of such a serious complication during blood transfusion:

ingestion of sodium nitrate and blood breakdown products in large quantities;
negative impact chilled blood;
large volume of fluid entering bloodstream, overloads the cardiovascular system.

Acute cardiac enlargement

The appearance of this condition is facilitated by the fairly rapid intake of a large volume of canned blood through jet injection or by applying pressure. Symptoms of this complication during blood transfusion include:

appearance pain syndrome in the right hypochondrium;
cyanosis;
shortness of breath;
increased heart rate;
a decrease in arterial blood pressure and an increase venous pressure.

If the above symptoms appear, stop the procedure. Bloodletting is carried out in an amount of no more than 300 ml. Next, they begin the administration of medications from the group of cardiac glycosides: “Strofanthin”, “Korglikon”, vasoconstrictor drugs and “Sodium chloride”.

Potassium and nitrate intoxication

When transfusing canned blood that has been stored for more than ten days, quite large volume, severe potassium intoxication may develop, leading to cardiac arrest. To prevent complications during blood transfusion, it is recommended to use blood that has been stored for no more than five days, and also to use red blood cells that have been washed and thawed.

A state of nitrate intoxication occurs during massive transfusion. A dose of 0.3 g/kg is considered toxic. Severe poisoning develops as a result of the accumulation of sodium nitrate in the recipient and its entry into chemical reaction with calcium ions in the blood. Intoxication is manifested by the following symptoms:

low pressure;
convulsions;
increased heart rate;
arrhythmia;
trembling.

In severe conditions, swelling of the brain and lungs is added to the above symptoms, and dilation of the pupils is observed. Prevention of complications during blood transfusion is as follows. During the period of blood transfusion it is necessary to administer medicine called "Calcium Chloride". For these purposes, use a 5% solution at the rate of 5 ml of the drug for every 500 ml of blood.

Air embolism

This complication occurs when:

violation of blood transfusion technique;
incorrect filling of the medical device for transfusion, as a result there is air in it;
premature completion of blood transfusion under pressure.

Air bubbles, having entered the vein, then penetrate the right half of the heart muscle and then clog the trunk or branches pulmonary artery. The entry of two or three cubic centimeters of air into the vein is enough for an embolism to occur. Clinical manifestations:

pressure drops;
shortness of breath appears;
the upper half of the body becomes bluish in color;
felt in the sternum area sharp pain;
there is a cough;
increased heart rate;
fear and anxiety appear.

In most cases, the prognosis is unfavorable. If these symptoms appear, the procedure should be stopped and resuscitation procedures should begin, including artificial respiration and administration of medications.

Homologous blood syndrome

With massive blood transfusion, the development of such a condition is possible. During the procedure, blood from different donors is used, compatible by group and Rh factor. Some recipients, due to individual intolerance to plasma proteins, develop a complication in the form of homologous blood syndrome. It manifests itself with the following symptoms:

shortness of breath;
wet wheezing;
dermis cold to the touch;
pallor and even cyanosis of the skin;
a decrease in blood pressure and an increase in venous pressure;
weak and frequent heart contractions;
pulmonary edema.

As the latter increases, the individual experiences moist wheezing and seething breathing. The hematocrit falls, replacement of blood loss from the outside cannot stop the sharp decrease in the volume of blood volume in the body. In addition, the blood clotting process is slowed down. The cause of the syndrome lies in microscopic blood clots, immobility of red blood cells, accumulation of blood and microcirculation failures. Prevention and treatment of complications during blood transfusion comes down to the following manipulations:

It is necessary to infuse donor blood and blood substitutes, i.e., carry out combination therapy. As a result, blood viscosity will decrease, and microcirculation and fluidity will improve.
Replenish the lack of blood and its components, taking into account the circulating volume.
You should not try to completely replenish the hemoglobin level during massive transfusion, since its content of about 80 g/l is quite enough to support the transport function of oxygen. It is recommended to fill the missing blood volume with blood substitutes.
Transfuse the individual with absolutely compatible transfusion media, washed and thawed red blood cells.

Infectious complications during blood transfusion

During transfusion, various pathogens can be transferred along with blood infectious diseases. Often this phenomenon is associated with imperfection laboratory methods and the hidden course of the existing pathology. The greatest danger is viral hepatitis, which an individual becomes ill two to four months after a transfusion. Broadcast cytomegalovirus infection occurs together with the white blood cells of the peripheral blood; to prevent this from happening, it is necessary to use special filters that will retain them, and only platelets and red blood cells will be transfused.

This measure will significantly reduce the risk of infection in the patient. In addition, HIV infection is a dangerous complication. Due to the fact that the period during which antibodies are formed ranges from 6 to 12 weeks, it is impossible to completely eliminate the risk of transmission of this infection. Thus, to avoid complications during transfusion of blood and its components, this procedure should be performed exclusively for health reasons and with comprehensive screening of donors for viral infections.

Transfusion shock is the most dangerous complication of transfusion of blood and its components. Since this procedure is a selective medical one, the main reason is errors in determining blood groups, Rh factor, and conducting compatibility tests.

According to statistics, they account for up to 60% of cases. Blood transfusions are carried out only in hospital settings. Doctors are trained in this technique. In large hospitals, a transfusiologist has been introduced who monitors transfusion cases, monitors the correct execution, ordering and receipt of prepared donor blood and its components from the “Blood Transfusion Station”.

What changes in the body occur during transfusion shock?

When blood incompatible with the ABO system enters the recipient's blood, the destruction of donor red blood cells (hemolysis) begins inside the blood vessels. This causes the release and accumulation in the body of:

free hemoglobin;
active thromboplastin;
adesine diphosphoric acid;
potassium;
erythrocyte coagulation factors;
biologically active substances, clotting activators.

This reaction is classified as cytotoxic, a type of allergic reaction.

As a result, several pathogenetic mechanisms of the blood transfusion shock state are launched at once:

altered hemoglobin loses connection with oxygen molecules, which leads to tissue hypoxia (oxygen deficiency);
the vessels first spasm, then paresis and expansion occur, microcirculation is disrupted;
increased permeability of vascular walls promotes the release of fluid, and blood viscosity increases;
increased coagulation causes the development of disseminated intravascular coagulation (DIC syndrome);
due to an increase in the content of acidic residues, metabolic acidosis occurs;
hydrochloric acid hematin accumulates in the renal tubules (the result of the breakdown of hemoglobin), in combination with spasm and impaired patency of the vascular glomeruli, this contributes to the development of acute renal failure, the filtration process gradually stops, and the concentration of nitrogenous substances and creatinine in the blood increases.

Impaired microcirculation and hypoxia lead to changes in internal organs, primarily in brain cells, lung tissue, liver, and endocrine glands. Hemodynamic parameters drop sharply.

Clinical manifestations

Transfusion shock develops immediately after transfusion, within several hours after it. The clinic is accompanied by bright characteristic symptoms, but there may be no clear picture. Therefore, after each blood transfusion, the patient should be under medical supervision. The patient's well-being is checked, laboratory signs blood transfusion shock. Early detection complications of blood transfusion require emergency care to save the patient’s life.

Initial symptoms are:

short-term excited state of the patient;
the appearance of shortness of breath, a feeling of heaviness when breathing;
bluish color of the skin and mucous membranes;
chills, trembling from feeling cold;
pain in the lower back, abdomen, chest, and muscles.

The doctor always asks the patient about lower back pain during and after blood transfusion. This sign serves as a “marker” of beginning changes in the kidneys.

Increasing circulatory changes cause further:

tachycardia;
pale skin;
sticky cold sweat;
sustained decrease in blood pressure.

Less common symptoms include:

sudden vomiting;
heat bodies;
the skin has a marbled tint;
cramps in the limbs;
involuntary passage of urine and feces.

With absence medical care During this period the patient develops:

hemolytic jaundice with a yellow color of the skin and sclera;
hemoglobinemia;
acute renal-liver failure.

Features of clinical manifestations of shock if the patient is under anesthesia in the operating room:

the anesthesiologist records the drop in blood pressure;
surgeons notice increased bleeding in the surgical wound;
urine with flakes resembling “meat slop” flows through the outlet catheter into the urinal.

Under anesthesia, the patient makes no complaints, so all responsibility for early diagnosis The shock falls on the doctors

Course of the pathology

The severity of shock depends on:

the patient's condition before blood transfusion;
volume of blood transfusion.

The doctor can use the level of blood pressure to determine the degree of shock. It is commonly accepted to distinguish 3 degrees:

first - symptoms appear against a background of pressure over 90 mm Hg. Art.;
the second is characterized by systolic pressure in the range of 70–90;
the third corresponds to a pressure below 70.

IN clinical course Transfusion shock is divided into periods. In the classical course, they follow each other; in severe shock, a fleeting change of signs is observed, not all periods can be noticed.

Transfusion shock itself is manifested by disseminated intravascular coagulation syndrome and a drop in blood pressure.
The period of oliguria and anuria is characterized by the development of renal block and signs of renal failure.
The stage of restoration of diuresis - occurs with high-quality medical care and restoration of the filtration capacity of the renal tubules.
The rehabilitation period is characterized by normalization of indicators of the coagulation system, hemoglobin, bilirubin, and red blood cells.

Primary measures to assist the patient

If characteristic patient complaints or signs of transfusion shock are detected, the doctor must immediately stop the transfusion if it has not yet been completed. IN as soon as possible necessary:

replace the transfusion system;
install a more convenient catheter for further treatment in the subclavian vein;
establish the supply of humidified oxygen through a mask;
begin to control the amount of urine excreted (diuresis);
call a laboratory assistant to urgently draw blood and determine the number of red blood cells, hemoglobin, hematocrit, fibrinogen;
Submit the patient's urine sample for full urgent analysis.

If possible:

measurement of central venous pressure;
analysis of free hemoglobin in plasma and urine;
electrolytes (potassium, sodium) in plasma, acid-base balance are determined;

The Baxter test is performed by experienced doctors without waiting for results laboratory tests. This is a fairly old method that allows you to determine the incompatibility of transfused blood. After injecting about 75 ml of donor blood into the patient, after 10 minutes 10 ml is taken from another vein, the tube is closed and centrifuged. Incompatibility can be suspected by the pink color of the plasma. Normally it should be colorless. This method was widely used in field hospitals in military settings.

Treatment

Treatment of transfusion shock is determined by the amount of diuresis (based on the amount of urine collected in the urine bag per hour). The schemes are different.

If diuresis is sufficient (more than 30 ml per hour), the following is administered to the patient over 4–6 hours:

Reopoliglyukin (Polyglyukin, Gelatinol);
sodium bicarbonate solution (soda), Lactasol for alkalizing urine;
Mannitol;
glucose solution;
Lasix to support diuresis of 100 ml or more per hour.

In total, at least 5–6 liters of liquid must be poured within the specified period.

To relieve vasospasm, the following are indicated: Eufillin, No-shpa, Baralgin

Permeability stabilizing agents vascular wall: Prednisolone, ascorbic acid, troxevasin, sodium etamsilate, Cytomac.
Heparin is first injected into a vein, then subcutaneously every 6 hours.
Inhibitors of protease enzymes (Trasilol, Kontrikal) are indicated.
Antihistamines(Diphenhydramine, Suprastin) are necessary to suppress the rejection reaction.
Disaggregants of the type are used nicotinic acid, Trentala, Complamina.

If the patient is conscious, Aspirin can be prescribed.

Reopoliglyukin is administered, soda solution, but in a much smaller volume. The remaining drugs are used in the same way.

At severe pain narcotic analgesics (Promedol) are indicated.

Increasing respiratory failure with hypoventilation of the lungs may require switching to artificial respiration.

If possible, a plasmapheresis procedure is performed - blood is taken, purified by passing through filters and injected into another vein.

If urine output is less than 30 ml per hour, the amount of fluid should be limited to 600 ml + urine output

If disturbances in the electrolyte composition are detected, potassium and sodium preparations are added to treatment.

If acute renal failure is diagnosed, urgent hemodialysis is a measure of help; more than one procedure may be required.

Forecast

The prognosis of the patient's condition depends on timely treatment. If therapy is carried out in the first 6 hours and is completely complete, then 2/3 of patients experience full recovery.

In 30% of patients, the condition is complicated by the development of renal and hepatic failure, thrombosis of the blood vessels of the brain and heart, and acute respiratory disorders. They have them for life chronic diseases internal organs.

Is it necessary to have a blood transfusion?

The question of the appropriateness of transfusions, as the most significant point in the prevention of transfusion shock, should be considered by the attending physicians before prescribing the procedure. Blood transfusions for anemia are actively used in hematology clinics. In addition to this pathology, absolute indications are:

large blood loss due to injury or during surgery;
blood diseases;
severe intoxication due to poisoning;
purulent-inflammatory diseases.

Contraindications are always taken into account:

decompensation of heart failure;
septic endocarditis;
cerebrovascular accident;
glomerulonephritis and renal amyloidosis;
allergic diseases;
liver failure;
tumor with decay.

You should definitely tell your doctor about:

experienced in the past allergic manifestations;
reactions to blood transfusions;
for women about unsuccessful childbirth, children with hemolytic jaundice.

Who has the right to transfuse blood to a patient?

Transfusion of blood and its components is carried out by the attending physician and nurse. The doctor is responsible for checking group compatibility and conducting biological tests. Nurses can perform a blood type test, but they do this only under the supervision of a doctor.

An individual blood container is used for each patient; it is strictly forbidden to share it with several patients

Transfusion begins with a biological test. The patient is injected with 10–15 ml of blood three times at a rate of 40–60 drops per minute. Breaks are 3 minutes.

Each administration is followed by checking the patient’s condition, measuring blood pressure, pulse, and asking about possible signs of incompatibility. If the patient's condition is satisfactory, then transfusion of the entire prescribed volume of blood continues.

After transfusion, the remainder of the material in the container and the closed tube with the recipient's blood, which was used to determine individual compatibility, should be stored in the refrigerator for two days.

In case of complications, they are used to judge the correctness of the actions of medical personnel. Sometimes you have to double-check the labeling of the package from the “Blood Transfusion Station”.

All information about the patient, the course of the transfusion, and the donor (from the label) is recorded in the medical history. Here the indications for blood transfusion are substantiated and the results of compatibility tests are given.

The recipient is monitored for 24 hours. His temperature, blood pressure and pulse are measured hourly, and his diuresis is monitored. The next day, blood and urine tests are required.

With a careful approach to the issue of prescribing and administering blood transfusions, no complications arise. Millions of donors save patients' lives. To identify transfusion shock, observation and monitoring of recipients, examination and persistent questioning about symptoms on the first day after transfusion are required. This is the key to success and complete recovery.