Post-transfusion reactions and complications. Complications associated with transfusion of incompatible blood Transfusion shock emergency care

The following complications may occur during blood transfusion:

hemolytic post-transfusion shock due to transfusion of incompatible blood;
post-transfusion shock caused by transfusion of compatible blood;
complications associated with errors in transfusion technique;
introduction of pathogenic bacteria along with donor blood.

Post-transfusion reactions should not be classified as post-transfusion complications.

Hemolytic post-transfusion shock, resulting from an erroneous transfusion of incompatible blood, is an extremely severe and dangerous complication. Its severity depends on the amount of blood transfused and the speed of its administration. With the intravenous injection of 20-30 ml of blood of a different group, a healthy person experiences tremendous chills and an increase in body temperature, usually without any consequences. In case of liver and kidney disease, the same doses of blood of a different group can be fatal.

Blood transfusion shock

Blood transfusion shock can be severe, moderate and mild.

The clinical picture of severe transfusion shock is very characteristic. As a rule, after the injection of 30-50 ml of incompatible blood of a different group, the patient becomes restless, pain in the lower back, a feeling of tightness in the chest, ringing in the ears, and a severe throbbing headache appear.

At the same time, a rapid and sharp reddening of the face is objectively noted, which is sometimes observed for many hours and even 2-3 days. More often, after a few minutes, the redness of the face is replaced by pallor and pronounced cyanosis of the lips. Acrocyanosis, shortness of breath, anxiety, increased heart rate up to 100-120 beats/min or more are noted, accompanied by a decrease in maximum blood pressure to 80-70 mm Hg. Art. Already during the administration of incompatible blood or after 20-30 minutes, the patient loses consciousness, involuntary bowel movements and urination occur. Sometimes death can occur within 10-20 minutes after blood transfusion.

However, more often the pain subsides, blood pressure stabilizes and begins to gradually increase, cardiac activity improves, consciousness is restored, but the temperature rises to 40° or more. Rapidly passing leukopenia is replaced by leukocytosis; due to intravascular hemolysis, hemoglobinemia develops, often jaundice. During this period of shock, renal dysfunction occurs, which progresses, and oliguria can quickly give way to anuria. If the measures taken are insufficient or untimely, the patient may die from uremia within 1-2 days.

A severe form of hemolytic post-transfusion shock is rare; moderate shock is more common. Its first signs completely coincide with the symptoms of severe shock, only they are less pronounced, the patient does not lose consciousness, and there is no involuntary defecation or urination. These signs usually appear later - 1-2 hours after the introduction of incompatible blood. In the second period of shock, oliguria develops slowly, the composition of urine changes significantly: its specific gravity increases, protein, red blood cells and casts appear. Jaundice is less pronounced or absent. If effective treatment is not started in a timely manner, the function of the kidneys and other parenchymal organs deteriorates, urine output decreases, and within 3-5 days the patient may die from uremia. With timely, vigorous treatment, despite the initially quite pronounced symptoms of transfusion shock, the patient recovers.

Clinical manifestations of the first period of hemolytic shock are explained by hemolysis, circulatory decompensation, and spasm of the renal vessels. The clinical manifestations of the second period are explained in acute renal failure, characterized by progressive oliguria, and then anuria with increasing azotemia. In the third period, kidney function is restored, the general condition of the patient improves and urine output quickly increases to 3-4 liters per day. At the same time, its specific gravity increases, the concentration of urea in the urine increases and the concentration in the blood decreases.

Mild hemolytic post-transfusion shock manifests itself more slowly, much later, and often in the form of post-transfusion uremia, which is usually preceded by a strong reaction (chills, discomfort or pain in the lower back, increased body temperature, tachycardia). Mild transfusion shock may go unnoticed and therefore often goes undiagnosed.

If blood of a different group is transfused to a patient who is under deep anesthesia, then a reaction may not occur, but later dysfunction of the kidneys and other parenchymal organs appears. According to I.I. Fedorov, anesthesia, by causing inhibition of the cerebral cortex and reducing the reflex activity of the body, inhibits the development of the clinical picture of hemolytic post-transfusion shock. But even under deep anesthesia, severe intoxication develops with damage to parenchymal organs and excretion of hemoglobin in the urine, that is, the clinical picture of protein shock.

With slow intravenous drip administration of incompatible blood, the speed and severity of hemolytic shock manifestations is less pronounced than with rapid blood transfusion.

In the development of post-transfusion complications, the subgroups Ai and Ag, factors M and N are of no practical importance, but the Rh factor is important.

Repeated transfusions of Rh-positive blood to patients with Rh-negative blood can lead to the formation of Rh antibodies in their blood. The recipient's Rh antibodies agglutinate with the donor's Rh-positive red blood cells, resulting in hemolytic post-transfusion shock. The formation of Rh antibodies occurs slowly and does not depend on the dose of blood transfused; Long periods of time between transfusions contribute to increased sensitization.

Post-transfusion shock

Post-transfusion shock after transfusion of compatible blood, it is most often caused by blood infection, overheating (above 40°) or repeated heating (even to a temperature not higher than 38°), during which the protein fractions of the blood are destroyed, which causes a strong reaction of the body. The cause of post-transfusion shock may also be a change in plasma composition due to improper blood collection, during which it clots, and insufficient stabilization. In other words, all kinds of changes in blood quality can cause the development of post-transfusion shock.

Shock after transfusion of infected, low-quality blood is usually even more severe than after the introduction of incompatible blood of a different group. The first signs of it usually appear 20-30 minutes or later after a blood transfusion, although in some cases they can be noticed when conducting a triple biological test. The body's reaction is manifested by severe chills with an increase in body temperature to 40-41°; Severe cyanosis, tachycardia with a drop in blood pressure quickly develop, and loss of vision with simultaneous loss of consciousness and motor agitation is often observed. Some women report pain in the lumbar region, vomiting, involuntary bowel movements and urination. Severe intoxication develops, kidney function is sharply impaired, and patients die from Uremia within 10-20 hours.

In some patients, shock takes on a torpid course. The activity of their cardiovascular system may improve, consciousness may be restored and the temperature may drop, but the next day the shocking chills and temperature increase to 40° or more are repeated. The patient's condition resembles a severe septic one: the skin acquires a gray-yellow color, oliguria develops, the number of leukocytes increases to 30,000-40,000 with a sharp shift in the formula to the left, toxic granularity of young forms of leukocytes is noted. If vigorous measures fail to improve the patient's condition or are applied late, renal function ceases and the patient usually dies from uremia within 2-5 days.

After transfusion of denatured blood (with destroyed protein fractions due to overheating or reheating), the described symptoms are less pronounced.

Prevention of post-transfusion complications

Prevention of post-transfusion complications comes down to strict adherence to the rules for collecting and preserving blood, its storage and transportation. Before transfusion, the vial of blood is carefully inspected, and if there is the slightest sign of unsuitability of the blood, another ampoule is used.

Contraindications to blood transfusion should be taken into account. It is not recommended to warm blood. If the blood ampoule has been removed from the refrigerator and has been in a warm room for a long time, it should not be used either.

Blood is not suitable for transfusion if it contains a lot of clots; if there are a small number of clots after filtering, blood can be transfused, but carefully (monitor the reaction of the recipient’s body).

When the first signs of post-transfusion shock appear, it is recommended to immediately administer intravenously up to 20 ml of a 1% novocaine solution, drip intravenously an isotonic sodium chloride solution up to 3000 ml per day, and perform a perinephric novocaine blockade.

Even better, instead of administering an isotonic solution, in the first period of blood transfusion shock, start an exchange transfusion of blood up to 1.5-2 liters, infusion of polyglucin, 40% glucose solution up to 100 ml or drip - up to 2-3 liters of 5% glucose solution, injections cardiac drugs. During exchange transfusion, up to 1.5-2 liters of blood are released, immediately replenishing it with single-group compatible freshly citrated blood. To neutralize sodium citrate, for every 400-500 ml of infused blood, 10 ml of a 10% calcium gluconate solution should be administered intravenously, and in its absence, 10 ml of a 10% calcium chloride solution. Bloodletting can be done from large veins or from an artery massively or in fractional doses of 500-700 ml.

In the second period of blood transfusion shock, all therapeutic measures should be aimed at normalizing water, electrolyte and protein balance and removing protein breakdown products from the body. It is necessary to systematically, depending on daily diuresis, administer up to 600-800 ml of liquid per day, intravenous drip - polyvinylpyrrolidone, polyglucin, hypertonic glucose solution up to 300-500 ml per day, multivitamins. Dairy-vegetable, nitrogen-free, carbohydrate- and vitamin-rich foods are indicated, but with a minimal amount of chlorides.

If these measures are ineffective, an exchange blood transfusion and hemodialysis should be performed using an artificial kidney apparatus.

With the beginning of renal function recovery, depending on the indications, antibacterial and restorative treatment is prescribed.

Allergic reactions due to blood transfusion are observed relatively rarely and can manifest themselves in the form of severe chills, an increase in body temperature to 38-39°, general malaise, skin rashes (most often like urticaria), accompanied by itching. The number of leukocytes increases to 10,000-12,000, eosinophils - to 5-8%.

To prevent allergic reactions, it is recommended to administer 5-10 ml of blood intramuscularly 1 hour before repeated blood transfusion. Blood transfusions should not be received from donors with allergic diseases. In case of anaphylactic shock, the patient should be slowly administered intravenously from 10 to 20 ml of a 10% calcium chloride solution, subcutaneously - 1 ml of adrenaline (1: 1000), given ether anesthesia for a few minutes, and cardiac medications.

Post-transfusion reactions

Currently, post-transfusion reactions are observed in 3-5% of patients.

In the occurrence of these reactions, the individual characteristics of the body and the altered reactivity of the recipient to the introduction of donor blood, damage to red blood cells and leukocytes during the procurement, transportation and transfusion of blood, various technical errors, insufficient treatment of utensils and tubing systems, as a result of which pyrogenic substances can enter the blood, are important. .

Post-transfusion reactions of mild (weak), moderate and severe are observed.

A mild reaction is characterized by a slight disturbance in the patient’s well-being and a slight increase in temperature.

A reaction of moderate severity is manifested by severe chills, a short-term increase in temperature to 39° and a disturbance in the patient’s subjective state for several hours; the next day there is only slight general weakness.

A severe reaction occurs soon after a blood transfusion. The subjective and objective state of the patient is sharply disturbed, breathing is difficult, shortness of breath, headache, cyanosis of the lips and face, increased heart rate up to 100-120 beats/min are pronounced, but blood pressure does not drop, as in shock. The temperature rises to 40° and is maintained, as a rule, until the next day, during which the patient complains of a feeling of weakness and weakness.

Complications during blood transfusion can also arise due to technical errors.

Pulmonary air embolism occurs as a result of the introduction of air into a vein along with infused blood. At the moment air enters the vein, signs of suffocation appear - the patient suffocates, rushes about, and cyanosis of the lips and face quickly appears. If more than 3 ml of air enters the vein, the patient may die from asphyxia.

This severe complication can be easily prevented if blood transfusion is carried out in compliance with existing rules: the system tubes must be connected to a short needle through which blood flows from the bottle to the recipient, air must flow through a long needle (its end reaches the bottom of the bottle) leakage of blood from a vial. If you mistakenly connect the system tube to a long needle, air will inevitably enter the system through it, which can penetrate into the vein. For monitoring, it is necessary to use glass tubes, since through them it is easy to notice the entry of air into the blood transfusion system. In such cases, the transfusion should be stopped immediately.

With embolism from a blood clot, the clinical picture of pulmonary infarction develops: acute chest pain, hemoptysis, fever. The blood transfusion is stopped immediately and painkillers and cardiac drugs are administered.

As a result of the rapid infusion of a large amount of blood into the vein of a severely exsanguinated patient, overload of the right heart, acute expansion and cardiac arrest may occur. There is a circulatory disorder in the pulmonary circulation: there is difficulty breathing, a feeling of tightness in the chest, the face and lips turn blue, and cardiac activity drops catastrophically. As soon as the first signs of heart failure appear, it is necessary to immediately stop the blood transfusion, lower the head end of the table or bed and begin external cardiac massage by rhythmically squeezing the chest and lightly tapping the palm in the heart area. With the appearance of a pulse on the radial artery, cardiac medications and rest are prescribed. Patients with heart disease should not receive a single transfusion of more than 200 ml of blood, unless there are vital indications for the administration of massive doses.

Along with the infused blood, pathogens of infectious and viral diseases can be introduced: syphilis, malaria, viral hepatitis, typhus, etc. These complications are possible as a result of insufficient examination of donors; at present they are practically never found.

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:

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 of this complication is non-compliance with blood transfusion techniques. The most common medical errors are incorrect determination 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. Hg 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 manifest themselves in the form of noticeable arrhythmias, pale skin, sweating and a persistent 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 urine 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 the development of 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 take blood and urine for a quick 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.

Transfusion shock is a fairly rare but serious complication that develops during transfusion of blood and its components.

Occurs during the procedure or immediately after it.

Requires immediate emergency anti-shock therapy.

Features and changes in organs

The basis of all pathological changes is the destruction of red blood cells of incompatible donor blood in the recipient’s vascular bed, as a result of which the following enters the blood:

Free hemoglobin - normally free hemoglobin is located inside red blood cells, its direct content in the bloodstream is insignificant (from 1 to 5%). Free hemoglobin is bound in the blood by haptaglobin, the resulting complex is destroyed in the liver and spleen and does not enter the kidneys. The release of a large amount of free hemoglobin into the blood leads to hemoglobinuria, i.e. all hemoglobin is not able to bind and begins to be filtered in the renal tubules.
Active thromboplastin, an activator of blood coagulation and the formation of a thrombus (blood clot), is not normally present in the blood.
Intraerythrocyte coagulation factors also promote clotting.

The release of these components leads to the following violations:

DIC syndrome, or disseminated intravascular coagulation syndrome - develops as a result of the release of coagulation activators into the blood.

Has several stages:

hypercoagulation - multiple microthrombi are formed in the capillary bed, which clog small vessels, resulting in multiple organ failure;
consumptive coagulopathy – at this stage, coagulation factors are consumed to form multiple blood clots. At the same time, the anticoagulation system of the blood is activated;
hypocoagulation - at the third stage, the blood loses its ability to clot (since the main coagulation factor - fibrinogen - is no longer present), resulting in massive bleeding.

Oxygen deficiency – Free hemoglobin loses its connection with oxygen, and hypoxia occurs in tissues and organs.

Microcirculation disturbance- as a result of spasm of small vessels, which is then replaced by pathological expansion.

Hemoglobinuria and renal hemosiderosis– develops as a result of the release of a large amount of free hemoglobin into the blood, which, when filtered in the renal tubules, leads to the formation of hemosiderin (salt hematin - a breakdown product of hemoglobin).

Hemosiderosis in combination with vasospasm, it leads to disruption of the filtration process in the kidneys and accumulation of nitrogenous substances and creatinine in the blood, thus developing acute renal failure.

In addition, impaired microcirculation and hypoxia lead to disruption of the functioning of many organs and systems: liver, brain, lungs, endocrine system, etc.

Symptoms and signs

The first signs of transfusion shock may appear already during a blood transfusion or in the first few hours after the procedure.

the patient is agitated and behaves restlessly;
pain in the chest area, a feeling of tightness behind the sternum;
breathing is difficult, shortness of breath appears;
the complexion changes: more often it turns red, but it can be pale, cyanotic (blue) or with a marbled tint;
lower back pain is a characteristic symptom of shock and indicates pathological changes in the kidneys;
tachycardia - rapid heart rate;
decreased blood pressure;
Sometimes there may be nausea or vomiting.

After a few hours, the symptoms subside and the patient feels better. But this is a period of imaginary well-being, after which the following symptoms appear:

Icterus (jaundice) of the eye sclera, mucous membranes and skin (hemolytic jaundice).
Increased body temperature.
Renewal and intensification of pain.
Kidney and liver failure develops.

When receiving a blood transfusion under anesthesia, signs of shock may include:

Fall in blood pressure.
Increased bleeding from the surgical wound.
The urinary catheter produces urine that is cherry-black or the color of “meat slop,” and there may be oligo- or anuria (decreased amount of urine or its absence).
Changes in urinary excretion are a manifestation of increasing renal failure.

Course of the pathology

There are 3 degrees of transfusion shock depending on the level of decrease in systolic blood pressure:

up to 90 mm Hg;
up to 80-70 mm;
below 70 mm. rt. Art.

There are also periods of shock characterized by a clinical picture:

Shock itself is the first period in which hypotension (a drop in blood pressure) and DIC occur.
The period of oliguria (anuria) – the impairment of kidney function progresses.
The stage of diuresis restoration is the restoration of the filtering function of the kidneys. Occurs with timely provision of medical care.
Convalescence (recovery) – restoration of the blood coagulation system, normalization of hemoglobin, red blood cells, etc.

Anaphylactic shock is a rapid and dangerous reaction of the body to an external irritant, which requires immediate medical attention. Following the link, we will consider the mechanism of development of this condition.

Types of treatment procedures

All therapeutic measures for blood transfusion shock are divided into 3 stages:

Emergency anti-shock therapy - to restore normal blood flow and prevent serious consequences. It includes:

infusion therapy;
intravenous administration of antishock drugs;
extracorporeal methods of blood purification (plasmapheresis);
correction of the function of systems and organs;
correction of hemostasis (blood clotting);
treatment of acute renal failure.

Symptomatic therapy – carried out after stabilization of the patient’s condition during the recovery period (recovery).

Preventive measures - identifying the cause of the development of shock and eliminating similar errors in the future, strict adherence to the sequence of transfusion procedures, conducting compatibility tests, etc.

First aid

If signs of transfusion shock or corresponding complaints from the recipient appear, it is necessary to urgently stop further blood transfusion without removing the needle from the vein, since anti-shock drugs will be administered intravenously and time cannot be wasted on new catheterization of the vein.

Emergency treatment includes:

Infusion therapy:

blood replacement solutions (reopolyglucin) - to stabilize hemodynamics, normalize BCC (circulating blood volume);
alkaline preparations (4% sodium bicarbonate solution) - to prevent the formation of hemosiderin in the kidneys;
polyionic saline solutions (Trisol, Ringer-Locke solution) - to remove free hemoglobin from the blood and preserve fibrinogen (i.e., to prevent stage 3 of DIC, in which bleeding begins).

Drug antishock therapy:

prednisolone – 90-120 mg;
aminophylline – 2.4% solution in a dosage of 10 ml;
lasix – 120 mg.

This is a classic triad for preventing shock, helping to increase blood pressure, relieve spasm of small vessels and stimulate kidney function. All drugs are administered intravenously. Also used:

antihistamines (diphenhydramine and others) - to dilate the renal arteries and restore blood flow through them;
narcotic analgesics (for example, promedol) - to relieve severe pain.

An extracorporeal treatment method – plasmapheresis – involves taking blood, purifying it of free hemoglobin and fibrinogen breakdown products, then returning the blood to the patient’s bloodstream.

Correction of functions of systems and organs:

transfer of the patient to mechanical ventilation (artificial ventilation) in case of a serious condition of the patient;
transfusion of washed red blood cells - carried out when there is a sharp drop in hemoglobin levels (less than 60 g/l).

Correction of hemostasis:

heparin therapy – 50-70 IU/kg;
antienzyme drugs (contrical) - prevents pathological fibrinolysis, leading to bleeding in shock.

Treatment of acute renal failure:

hemodialysis and hemosorption are procedures for purifying blood outside the kidneys, carried out when oligo- or anuria develops and previous measures are ineffective.

Principles and methods of treatment procedures

The basic principle of treating transfusion shock is emergency intensive care. It is important to start treatment as early as possible, only then can we hope for a favorable outcome.

Treatment methods differ fundamentally depending on diuresis indicators:

Diuresis is preserved and amounts to more than 30 ml/h - active infusion therapy is carried out with a large volume of infused liquid and forced diuresis, before which it is necessary to pre-administer sodium bicarbonate (to alkalinize urine and prevent the formation of hydrochloric acid hematin);
Diuresis less than 30 ml/h (stage of oligoanuria) – strict limitation of the administered fluid during infusion therapy. Forced diuresis is contraindicated. At this stage, hemosorption and hemodialysis are usually used, since renal failure is severe.

Forecasts

The patient's prognosis directly depends on the early provision of anti-shock measures and the completeness of treatment. Therapy in the first few hours (5-6 hours) ends with a favorable outcome in 2/3 of cases, i.e. patients recover completely.

In 1/3 of patients, irreversible complications remain, developing into chronic pathologies of systems and organs.

Most often this happens with the development of severe renal failure, thrombosis of vital vessels (brain, heart).

If emergency care is not provided in a timely or adequate manner, the outcome for the patient can be fatal.

Blood transfusion is a very important and necessary procedure that heals and saves many people, but in order for donor blood to bring benefit and not harm to the patient, it is necessary to carefully follow all the rules for its transfusion.

This is done by specially trained people who work in blood transfusion departments or stations. They carefully select donors; after blood collection, blood goes through all stages of preparation, safety testing, etc.

Blood transfusion, like preparation, is a carefully controlled process, carried out only by trained professionals. It is thanks to the work of these people that today this process is quite safe, the risk of complications is low, and the number of people saved is very large.

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Transfusion of blood and its components is widely used in clinical practice. A prerequisite for blood transfusion is strict adherence to the instructions. After transfusion of incompatible blood, various reactions (pyrogenic, allergic, anaphylactic) and blood transfusion shock can be observed.

Pyrogenic reactions manifested by increased body temperature, sometimes chills, pain in the lower back and bones. In these cases, the use of antipyretics and cardiac therapy is indicated.

For an allergic reaction The increase in body temperature is accompanied by shortness of breath, nausea, and vomiting. In these cases, in addition to antipyretics, antihistamines (diphenhydramine, suprastin), corticosteroids, cardiac and desensitizing drugs are used.

The most severe reaction is anaphylactic shock, which is characterized by vasomotor disorders, skin hyperemia, cyanosis, and cold sweat. The pulse is frequent, thread-like. Blood pressure is reduced. Heart sounds are muffled. Pulmonary edema and urticaria may develop.

Complications after blood transfusion are associated with incompatibility of the blood of the donor and recipient, bacterial contamination of the blood, and violation of blood transfusion technique (air embolism, thromboembolism), circulatory overload, massive blood transfusion, underestimation of contraindications to blood transfusion. Most often, the occurrence of transfusion shock is caused by transfusion of completely or partially incompatible blood.

Blood transfusion shock develops as a result of transfusion of incompatible blood group or Rh factor. Currently, there are many known agglutinogens that are present in human blood. Determining blood groups and Rhesus status does not always make blood transfusion completely safe. More often post-transfusion shock occurs in case of incompatibility of the blood of the recipient and the donor according to the AB0 system. An immunological conflict during blood transfusion shock can also be caused by isommunization and different Rhesus status of the patient and the donor. Blood transfusion is the introduction of a foreign protein, and therefore it is necessary to establish strict indications. Blood transfusion should not be performed in cases where it can be avoided. Only a doctor should perform a blood transfusion. Careful observation of the patient allows us to notice initial abnormalities indicating a dangerous pathology. Sometimes the first signs of a post-hemorrhagic reaction are the patient’s anxiety, lower back pain, and chills. In such cases, blood transfusion should be stopped immediately.

Clinical picture, which develops as a result of transfusion of incompatible blood, can be very diverse. When transfusion of group-incompatible blood occurs, clinical signs of complications appear after the administration of small amounts of blood (25 - 75 ml). The patient becomes restless, complains of feeling unwell, then of pain in the lower back caused by spasm of the renal vessels, a feeling of tightness in the chest, and fever. If blood transfusion does not stop, blood pressure decreases, pale skin appears, and sometimes vomiting. Hemoglobinuria develops quite quickly (urine becomes the color of dark beer). If the transfusion is stopped in time, these symptoms may disappear without a trace. However, strict medical supervision is necessary, since later severe renal dysfunction may occur, including the development of acute renal failure.

9. Indications and contraindications for blood transfusion!

Indications for blood transfusion!

A) Absolute - acute blood loss (15% of bcc); traumatic shock; severe operations accompanied by extensive tissue damage and bleeding.

B) Relative p- anemia, inflammatory diseases with severe intoxication, ongoing bleeding, coagulation system disorders, decreased immune status of the body, long-term chronic inflammatory processes with decreased regeneration and reactivity, some poisoning.

Contraindications to blood transfusion! can be divided into two groups:

Absolute:

acute septic endocarditis;

· fresh thrombosis and embolism;

pulmonary edema;

· severe cerebrovascular accidents;

· heart defects, myocarditis and myocardiosclerosis of various types with impairment of general blood circulation of II─III degree;

· hypertension of the ΙΙΙ degree with severe atherosclerosis of cerebral vessels, nephrosclerosis.

Relative:

· subacute septic endocarditis without progressive development of diffuse glomerulonephritis and general circulatory disorders.

· heart defects with circulatory failure, degree IIb;

· severe amyloidosis;

· acute tuberculosis.

The importance of nurse competence when working with blood.

A physician should be someone who puts the life and health of the patient above personal interests. The motto of medicine, proposed by the 17th century Dutch physician Van Tulpius - aliis inserviendo consumer (lat.) - while serving others, I burn myself.

In the complex of medical measures, professional competence in all matters plays a huge role, especially when it comes to blood transfusion and its components. The most effective medications, skillfully performed operations, etc. sometimes cannot ensure recovery if blood transfusions, its components and blood substitutes are not carried out systematically.

Therefore, the most characteristic feature for a nurse should be awareness of their responsibility when performing immediate duties, which must be carried out not only correctly, but also in a timely manner. You need to know the effect of blood, its antigenic structure, the effect of IV procedures on the patient. If, instead of a beneficial effect, some complication arises, you must stop the procedure immediately. You cannot blindly and mechanically carry out assignments. If the prescribed intravenous infusion of blood or its components exhibits an unusual effect, then an observant, attentive and medically educated nurse will invite a doctor who will decide what to do. From all of the above, we can conclude that the competence of a nurse is very important. If earlier it was only an assistant, then in our time the specialty “nurse” is distinguished as a new independent discipline due to changing environmental conditions, society, views and scientific discoveries.

LECTURE.

Topic: Blood transfusion and blood substitutes .

The role of knowledge about transfusiology in the work of a nurse.

Blood transfusion is a serious operation involving the transplantation of living human tissue. This treatment method is widely used in clinical practice. Blood transfusions are used by nurses of various specialties: departments of surgery, gynecology, traumatology, etc. The achievements of modern science, in particular transfusiology, make it possible to prevent complications during blood transfusion. The cause of complications is errors during blood transfusion, which are caused either by insufficient knowledge of the basics of transfusion, violation of the rules and techniques of blood transfusion at various stages. Scrupulous, competent implementation of the rules and reasonable consistent actions of the nurse during blood transfusion determine its successful implementation. In the healthcare system, this important role belongs to the category of paramedical workers, on whose highest knowledge, qualifications and personal qualities not only the success of the treatment, but also the quality of life of the patient depends. A professional nurse is required to know a lot: i.e. a nurse involved in preparing a patient and transfusion of blood, blood components and blood substitutes must know and be able to do a lot, and in practice apply all the knowledge, be with the patient at the first call and help him cope with the situation that has arisen.

1. The concept of blood transfusion of its components and blood substitutes.

Blood transfusion (haemotransfusio, transfusio sanguinis; synonym: blood transfusion, blood transfusion) a therapeutic method that consists of introducing into the bloodstream of the patient (recipient) whole blood or its components collected from the donor or the recipient himself, as well as blood spilled into the body cavity during injuries and operations.

Blood transfusion is a method of transfusion therapy, this is an intervention that results in transplantation (transplantation) of allogeneic or autogenous tissue. The term “blood transfusion” combines the transfusion of whole blood, its cellular components and plasma protein preparations into a patient.

In clinical practice, the following main types of L. are used: indirect, direct, exchange, autohemotransfusion. The most common method is indirect transfusion of whole blood and its components (erythrocytes, platelets or leukocytes, fresh frozen plasma). Blood and its components are usually administered intravenously using a disposable blood transfusion system to which a vial or plastic container containing the transfusion medium is connected. There are other ways of introducing blood and red blood cells - intra-arterial, intra-aortic, intraosseous.

2. History of the development of transfusiology.

There are 2 periods in the history of blood transfusion. 1st period - from ancient times until the discovery of the laws of isohemagglutination and group blood factors (erythrocyte antigens). This period lasted from ancient times until W. Harvey's discovery of blood circulation (628) and continued until K. Landsteiner's discovery of group blood factors. The first successful blood transfusion took place in 1667, when French explorers Denis and Emmeretz transfused the blood of an animal (lamb) into a human. But the 4th transfusion to another patient ended in death. Human blood transfusions were stopped for almost 100 years.

In the Russian Fatherland in 1832. G. Wolf transfused blood to a woman who was dying after childbirth from uterine bleeding, which led to the recovery of the woman in labor. In 1847, the prosector of Moscow University I.M. Sokolov for the first time transfused human blood serum to a cholera patient.

In Russia, the first fundamental work on blood transfusion was the book by A. M. Filomafitsky “Treatise on Blood Transfusion...”.

In the 60-80s. XIX century in Russia 3 important discoveries were made in blood transfusion; S.P. Kolomnin introduced the method of intra-arterial transfusion, V.V. Sutugin - the method of chemical stabilization of blood. N.I. Pirogov emphasized the benefits of blood transfusion for some wounds in the field.

1900-1925 were associated with the development of the doctrine of immunity - the immunity of the human body to infectious and non-infectious agents and substances with foreign antigenic properties.

For a long time, immunity meant the body's immunity only to infectious diseases. This opinion was also shared by I. I. Mechnikov (1903), who wrote: “By immunity to infectious diseases we must understand the general system of phenomena due to which the body can withstand attacks by pathogenic microbes.” Subsequently, the concept of “immunity” received a broader interpretation.

In 1901 K. Landsteiner discovered blood groups; there were 3 of them. In 1907, J. Jansky identified the 4th blood group.

Blood transfusions quickly became a part of medical practice in the USSR. In 1919, V.N. Shamov, N.N. Elansky and I.R. Petrov for the first time received standard sera to determine blood group and, taking them into account, performed a blood transfusion. In 1926, N. N. Elansky’s monograph “Blood Transfusion” was published. Institutes began to open (1926) and blood transfusion stations. Our country has taken one of the leading places in the development of blood transfusion.

The theory of blood clotting belongs to the physiologist A. A. Schmidt - 2nd half of the 19th century. Rosengardt and Yurevich proposed sodium citrate (citrate) as a means to stabilize blood. This played a huge role in the development of indirect blood transfusions, called "citrate" blood transfusions.

In recent years, the indications for blood transfusion have been revised. Currently, new principles of transfusion tactics have been introduced into practice, these are component and infusion-transfusion hemotherapy, the essence of which is the differentiated or complex use of transfusion of blood and its components, drugs, saline solutions and blood substitutes.

3. Methods and methods of administering blood transfusion media.

Blood transfusions can lead to reactions and complications. Reactions manifest themselves in fever, chills, headache, and some malaise. It is customary to distinguish 3 types of reactions: mild (increase in temperature to 38°, slight chills), moderate (increase in temperature to 39°, more pronounced chills, slight headache) and severe (increase in temperature above 40°, severe chills, nausea ). The reactions are characterized by their short duration (several hours, rarely longer) and the absence of dysfunction of vital organs. Therapeutic measures are reduced to the prescription of symptomatic drugs: cardiac drugs, drugs, heating pads, bed rest. When reactions are allergic in nature (urticarial rash, itchy skin, facial swelling of the Quincke type), the use of desensitizing agents (diphenhydramine, suprastin, intravenous infusion of 10% calcium chloride solution) is indicated.

A more serious clinical picture develops with post-transfusion complications. Their reasons are different. Usually they are caused by transfusion of incompatible blood (based on group affiliation or Rh factor), much less often - transfusion of poor-quality blood or plasma (infection, denaturation, hemolysis of blood) and violations of the transfusion technique (air embolism), as well as errors in determining indications for transfusion blood, choice of transfusion technique and dosage. Complications are expressed in the form of acute heart failure, pulmonary and cerebral edema.

The time for the development of transfusion complications varies and depends largely on their causes. Thus, with an air embolism, a catastrophe can occur immediately after air enters the bloodstream. On the contrary, complications associated with heart failure develop at the end or shortly after transfusion of large doses of blood and plasma. Complications from transfusion of incompatible blood develop quickly, often after the administration of small quantities of such blood; less often, a catastrophe occurs in the near future after the end of the transfusion.

The course of post-transfusion complications can be divided into 4 periods: 1) blood transfusion shock; 2) oligoanuria; 3) restoration of diuresis; 4) recovery (V. A. Agranenko).

The picture of transfusion shock (Period I) is characterized by a drop in blood pressure, tachycardia, severe respiratory distress, anuria, and increased bleeding, which can lead to the development of bleeding, especially if an incompatible blood transfusion was performed during surgery or in the immediate hours after it. In the absence of rational therapy, transfusion shock can lead to death. In the second period, the patient's condition remains severe due to progressive impairment of renal function, electrolyte and water metabolism, increasing azotemia and increased intoxication, which often leads to death. The duration of this period is usually from 2 to 3 weeks and depends on the severity of the kidney damage. The third period is less dangerous, when kidney function is restored and diuresis is normalized. In the fourth period (recovery), anemia lasts for a long time.

In the first period of transfusion complications, it is necessary to combat severe hemodynamic disturbances and prevent the negative impact of toxic factors on the functions of vital organs, primarily the kidneys, liver, and heart. Massive exchange blood transfusions in a dose of up to 2-3 liters using single-group Rh-compatible blood with short shelf life, polyglucin, and cardiovascular drugs are justified here. In the second period (oliguria, anuria, azotemia), therapy should be aimed at normalizing water and electrolyte metabolism and combating intoxication and impaired renal function. The patient is given a strict water regime. Liquid intake is limited to 600 ml per day with the addition of the amount of liquid that the patient excreted in the form of vomit and urine. Hypertonic glucose solutions (10-20% and even 40%) are indicated as transfusion fluids. Gastric lavage and siphon enemas are prescribed at least 2 times a day. With increasing azotemia and increased intoxication, exchange transfusions, intra-abdominal and intra-intestinal dialysis, and especially hemodialysis using an artificial kidney apparatus are indicated. In the III and especially in the IV periods, symptomatic therapy is carried out.

Pathological anatomy of complications. The earliest pathomorphological changes at the height of shock are detected in the blood and lymph circulation. Swelling and foci of hemorrhages are observed in the membranes of the brain and its substance, in the lungs, hemorrhagic effusion in the pleural cavities, often small-point hemorrhages in the membranes and muscle of the heart, significant congestion and leukostasis in the vessels of the lungs and liver.

In the kidneys at the height of shock, a significant plethora of the stroma is revealed. However, the glomerular vasculature remains free of blood. In the liver at the height of shock, fiber disintegration and swelling of the vascular walls, expansion of the pericapillary spaces are sharply expressed, fields of light-colored liver cells with swollen vacuolated protoplasm and an eccentrically located nucleus are often detected. If death does not occur at the height of shock, but in the next few hours, then in the kidneys there is swelling of the epithelium of the convoluted tubules, the lumens of which contain protein. The swelling of the stroma of the medulla is extremely pronounced. Necrobiosis of the tubular epithelium appears after 8-10 hours. and is most pronounced on the second or third day. In this case, in many straight tubules the main membrane is exposed, the lumen is filled with accumulations of destroyed epithelial cells, leukocytes and hyaline or hemoglobin casts. In case of death, 1-2 days after blood transfusion, extensive areas of necrosis can be found in the liver. If death occurs in the first hours after transfusion of blood of an incompatible group, along with pronounced circulatory disorders, accumulations of hemolyzed erythrocytes and free hemoglobin are detected in the lumens of the vessels of the liver, lungs, heart and other organs. Hemoglobin products released during the hemolysis of red blood cells are also found in the lumens of the renal tubules in the form of amorphous or granular masses, as well as hemoglobin casts.

In the event of death from a transfusion of Rh-positive blood to a recipient sensitized to the Rh factor, massive intravascular hemolysis comes to the fore. Microscopic examination of the kidneys reveals a sharp expansion of the tubules; their lumens contain hemoglobin casts, fine-grained masses of hemoglobin with an admixture of decaying epithelial cells and leukocytes (Fig. 5). 1-2 days and later after blood transfusion in the kidneys, along with stromal edema, necrosis of the epithelium is detected. After 4-5 days, you can see signs of its regeneration, in the stroma - focal lymphocytic and leukocyte infiltrates. Kidney damage may be combined with changes in other organs characteristic of uremia.

In case of complications from the injection of poor-quality blood (infected, overheated, etc.), the signs of hemolysis are usually mildly expressed. The main ones are early and massive dystrophic changes, as well as multiple hemorrhages on the mucous and serous membranes and in the internal organs, especially often in the adrenal glands. When introducing bacterially contaminated blood, hyperplasia and proliferation of reticuloendothelial cells in the liver are also characteristic. Accumulations of microorganisms may be found in the vessels of organs. When overheated blood is transfused, widespread vascular thrombosis is often observed.

In cases of death from post-transfusion complications associated with increased sensitivity of the recipient, changes characteristic of blood transfusion shock can be combined with morphological signs of an allergic condition. In a small proportion of cases, blood transfusion complications occur without a clinical picture of shock and are associated with the presence of contraindications to blood transfusion in patients. The pathological changes observed in these cases indicate an exacerbation or intensification of the underlying disease.

Rice. 5. Hemoglobin casts and granular masses of hemoglobin in the lumen of the kidney tubules.