Haemo transfusion shock
Haemo transfusion shock – one of the most dangerous complications of transfusion of components of blood which is expressed in destruction of erythrocytes with emission of toxic substances in the vascular course of the patient. It is characterized by psychoemotional excitement, painful feelings in lumbar area, tachycardia, falling of arterial pressure, jaundice. It is diagnosed on the basis of a clinical picture, a number of indicators of the general analysis and biochemical composition of blood, the antiglobulinovy test. Treatment assumes the immediate termination of a hemotransfusion and symptomatic therapy: removal of products of disintegration of erythrocytes, partial or full replacement of function of target organs.
Haemo transfusion shock
Haemo transfusion shock – extreme manifestation of reaction of incompatibility. Meets seldom (in 7% of all transfusions of blood), but dominates in structure of complications of transfusion (from 50% to 61,5%). At the same time the lethality, on different sources, can reach 71,2%. Develops directly in time of the procedure or in the next 1-2 hours after its termination. Signs of shock are, as a rule, shown within 30-45 minutes from the beginning of a hemotransfusion. Due to the danger of development of a state of shock and emergence of fatal consequences transfusion is carried out only in the conditions of a hospital by the doctor-transfuziologom or the intensivist who underwent special training.
Reasons of haemo transfusion shock
It is considered that incompatibility of blood of the donor and patient is the main reason of development of a state. In this regard major factors of risk are violation of the rules of a hemotransfusion, lack of sufficient qualification at the doctor who is carrying out transfusion. Haemo transfusion shock develops at:
- Incompatibility of group of blood on the ABO system. Meets most seldom since standards of delivery of health care are strictly regulated and assume at least triple definition of a blood type of the recipient and double – the donor. Incompatibility can arise at the phenomenon of "a blood chimera" (simultaneous presence at the person of anti-genes of two different groups).
- Incompatibility of a Rhesus factor (Rh). It is characteristic of patients with a slabopolozhitelny Rhesus factor as they possess smaller number of anti-genes in comparison with the persons having it is expressed a positive factor. In cases of a doubtful Rh-factor the interpretation of a Rhesus factor as not containing anti-genes and a hemotransfusion of Rh-negative blood is recommended.
- Incompatibility of others antigenov. Not less than 500 anti-genes of blood forming 40 serological systems are known. Often violation of compatibility on system Kel meets, is more rare - Daffi, Levis and Kidd or because of existence of not defined rare trombotsitarny anti-genes that can also lead to haemo transfusion shock. Triple conducting biological test serves solving in definition of compatibility.
The shock phenomena can develop after transfusion of the infected environment in case of violation of tightness of a gemakon, its inadequate storage or non-compliance with term of a quarantine of plasma. In literature the potential possibility of development of a haemo transfusion complication at a severe form of other allergic reactions, system diseases is described, at transfusion of incompatible components in the anamnesis.
The second type of allergic reactions – cytotoxic is the cornerstone of the pathogenetic mechanism of haemo transfusion shock. These reactions differ in bystry emission of a histamine, high speed of development (sometimes within several minutes). At receipt in a blood-groove of the patient of incompatible components of 0,01% and more from OTsK begins (destruction of the poured erythrocytes) in vessels of the recipient. At the same time biologically active agents are thrown out blood. Are significant untied hemoglobin, active and vnutrieritrotsitarny factors of folding.
As a result of emission of hemoglobin its deficiency as oxygen carrier is formed, it passes through a kidney barrier, injuring a kidney ‒ the gematuriya appears. All factors cause a spasm, and then expansion of small vessels. During narrowing of a gleam of capillaries develops – the dangerous process leading to sharp kidney damage owing to violation of a filtration. At high emission of factors of folding the probability of the DVS-syndrome is high. Significantly permeability vascular an endoteliya increases: a liquid part of blood leaves the course, the condensation provides growth of concentration of electrolytes. As a result of increase in concentration of the acid remains acidosis accrues.
Microcirculation violations, redistribution of liquid between vessels and interstitsiy, a hypoxia lead to a syndrome of polyorgan insufficiency – the liver, kidneys, lungs, endocrine and cardiovascular systems are surprised. Set of violations involves critical to a lowering of arterial pressure. Haemo transfusion shock belongs to redistribution shocks.
Allocate three degrees of haemo transfusion shock in dependence on the level of decrease in systolic arterial pressure: The I degree – HELL falls to 90 mm of mercury.; II – to 70 mm of mercury.; III – lower than 70 mm of mercury. The periods of development of shock which distinctive features is the developed clinical picture and damage of target organs are more indicative:
- Shock period. Begins with redistribution of liquid and violations of microcirculation. The main clinical aspect - falling of arterial pressure. Often there is a DVS-syndrome. Leading are manifestations from cardiovascular system. Proceeds of several minutes till 24 o'clock.
- Period oligurii / anuries. It is characterized by further damage of kidneys, violation of their filtrational ability, decrease in a reabsorption. At artificial removal of urine the gematuriya, urethra bleeding is observed. Symptoms of shock become greased. In case of inadequate treatment the increasing doses of simpatomimetik are required.
- Restoration period. Comes at timely start of therapy. Filtrational function of kidneys improves. At the long second period of shock injury of a kidney is irreversible, on it the proteinuria and decrease in albumine will specify in plasma.
- Convalescence (recovery). The period of normalization of activity of all systems, functional defects completely regress, anatomic ‒ are compensated. There is a complete recovery of folding, a vascular barrier, balance of electrolytes. Duration is 4-6 months. Upon completion of a stage it is possible to judge chronic defeat of bodies.
Symptoms of haemo transfusion shock
Clinical manifestations are observed already during a hemotransfusion, but can proceed is erased and to remain unnoticed against the background of weight of the main disease. More than at 70% of patients mental excitement, not clear concern are observed; hyperaemia of the person against the background of the general pallor, cyanosis or a mramornost; the breast pains pressing, constraining breath; short wind, feeling of shortage of air; tachycardia. Seldom nausea or vomiting meets. A characteristic adverse sign is the waist pain indicating damage of kidneys.
At a lightning current of shock the patient within several minutes can die from critical falling of arterial pressure, refractory to simpatomimetichesky means. If development of shock gradual, at patients occurs temporary imaginary improvement. Further the clinic accrues: body temperature increases, yellowness mucous appears and integuments, pain amplifies. Over time at the large volume of a hemotransfusion hypostases and a gematuriya develop.
At emergence of a haemo transfusion complication during an anesthesia the picture always erased many symptoms are absent. The patient in a coma or under the general anesthesia cannot express concern therefore timely identification of a zhizneugrozhayushchy state completely lays down on a transfuziolog and the anesthesiologist. In the absence of consciousness emergence of urine of color of "meat slops", jump of temperature, pressure drop, cyanosis and the raised bleeding of an operational wound become the leading signs.
Among the main complications of shock ‒ polyorgan insufficiency and sharp renal failure. At inefficiency of treatment sharp process hronizirutsya and leads to the patient's invalidization. The large volume of a hemotransfusion and late diagnostics cause accumulation of critical concentration of electrolytes. Giperkaliyemiya causes refractory zhizneugrozhayushchy arrhythmias. After injury of a myocardium and kidneys at haemo transfusion shock blood supply of all bodies and fabrics is broken. Respiratory dysfunction develops. Lungs cannot perform secretory function and bring toxins out of an organism, aggravating intoxication and ischemia. The vicious circle and polyorgan insufficiency is formed.
The main diagnostic criterion of haemo transfusion shock is communication of a hemotransfusion with symptoms. The clinical picture allows to suspect development of shock and to differentiate it from some other complications of transfusion. At emergence of typical symptoms hold laboratory diagnostics, consultation of the hematologist and a transfuziolog. Mandatory tests are:
- General and biochemical blood tests. At patients with a transfusion of incompatible blood gipokhromny anemia progresses, the number of platelets is lowered, in plasma there is a free hemoglobin, is defined . In 12–18 hours transaminelements, urea, creatinine, potassium and sodium raise. The gas analysis and KShchS of blood allow to estimate efficiency of oxygenation, function of lungs, possibilities of an organism on compensation of acidosis and a giperkaliyemiya.
- Hemostasis research. Koagulogramma is characteristic of the DVS-syndrome. The stage of hyper coagulation is replaced by exhaustion of the curtailing components, up to total absence. At the elderly patients accepting the tromboelastogramma is expedient. On the basis of data the issue of need of application of coagulants, transfusions of plasma and plasma factors, trombotsitarny weight is resolved.
- Antiglobulinovy tests. Are the standard of inspection of patients with complications of a hemotransfusion and differential diagnostics. The main of them – Koombs's test. The positive result means presence of At to a Rhesus factor and the specific antibodies globulins which are fixed on erythrocytes. Bakster's test allows with high probability to suspect the right diagnosis and to begin intensive therapy to readiness of other laboratory data.
- Urine researches. Oliguriya or an anury demonstrate damage of kidneys. In urine free hemoglobin, a makrogematuriya, protein appears. A boundary indicator for transfer of the patient to resuscitation is decrease in a daily diuresis to 500 ml.
In the conditions of intensive care unit monitoring of the ECG is carried out each hour before knocking over of a sharp state. Differential diagnostics is carried out with sharp kidney damage of other etiology and a syndrome of massive hemotransfusions. In the first case a key role is played by a hemotransfusion and time of development of shock, in the second – Koombs's test and volume of the poured environment. The syndrome of a massive hemotransfusion and shock have similar pathogenesis and the principles of therapy, do not demand differentiation in the first days of treatment. Quite often these diagnoses are established retrospectively.
Treatment of haemo transfusion shock
At suspicion on incompatibility it is necessary to stop immediately a hemotransfusion and to begin infusional therapy. Treatment is carried out to ORIT under control of the resuscitator and with participation of a transfuziolog. The main actions are directed to the accelerated removal of toxic substances, maintenance of a homeostasis, in case of need – prosthetics of vital functions. The kateterization of the central vein is obligatory. Medicamentous therapy includes:
- Medicines for increase HELL. For the purpose of maintenance of pressure and pump function of a myocardium apply simpatomimetik (adrenaline, noradrenaline, dopamine). Infusional therapy fills volume in the vascular course, provides sufficient warm emission. Use of crystallites together with colloids for reduction of effect of the return outflow is obligatory.
- Antishock medicines. Antihistamines and glucocorticosteroids reduce puffiness and redistribution of liquid. Chloride of calcium is capable to reduce permeability of a vascular wall. NPVP reduce pain and hypostasis of fabrics, stabilize endoteliya. At their inefficiency, the expressed concern of the patient apply narcotic analgetics.
- Correction of the curtailing system. For the purpose of reduction of a tromboobrazovaniye in the period of hyper coagulation and leveling of consequences of change of microcirculation dezagregant apply. For improvement of rheological properties of blood antioxidants are shown. Anticoagulants, a trombomassa and plasma are used depending on the DVS-syndrome stage under control of a koagulogramma.
- The forced diuresis. Assumes introduction of diuretics in combination with the large volume of infusion. Stimulation of a diuresis promotes the accelerated removal from an organism of products of disintegration. In time the begun forced diuresis at the small volume of the poured incompatible components reduces weight of damage of kidneys. In the conditions of shock it is necessary to keep strictly account of water balance of avoidance of hypostasis of lungs and a brain.
Replacement therapy is carried out strictly according to indications. The plasma exchange is effective only at the first stage of shock when removal of complexes an anti-gene antibody can be sufficient for a patronage of kidneys. The hemodialysis is used for elimination of toxins, correction of electrolytic structure at the expressed dysfunction of kidneys. Preventive protection of other target organs consists in timely oxygenotherapy ‒ from an oxygen insuflyation before artificial ventilation of lungs, decrease in energy needs of bodies (a medicamentous coma) and symptomatic therapy.
Forecast and prevention
Forecast of haemo transfusion shock adverse. The invalidization, chronic kidney damage occur at more than 90% of the survived patients. However modern methods of replacement kidney therapy give to many patients chance of worthy quality of life. At timely intensive therapy perhaps compensated current of HPN for many years. Transplantation of a kidney for increase in life expectancy can be required.
Prevention consists in strict observance of the established rules of transfusion, accurate drawing of absolute and relative indications to a hemotransfusion, determination of minimum sufficient volume of components of blood. It is extremely important to show attention when determining compatibility, to carefully collect the anamnesis. A special role is played by biological test on compatibility, visual assessment of gemakon.