输血风险（非感染性）华山M.D.，Ph.D 约翰霍伯金斯医学院美国，马里兰州，巴尔的摩危险肝炎同种致敏作用循环超负荷过敏反应败血症输血反应(TR) 输血反应表1 标本贴签要求和拒绝标准——————————————————————————————————————要求手写标签符合申请表资料病人全名病人住院的身份号绝对拒绝有证据显示贴标签不是在床边完成打印或自动生成的标签名字错误或没有姓错误或没有没有病人的住院身份号身份号超过1 个数字有误，除非只有2 位数，数字顺序颠倒脐带样本没有标明“脐带”或“婴儿”或“男孩/ 女孩”难以执行只有首写字母，罕见的姓氏手写标签在自动标签上样本标签符合臂章，但与申请表的资料不符可接受名字错误但可以理解，或者两个名字姓有细微的拼写错误病人身份号的一个数字错误或两个数字颠倒；罕见名字——————————————————————————————————————抽取血标本的病人的住院病房、床号和日期必须写在标本的标签上或是输血申请单上不良事件的报告和咨询表2：ABO 和/或Rh 血型错误的频率———————————————————标本标本分型错误百分比———————————————————正确标签40,274 14 0.035 错误标签（拒绝）496 7 1.4 相容性试验的组成元素确认病人确认标本抽错血标本的几率是1/2900 确认受者溶血性输血反应的治疗1 、停止输血2 、维持静脉通路3 、开始利尿4 、输液5 、维持血压6 、监测肾功能7 、监测凝血状态8 、避免输注抗原阳性血溶血性输血反应的调查1 、停止输血2 、取血样3 、检查是否有笔误4 、进行直接抗球蛋白试验5 、观察血浆的溶血状况或黄疸6 、如果怀疑溶血反应，重复相容性实验血管外溶血性输血反应症状：虚弱不舒服头疼体征红细胞压积降低黄疸（高胆红素血症）发热直抗试验阳性*很多病人可能没有症状病理免疫介导的组胺的释放处理抗组胺剂类固醇（严重）肾上腺素（严重）洗涤红细胞（抗-IgA ）存在有输血相关的移植物抗宿主病风险的病人子宫内的输血年幼儿童有先天免疫缺陷的病人有获得性免疫抑制、癌症、接受免疫抑制治疗的病人亲缘性输血的受血者Prevention of TA-GVHD: IRRADIATED BLOOD Irradiation at the correct dose destroys lymphocytes’ability to reproduce, therefore eliminate risk of TA-GVHD Luokoreduction is NOT sufficient, because a very small number of live lymphocytes can still cause TA-GVHD TA-GVHD 预防血液辐照适当剂量的辐照损坏白细胞的再生能力，因此可减少输血相关移植物抗宿主病的风险去白是不够的，因为非常少量的活的白细胞仍旧可以造成输血相关移植物抗宿主病FEBRILE, NON-HEMOLYTIC REACTIONS Temperature elevation > 1 C WBC antibodies in patient serum reacting with donor WBC or platelets Cytokines generated by stored WBC Must be distinguished from hemolytic and septic reactions 非溶血的发热反应温度升高>1C 病人血清中的白细胞抗体与捐献者的白细胞或血小板反应储存的白细胞产生细胞因子必须与溶血反应和败血症区别FEBRILE, NON-HEMOLYTIC REACTIONS Preventable by use of leukoreduced blood components May be applied for selected patients with previous reactions or universally to prevent reactions in all patients Pre-medication: Tylenol Washing components may also help to remove cytokines or white cells from blood components 非溶血性发热反应通过使用去白血液制品可以预防去白血制品可用于以前有反应的病人或者普遍用于预防输血反应输前用药：羟苯基乙酰胺血液成份洗涤也可有助于去除细胞因子或白细胞过敏反应ALLERGIC REACTIONS Hypersensitivity (IgE) response to donor plasma proteins; hives, flushing, tachycardia are most common signs and symptoms Bronchospasm or anaphylaxis can occur, often with IgA deficiency Benadryl, corticosteroids, concentrated or washed products Most common cause of transfusion reaction, particularly with products containing plasma 过敏反应对捐献者的血浆蛋白超敏反应（IgE ），麻疹、脸红、心动过速都是常见的体征和症状会发生支气管痉挛或过敏反应，常常IgA 缺乏二苯醇胺、皮质类固醇，浓缩或洗涤血液产品是最普遍的输血反应的原因，特别是含血浆的血制品Massive Transfusion Definition: 		Receiving >10 units of blood (replacing one blood volume) in 24 hours: 		Replacing >50% of the circulating blood volume in < 3 hours Usually happens in: 		Trauma, ruptured aortic aneurysms, severe bleed (gastrointestinal, intraoperative, etc) 大量输血定义24 小时内接受>10U 血液： 在3 小时内置换了50% 循环血量通常发生在： 外伤、主动脉瘤破裂、严重的出血（胃肠道、外科手术中等）Massive Transfusion-Complications Hypothermia Hemostatic abnormalities 		Dilutional coagulopathy 		DIC Metabolic abnormalities 		Citrate toxicity (citrate delivery >> liver‘s 		capacity for clearance) Hypocalcemia and hypomagnesemia Acid-base balance 		metabolic alkalosis Hyperkalemia	 大量输血并发症体温降低止血异常	 稀释凝血障碍	 弥漫性血管内凝血代谢异常	 柠檬酸中毒（柠檬酸传递>> 肝脏清除能力）低钙和低镁血症酸碱平衡	 代谢性碱中毒高血钾症	 Prevention of Complications During Massive Transfusion Use of a blood warmer Close monitoring of patient signs/symptoms and lab results Use Type O, Rh- red cells and type AB plasma Correct citrate toxicity, acid-base imbalance and hemostatic abnormalities 在大量输血中预防并发症血液预温密切监控病人的体征/ 症状和实验室结果使用O 型Rh—红细胞和AB 型血浆纠正柠檬酸中毒、酸碱不平衡和止血异常Complications of Neonatal Transfusion Impaired glucose homeostasis: 		Hypoglycemia Hypocalcemia Hyperkalemia Susceptibility to circulatory overload, TA-GVHD and other complications 新生儿输血并发症削弱的血糖稳态：	 低血糖低血钙高钾对循环过载敏感，输血相关移植物抗宿主病和其他并发症Neonatal Transfusion- Prevention of Complications Irradiated blood Leukoreduced blood Fresh blood or washed blood Close monitoring 	Volume, metabolic changes 新生儿输血并发症的预防血液辐照血液去白新鲜血液或洗涤血液密切监视血容量和代谢改变CONCLUSIONS Many adverse effects of transfusion can be directly attributed to errors at the blood center, errors in the transfusion service, or errors in the hospital or clinic. Recognizing transfusion reactions and trying to fix these errors can prevent further reactions in other patients. Evolving blood components can reduce the residual risk of some adverse effects Error reduction and patient safety are important concerns in transfusion medicine. 结论很多输血的不利作用都直接由于血站、输血服务、或医院、临床的差错。发现输血反应、尝试纠正差错可防止其他病人发生输血反应。开展成份血液可减少输血不良反应的风险。减少差错和病人的安全是输血医学的重要关注点* Traditional method of estimating residual risk: incidence and window period method Busch used doubling time methods to arrive at a window period, combine with incidence estimated using detuned testing 1, Busch MP, Glynn SA, Stramer SL, et al. A new strategy for estimating risks of transfusion-transmitted viral infections based on rates of detection of recently infected donors. Transfusion 2005;45:254-64. 2, Dodd RY, Notari IVEP, Stramer SL. Current prevalence and incidence of infectious disease markers and estimated window-period risk in the American Red Cross blood donor population.Transfusion 2002;42:975-9 3, Schreiber GB, Busch MP, Kleinman SH, Korelitz JJ. The risk of transfusion-transmitted viral infections. The Retrovirus Epidemiology Donor Study. N Engl J Med. 1996 Jun 27;334(26):1685-90. Incidence: various numbers from different studies AHTR: 1:77,000 (New York 1990-1999) Mayo Clinic: 1:21,000 (1974-77) DHTR: 5-10 time more 延迟性溶血性输血反应—实验室发现无法解释的贫血直抗阳性输血后红细胞洗出液存在抗体：非-ABO 红细胞同种抗体Antibodies Implicated in DHTRJohns Hopkins series Anti-E 47% Anti-Jka 23% ( clinically important) Anti –K 15% 延迟性溶血性输血反应中的抗体 霍普金斯医院资料抗- E 47% 抗- Jka 23% （临床意义）抗- K 15% DHTR Timeline TIME (DAYS) EVENT CAUSE 0 Negative tests Antibody not detectable 1 RBC’s given 3-10 Clinical hemolysis Accelerated RBC destruction 10-21 Positive DAT and A/S detected Antibody titer increases and sensitizes cells >21 DAT negative Sensitized donor cells cleared 延迟性溶血性输血反应时间表天事件原因0 试验阴性抗体不可被检测1 RBC’s given 3-10 临床溶血红细胞破坏加速10-21 直抗阳性，监测到A/S 抗体滴度增加，细胞致敏>21 直抗阴性捐献者致敏细胞被清除DHTR Prevention Improved patient care by developing mechanism to identify patients, counsel them about future transfusions, provide early warnings to health care providers. Prevention with careful transfusion history, registries of alloimmunized patients 延迟性溶血性输血反应的预防通过对病人身份鉴定、和他们商讨未来的的输血，对健康看护者提供早期警告来改进对病人的照顾对同种免疫的病人备案，仔细询问既往输血史预防延迟性溶血性输血反应Typical sequence of chest X-rays changes: Left: 	 Normal CXR prior to