Antipyretics for children are prescribed by a pediatrician. But there are emergency situations for fever when the child needs to be given medicine immediately. Then the parents take responsibility and use antipyretic drugs. What is allowed to give to infants? How can you bring down the temperature in older children? What medicines are the safest?
8.2. Indications and contraindications for transfusion of fresh frozen plasma
Indications for the appointment of fresh frozen plasma transfusions are:
acute syndrome of disseminated intravascular coagulation (DIC), complicating the course of shocks of various origins (septic, hemorrhagic, hemolytic) or caused by other causes (amniotic fluid embolism, crush syndrome, severe injuries with tissue crushing, extensive surgical operations, especially on the lungs, blood vessels, brain, prostate), massive transfusion syndrome;
acute massive blood loss (more than 30% of the circulating blood volume) with the development of hemorrhagic shock and DIC;
liver diseases accompanied by a decrease in the production of plasma coagulation factors and, accordingly, their deficiency in circulation (acute fulminant hepatitis, cirrhosis of the liver);
overdose of anticoagulants of indirect action (dicumarin and others);
when performing therapeutic plasmapheresis in patients with thrombotic thrombocytopenic purpura (Moshkowitz's disease), severe poisoning, sepsis, acute DIC.
coagulopathy due to deficiency of plasma physiological anticoagulants.
It is not recommended to transfuse fresh frozen plasma for the purpose of replenishing the circulating blood volume (for this there are safer and more economical means) or for the purposes of parenteral nutrition. With caution, transfusion of fresh frozen plasma should be prescribed in individuals with a burdened transfusion history, in the presence of congestive heart failure.
8.3. Features of transfusion of fresh frozen plasma
Transfusion of fresh frozen plasma is carried out through a standard blood transfusion system with a filter, depending on clinical indications - infusion or drip, in acute DIC with severe hemorrhagic syndrome - infusion. It is forbidden to transfuse fresh frozen plasma to several patients from one container or bottle.
When transfusing fresh frozen plasma, it is necessary to perform a biological test (similar to the transfusion of blood gas carriers).
The first few minutes after the start of fresh frozen plasma infusion, when a small amount of transfused volume has entered the recipient's circulation, are decisive for the occurrence of possible anaphylactic, allergic and other reactions.
The volume of transfused fresh frozen plasma depends on the clinical indications. In case of bleeding associated with DIC, the administration of at least 1000 ml of fresh frozen plasma at one time is indicated under the control of hemodynamic parameters and central venous pressure. It is often necessary to re-introduce the same volumes of fresh frozen plasma under the dynamic control of the coagulogram and the clinical picture. In this state, the introduction of small amounts (300-400 ml) of plasma is ineffective.
In acute massive blood loss (more than 30% of the volume of circulating blood, for adults - more than 1500 ml), accompanied by the development of acute DIC, the amount of transfused fresh frozen plasma should be at least 25-30% of the total volume of transfusion media prescribed to compensate for blood loss, t .e. not less than 800-1000 ml.
In chronic DIC, as a rule, transfusion of fresh frozen plasma is combined with the appointment of direct anticoagulants and antiplatelet agents (coagulological control is necessary, which is a criterion for the adequacy of the therapy). In this clinical situation, the volume of transfused fresh frozen plasma is at least 600 ml.
In severe liver diseases, accompanied by a sharp decrease in the level of plasma coagulation factors and developed bleeding or the threat of bleeding during surgery, transfusion of fresh frozen plasma at the rate of 15 ml / kg of body weight is indicated, followed by repeated transfusion of plasma in a smaller volume after 4-8 hours ( 5-10 ml/kg).
Immediately before transfusion, fresh frozen plasma is thawed in a water bath at 37°C. Thawed plasma may contain fibrin flakes, which does not preclude its use with standard filtered intravenous transfusion devices.
The possibility of long-term storage of fresh-frozen plasma makes it possible to accumulate it from one donor in order to implement the "one donor - one recipient" principle, which makes it possible to drastically reduce the antigenic load on the recipient.
FFP is a component of the blood, it contains in physiological concentration all the factors of the coagulant and anticoagulant systems, with the exception of the labile factors V and VIII, the concentration of which depends on the quality of the preparation. Also contains plasma proteins in physiological concentration (i.e. is approximately 4-5% albumin solution).
Indications for the introduction of FFP are any situations where the deficiency of any of the components (factors) of the coagulant and anticoagulant systems is confirmed by laboratory.
Recombinant drugs
The use of these drugs is indicated only for hypocoagulative coagulopathy in order to prevent possible bleeding or with an already developed hemorrhagic syndrome. Unreasonable use is fraught with excessive thrombus formation in unnecessary places and the development of such fatal complications as DVT, PE, AMI.
NovoSeven(NovoSeven, Eptacog alfa (activated), RAFVII).
INDICATIONS.
To stop bleeding and prevent their development during surgical interventions and invasive procedures in patients with the following pathology:
Hereditary hemophilia with a titer of inhibitors of coagulation factors VIII or IX more than 5 BU (Bethesda units);
Hereditary hemophilia with an expected immune response to the introduction of factor VIII or factor IX based on history;
Acquired hemophilia;
Congenital factor VII deficiency;
Glanzman's thrombasthenia in the presence of antibodies to glycoproteins IIb-IIIa and refractoriness (current or past) to platelet transfusions.
Bleeding (including prophylaxis for surgical operations) in patients with hereditary or acquired hemophilia with inhibitors to coagulation factors (FVIII or FIX).
FEIBA(FEIBA, Feiba Tim 4 Immuno)
Anti-inhibitor coagulant complex with standard FEIBA activity (Factor Eight Inhibitor Bypass Activity). Contains factors II, IX and X (mainly in non-activated form), activated factor VII, VIII.
INDICATIONS. Bleeding in inhibitory forms of hemophilia A and B; severe or life-threatening bleeding in patients with acquired deficiency of factors VII, VIII, IX and XII.
Hemocontact infections
HIV is an infection in medical practice. Standard Precautions
The problem of HIV infection, the role of which is documented as a representative of one of the three major blood-borne infections (HIV, HBV and HCV), is relevant for doctors and nurses of all specialties, especially surgical specialists, when they perform invasive medical interventions. Due to the need for direct contact with wounds during injuries, fractures, operations, and other types of manipulations, medical workers are at risk of infection, and therefore, they must have basic basic information about both the nature of HIV infection and other blood-borne infections, and measures for their own protection and the protection of patients.
The overarching goal remains to ensure the quality of medical interventions in the interests of patient health, and all healthcare professionals have a responsibility to prevent the transmission of infections when providing medical care. That is, the medical procedures performed must NOT harm the patient, DO NOT expose the healthcare worker to the risk of infection, and DO NOT generate waste that is potentially harmful to others. These are the basic requirements for the practice of safe injections and medical procedures.
According to global estimates, as of 2000 alone, unsafe injection practices resulted in:
▪ 21 million HBV cases (32% of new HBV cases)
▪ 2 million HCV cases (40% of new HCV cases)
▪ 260,000 cases of HIV - human immunodeficiency virus (5% of new HIV infections)
▪ These pathogens (HBV/HCV/HIV) have also caused illness among medical staff.
▪ Nearly 4.4% of HIV cases among healthcare workers and 39% of HBV and HCV cases were related to occupational injuries (WHO, 2010).
HIV infection and AIDS. General information.
Key Facts By HIV AIDS.
The first cases of HIV/AIDS were officially registered in 1982 in the USA. Initially, they were considered as a specific disease individual groups population (homosexuals, injecting drug users), but subsequently the disease spread to other segments of the population.
1983 - Luc Montagnier (France) and Robert Gallo (USA) isolate the HIV culture.
1983 - Centers for Disease Control (CDC), Atlanta USA develops case definition for AIDS.
1987 - The first "imported" cases of HIV infection were registered in former USSR
1987-1989 – the first cases of HIV infection were registered in Kazakhstan
2013 - more than 20 thousand cases of HIV infection were officially registered in Kazakhstan.
HIV infection remains one of the major public health problems, as it has claimed more than 25 million human lives over the past three decades:
● In 2011, there were approximately 34 million people living with HIV worldwide
● The most affected region is sub-Saharan Africa, where almost one in 20 adults has HIV and 60% of all people living with HIV live in this region
● HIV infection is usually diagnosed with a blood test that checks for the presence or absence of HIV antibodies.
● In 2012, 10 million people were on ART in low- and middle-income countries and ART will further expand to 25 million by 2015.
HIV/AIDS Situation in Eastern Europe and Central Asia
● EECA region sees rise in HIV prevalence, new HIV cases and AIDS-related deaths
● Injecting drug use and sexual transmission of HIV remain the main drivers of the epidemic in the EECA region.
through IDU partners
● Between 2001 and 2011, the estimated number of people living with HIV in the region increased from 970 000 to 1.4 million
● HIV prevalence among young people aged 15-24 increased from 0.2% to 0.5% among women and from 0.3% to 0.7% among men
● AIDS-related deaths increased by 21% in the region from 76,000 to 92,000 between 2005 and 2011
● Treatment coverage in the region remains low, with only 25% of people eligible for HIV treatment receiving ART (UNAIDS Bulletin 2012).
Situation on HIV/AIDS in Kazakhstan. At the beginning of 2013, 19,748 HIV-infected people were cumulatively registered in Kazakhstan, of which 400 (2%) children under 14 years of age. A greater number of cases of HIV infection were detected in Almaty, Pavlodar, East Kazakhstan and Karaganda regions. Other regions of the republic are also involved in the epidemic. The proportion of men during this period was 69%, women 31%. Basically, HIV infection is detected among young people aged 15-39 years - 16106 (82%). The main route of HIV transmission remains intravenous drug use (63%), but sexual transmission of HIV is on the rise (32%).
Concepts of HIV/AIDS
HIV infection is a disease caused by HIV, a chronic infection, characterized by damage to the immune system, leading to the formation of acquired immunodeficiency syndrome (AIDS), accompanied by the development of opportunistic infections and secondary malignant neoplasms.
AIDS is a condition that develops against the background of HIV infection and is characterized by the appearance of one or more diseases classified as AIDS-indicative. AIDS is the latest stage of HIV infection, which in different people may develop 2-15 years after infection. According to the existing clinical classification, the AIDS stage corresponds to the 4 stages of HIV infection.
Pathogen HIV infection - human immunodeficiency virus - belongs to the family of retroviruses, subfamily of lentiviruses, i.e. a group of viruses that cause slow, asymptomatic or initially asymptomatic infections, such as viral hepatitis C. There are two types of virus: HIV-1 and HIV-2. HIV strikes immune system and the system for monitoring and protecting people from infections and certain types of cancer is weakening. HIV disrupts the function of immune cells, as a result, infected people gradually develop an immunodeficiency state, which is usually measured by the number of CD4-lymphocytes ("T-helper cells"). Immunodeficiency leads to increased susceptibility to a wide range of infections and diseases that people with a damaged immune system cannot resist.
Structure of HIV(Fig. 54. )
HIV belongs to the lentivirus subfamily. Lentiviruses cause chronic infections with a long latent course, persistent viral reproduction and CNS damage. Currently, three types of the virus are known - HIV-1, HIV-2 and HIV-3, of which two types of HIV-1 and HIV-2 are widespread, both viruses are pathogenic, but HIV-2 infection is milder. Like all retroviruses, HIV is characterized by high variability.
Morphology of HIV
The diameter of HIV-1 is 100 nm. Outside, the virus is surrounded by a lipid membrane into which 72 glycoprotein complexes are embedded. Each of these complexes is formed by a surface glycoprotein (gp120) and a transmembrane (gp41). Inside, the p17 protein is adjacent to the shell. The core of the virus (capsid) is the p24 protein, which surrounds the protein-nucleic acid complex: two viral RNA molecules associated with the p7 protein and the p66 reverse transcriptase. The virus contains all the necessary enzymes for replication: reverse transcriptase, p32 integrase, and p11 protease.
HIV genome. The reproduction of most retroviruses is determined by three genes: gag, pol And env. The name of the genes comes from the proteins they encode: gag - " g row- a nti g en "(capsid protein), pol - " pol ymerase" (polymerase), env - " env elope" (shell).
Structural genes (3):
The Gag gene is responsible for the synthesis of three core proteins
Pol-gene encodes the synthesis of revertase;
· Env-gene encodes the synthesis of two glycoproteins: gp120 and gp41.
Rice. 54. Scheme of the structure of HIV
source HIV infections are people infected with HIV at any stage of the disease, including during the incubation period due to the constant replication (multiplication) of the virus. Up to 7-10 billion viral particles are produced per day (Fig. 55).
Rice. 55. Stages of HIV replication
Risk factors.
Behaviors and conditions that increase people's risk of contracting HIV include:
● unprotected vaginal or anal sex;
● having another sexually transmitted infection such as syphilis, herpes, chlamydia, gonorrhea and bacterial vaginosis;
● sharing of non-sterile (contaminated with the blood of infected persons) needles, syringes and other injection equipment and solutions
● unsafe injections, blood transfusions, medical procedures involving unsterile incisions or punctures;
● accidental injuries from needle sticks, sharp instruments while caring for patients by healthcare workers
Ways, mechanism and factors of HIV transmission.
Transmission routes HIV infections:
n Sexual (heterosexual, homosexual)
n Parenteral (through blood, instrumentation)
n From mother to child
HIV infection can be transmitted through both natural and artificial transmission mechanisms.
The natural mechanism of HIV transmission includes:
Contact, which is realized mainly during sexual intercourse (both homo- and heterosexual) and upon contact of the mucous or wound surface with blood.
Vertical: Infection of a child from an HIV-infected mother during pregnancy, childbirth and breastfeeding.
The artificial transmission mechanism includes:
Artifical in non-medical invasive procedures, including intravenous administration drugs by drug users (sharing of needles and syringes, other injecting equipment and materials).
Artifical in invasive interventions in LPO. At the same time, HIV infection can occur during the transfusion of blood and its components as a result of unsafe blood transfusions, organ and tissue transplantation, the use of donor sperm, donor breast milk from an HIV-infected donor, as well as the unsafe practice of medical injections and manipulations through medical instruments for parenteral interventions, medical devices contaminated with HIV and not subjected to processing in accordance with the requirements of regulatory documents.
Main transmission factors HIV are the following human biological fluids: blood and blood components, seminal fluid (semen), vaginal discharge, breast milk). The rest of the liquids are not dangerous in the transmission of HIV, if there is no admixture of blood. People cannot become infected through normal everyday contact, such as kissing, hugging, and shaking hands, or by ingesting food and water (Fig. 56).
At vulnerable populations(UGN) for HIV infections are: injecting drug users (IDUs), commercial sex workers (CSWs), men who have sex with men (MSM). group increased risk HIV infections are represented by CSW clients, sexual partners of IDUs, prisoners, street children, persons with a large number of sexual partners, and migrants.
In order to prevent HIV infection, an important point is the counseling and testing of the population for HIV, including, first of all, persons from the criminal population, in accordance with the current regulatory documents (adult testing algorithm in the Republic of Kazakhstan, Appendix 1).
Plasma is a liquid component of blood, rich in biologically active components: proteins, lipids, hormones, enzymes. Fresh frozen plasma fluid is considered the best product due to the fact that it retains the greatest number of useful components. Whereas liquid native, dry lyophilized and antihemophilic plasma somewhat loses the therapeutic characteristics inherent in this component, therefore they are less in demand.
Plasma and its structure
Blood plasma: why transfuse?
Transfusion of any kind of blood plasma allows you to restore the normal volume of blood circulating in the body, the balance between hydrostatic and colloid-oncotic pressure.
The positive effect of this kind of procedure becomes possible due to the fact that the molecular weight of plasma proteins and the molecular weight of the blood of the recipient are different. In view of this, the permeability of the walls of blood vessels is low, and nutrients are not absorbed, they are in the bloodstream for a long time.
If a person has acute bleeding, intravenous plasma transfusion is implemented at a dose of 0.5 liters to 2 liters. In this case, everything depends on blood pressure patient and the complexity of the course of his disease. In particularly severe situations, it is recommended to combine the infusion of plasma and erythrocyte mass.
Plasma is infused by stream or drip, depending on the indications. If microcirculation is disturbed, reopoliglyukin or other drugs of this group are added to the plasma.
Terms: A hemotransfusion is an intravascular transfusion of whole blood to a recipient. In fact, the most complicated operation involving the transplantation of living tissue to a person.
Blood plasma transfusion: indications
The RLS pharmacological guide dictates the following indications for the transfusion of fresh frozen blood plasma:
- Acute DIC, which simultaneously complicates the course of shock of various origins; massive transfusion syndrome;
- Severe bleeding, which involves the loss of more than a third of the total blood volume. In this case, a further complication is possible in the form of the same syndrome of disseminated intravascular coagulation;
Indications for transfusion of fresh frozen plasma - Pathological changes liver and kidneys (conditional indications);
- Overdose of anticoagulants, for example, dicoumarin;
- During the procedure of plasmapheresis of a therapeutic nature, caused by Moshkowitz's syndrome, acute poisoning, sepsis;
- thrombocytopenic purpura;
- Open heart surgery with the connection of a heart-lung machine;
- Coagulopathy arising from low concentrations of physiological anticoagulants, etc.
We have reviewed the most common indications for transfusion of fresh frozen plasma. It is not recommended to perform a similar procedure to replenish the entire volume of circulating blood. In this case, other methods are used. Do not prescribe plasma transfusion to patients suffering from congestive heart failure.
Fresh frozen blood plasma
Fresh frozen plasma is considered one of the basic components of blood, it is created by rapid freezing after separation of its uniform elements. Store such a substance in special plastic containers.
The main disadvantages of using this biomaterial:
- the risk of transmission of an infectious disease;
- the risk of allergic reactions;
- conflict between the biomaterial of the donor and the recipient (before transfusion, a biological test for compatibility is required).
Fresh frozen plasma Fresh frozen plasma is produced by two methods:
- plasmapheresis;
- centrifugation.
The plasma is frozen at -20 degrees. It is allowed to use it within a year. Only for this time the safety of labile factors of the hemostasis system is ensured. After the expiration date, the plasma is disposed of as biological waste.
Terms: Hemostasis is such a system in the human body, the main task of which is to stop bleeding and dissolve blood clots while maintaining the liquid state of blood in the vessels.
Hemostasis Immediately before the plasma infusion itself, the blood is thawed at a temperature of + 38 degrees. At the same time, fibrin flakes fall out. This is not scary, since they will not interfere with the normal flow of blood through plasticizers with filters. Whereas large clots and turbidity of the plasma indicate a poor-quality product. And for doctors, this is a contraindication for its further use, although laboratory assistants could not reveal defects during blood donation and samples.
Important! Due to the fact that such a product can be stored for a long time, doctors try to adhere to the “one donor - one recipient” rule.
Plasma proteins are immunogenic. This means that with frequent and large transfusions, the recipient may develop sensitization. This can lead to anaphylactic shock during the next procedure. This circumstance leads to the fact that doctors try to transfuse plasma according to strict indications. In the treatment of coagulopathy, it is preferable to use cryoprecipitate (a protein preparation containing blood coagulation factors, which a person lacks).
Transfusion When using a biomaterial, it is important to follow strict rules: you cannot use the same plasma container for transfusion to several recipients. Do not re-freeze blood plasma!
Blood plasma transfusion: consequences
Practice shows that most often complications and problems after transfusion of blood plasma are not expected. If we consider studies, then this is less than one percent out of a hundred. However side effects can cause significant disruptions in the functioning of the whole organism and even death. In view of the fact that blood transfusion with a plasma substitute (plasma) does not provide 100% safety, patients are initially consented to such a procedure, be sure to bring to their knowledge all positive sides, efficacy and possible alternatives to transfusion.
- Any clinic where plasma transfusion is performed should be equipped with a system that allows for the quickest possible detection and treatment of side effects that threaten a person's life. Modern federal regulations and guidelines require that such incidents be continually reported, as is the case with accidents and medical errors.
Acute adverse effects
Immunological acute adverse effects include the following:
- Febrile reaction to transfusion. In this case, fever occurs most often. If such a reaction accompanies the incompatibility of the blood of the donor and the recipient (hemolysis), then the transfusion must be stopped immediately. If this is a non-hemolytic reaction, then it is not life threatening. Such a reaction is often accompanied by headache, itching and other manifestations of allergies. Treated with acetaminophen.
- Urticarial rash makes itself felt immediately after plasma transfusion. This is a very common phenomenon, the mechanism of which is closely related to the release of histamine. Most often, doctors in this case write a prescription for the use medicinal product"benadryl". And as soon as the rash disappears, we can say that the reaction is over.
Urticarial rash - Literally two to three hours after blood plasma transfusion, respiratory distress syndrome, a decrease in hemoglobin and hypotension can appear sharply. This indicates the development of acute lung injury. In this case, prompt intervention of doctors is required to organize respiratory support with mechanical ventilation. But there is no need to worry too much, studies have shown that less than ten percent of recipients die from such an effect. The main thing is to orient the medical staff in time.
- Acute hemolysis occurs due to inconsistencies in the identification of the recipient's blood plasma, in other words, due to personnel error. The whole complexity of this effect lies in the fact that clinical indications may remain unexpressed, accompanied only by anemia (delayed hemolysis). Whereas complications occur in the case of concomitant aggravating factors: renal failure in acute form, shock, arterial hypotension, poor blood clotting.
Important! If a person is under anesthesia or has fallen into a coma, internal bleeding for unknown reasons from the injection site becomes a sign of hemolysis.
In this case, doctors will definitely take advantage of active hydration and the appointment of vasoactive drugs.
- Anaphylaxis most often makes itself felt in the first minute of a blood transfusion. Clinical picture: respiratory distress, shock, arterial hypotension, edema. This is a very dangerous phenomenon that requires emergency intervention of specialists. Here you need to do everything to support the respiratory function of a person, including the introduction of adrenaline, so all drugs must be at hand.
Non-immunological complications include:
- Volume overload (hypervolemia). If the volume of transfused plasma is incorrectly calculated, the load on the heart increases. The volume of intravascular fluid increases unnecessarily. Treated with diuretics.
Bacterial infection of platelets Symptoms of hypervolemia: severe shortness of breath, hypertension and even tachycardia. Most often, it manifests itself after six hours after the transfusion of blood plasma.
Chemical effects include: citrate intoxication, hypothermia, hyperkalemia, coagulopathy, and so on.
What is the blood plasma transfusion technique?
Indications for transfusion of blood plasma and all its physiological components are determined exclusively by the attending physician on the basis of previously conducted laboratory, physical and instrumental studies. It is important to understand that there is no standard and well-established scheme for the treatment and diagnosis of diseases in this case. For each person, the consequences and the transfusion itself proceed individually, depending on the reaction of the body to what is happening. In any case, this is a significant burden on him.
Frequently asked questions regarding various transfusion techniques can be found in the guidelines.
What is indirect and direct blood transfusion?
Indirect blood transfusion is the most commonly used. It is delivered directly into the vein through a disposable filter bottle. At the same time, the technology for filling a disposable system is necessarily described in the manufacturer's instructions. In medical practice, other ways of introducing plasma are also used: not only into a vein, but also intra-arterially, intra-aortically and intraosseously. It all depends on what result you want to achieve, and whether it is even possible to provide plasma transfusion.
Indirect blood transfusion Direct transfusion of blood mass does not imply its stabilization and conservation. In this case, the procedure is performed directly from the donor to the recipient. In this case, only whole blood transfusion is possible. Blood can only be administered intravenously, no other options are expected.
8. Transfusion of correctors of plasma coagulation hemostasis
8.1. Characteristics of correctors for plasma coagulation hemostasis
8.2. Indications and contraindications for plasma transfusion
fresh frozen
8.3. Features of transfusion of fresh frozen plasma
8.4. Reactions during transfusion of fresh frozen plasma
Plasma is the liquid part of the blood, devoid of cellular elements. Normal plasma volume is about 4% of total body weight (40 - 45 ml/kg). Plasma components maintain normal circulating blood volume and fluidity. Plasma proteins determine its colloid-oncotic pressure and balance with hydrostatic pressure; they also support the systems of blood coagulation and fibrinolysis in an equilibrium state. In addition, plasma ensures the balance of electrolytes and the acid-base balance of the blood.
In medical practice, fresh frozen plasma, native plasma, cryoprecipitate and plasma preparations are used: albumin, gamma globulins, blood coagulation factors, physiological anticoagulants (antithrombin III, protein C and S), components of the fibrinolytic system.
8.1. Characteristics of correctors for plasma coagulation hemostasis
Fresh-frozen plasma is understood to mean plasma that is separated from erythrocytes by centrifugation or apheresis within 4-6 hours after blood exfusion and placed in a low-temperature refrigerator that provides complete freezing to a temperature of -30°C per hour. This mode of plasma preparation ensures its long-term (up to a year) storage. In fresh frozen plasma, labile (V and VIII) and stable (I, II, VII, IX) coagulation factors are preserved in the optimal ratio.
If cryoprecipitate is removed from the plasma during fractionation, then the remaining part of the plasma is the supernatant plasma fraction (cryosupernatant), which has its own indications for use.
After separation from the plasma of water, the concentration of total protein in it, plasma coagulation factors, in particular, IX, increases significantly - such plasma is called "native concentrated plasma".
The transfused fresh frozen plasma must be of the same group as the recipient according to the AB0 system. Rh compatibility is not mandatory, since fresh frozen plasma is a cell-free medium, however, with volumetric transfusions of fresh frozen plasma (more than 1 liter), Rh compatibility is mandatory. Compatibility for minor erythrocyte antigens is not required.
It is desirable that fresh frozen plasma meet the following standard quality criteria: protein content of at least 60 g/l, hemoglobin content of less than 0.05 g/l, potassium level of less than 5 mmol/l. The level of transaminases should be within the normal range. The results of tests for markers of syphilis, hepatitis B and C, HIV are negative.
Once thawed, plasma should be used within one hour and should not be re-frozen. In emergency cases, in the absence of single-group fresh frozen plasma, transfusion of plasma of group AB (IV) to a recipient with any blood group is allowed.
The volume of fresh frozen plasma, obtained by centrifugation from a single dose of blood, is 200 - 250 ml. When conducting double donor plasmapheresis, the plasma output can be 400 - 500 ml, hardware plasmapheresis - no more than 600 ml.
8.2. Indications and contraindications for transfusion of fresh frozen plasma
Indications for the appointment of fresh frozen plasma transfusions are:
Acute syndrome of disseminated intravascular coagulation (DIC), complicating the course of shocks of various origins (septic, hemorrhagic, hemolytic) or caused by other causes (amniotic fluid embolism, crush syndrome, severe injuries with tissue crushing, extensive surgical operations, especially on the lungs, blood vessels, head brain, prostate), massive transfusion syndrome.
Acute massive blood loss (more than 30% of circulating blood volume) with the development of hemorrhagic shock and DIC;
Liver diseases, accompanied by a decrease in the production of plasma coagulation factors and, accordingly, their deficiency in circulation (acute fulminant hepatitis, liver cirrhosis);
Overdose of anticoagulants of indirect action (dicumarin and others);
When performing therapeutic plasmapheresis in patients with thrombotic thrombocytopenic purpura (Moshkowitz's disease), severe poisoning, sepsis, acute DIC;
Coagulopathy due to deficiency of plasma physiological anticoagulants.
It is not recommended to transfuse fresh frozen plasma for the purpose of replenishing the circulating blood volume (for this there are safer and more economical means) or for the purposes of parenteral nutrition. With caution, transfusion of fresh frozen plasma should be prescribed in individuals with a burdened transfusion history, in the presence of congestive heart failure.
8.3. Features of transfusion of fresh frozen plasma
Transfusion of fresh frozen plasma is carried out through a standard blood transfusion system with a filter, depending on clinical indications - infusion or drip, in acute DIC with severe hemorrhagic syndrome - infusion. It is forbidden to transfuse fresh frozen plasma to several patients from one container or bottle.
When transfusing fresh frozen plasma, it is necessary to perform a biological test (similar to the transfusion of blood gas carriers). The first few minutes after the start of infusion of fresh frozen plasma, when a small amount of transfused volume has entered the recipient's circulation, are decisive for the occurrence of possible anaphylactic, allergic and other reactions.
The volume of transfused fresh frozen plasma depends on the clinical indications. In case of bleeding associated with DIC, the administration of at least 1000 ml of fresh frozen plasma at once is indicated under the control of hemodynamic parameters and central venous pressure. It is often necessary to re-introduce the same volumes of fresh frozen plasma under the dynamic control of the coagulogram and the clinical picture. In this state, the introduction of small amounts (300 - 400 ml) of plasma is ineffective.
In case of acute massive blood loss (more than 30% of the volume of circulating blood, for adults - more than 1500 ml), accompanied by the development of acute DIC, the amount of transfused fresh frozen plasma should be at least 25-30% of the total volume of transfusion media prescribed to compensate for blood loss, t .e. not less than 800 - 1000 ml.
In chronic DIC, as a rule, transfusion of fresh frozen plasma is combined with the appointment of direct anticoagulants and antiplatelet agents (coagulological control is necessary, which is a criterion for the adequacy of the therapy). In this clinical situation, the volume of transfused fresh frozen plasma is not less than 600 ml.
In severe liver diseases, accompanied by a sharp decrease in the level of plasma coagulation factors and developed bleeding or the threat of bleeding during surgery, transfusion of fresh frozen plasma at the rate of 15 ml / kg of body weight is indicated, followed, after 4–8 hours, by repeated transfusion of plasma in a smaller volume ( 5 - 10 ml/kg).
Immediately before transfusion, fresh frozen plasma is thawed in a water bath at 37°C. Thawed plasma may contain fibrin flakes, which does not preclude its use with standard filtered intravenous transfusion devices.
The possibility of long-term storage of fresh frozen plasma makes it possible to accumulate it from one donor in order to implement the "one donor - one recipient" principle, which makes it possible to drastically reduce the antigenic load on the recipient.
8.4. Reactions during transfusion of fresh frozen plasma
The most severe risk in transfusion of fresh frozen plasma is the possibility of transmission of viral and bacterial infections. That is why today much attention is paid to methods of viral inactivation of fresh frozen plasma (plasma quarantine for 3-6 months, detergent treatment, etc.).
In addition, immunological reactions associated with the presence of antibodies in the plasma of the donor and recipient are potentially possible. The most severe of them is anaphylactic shock, which is clinically manifested by chills, hypotension, bronchospasm, retrosternal pain. As a rule, such a reaction is due to IgA deficiency in the recipient. In these cases, the cessation of plasma transfusion, the introduction of adrenaline and prednisolone is required. If it is vital to continue therapy with a transfusion of fresh frozen plasma, it is possible to prescribe antihistamines and corticosteroids 1 hour before the start of the infusion and re-administer them during the transfusion.
8.5. Transfusion of cryoprecipitate
Recently, cryoprecipitate, which is a drug obtained from donor blood, is considered not so much as a transfusion medium for the treatment of patients with hemophilia A, von Willebrand disease, but as a feedstock for further fractionation in order to obtain purified factor VIII concentrates.
For hemostasis, it is necessary to maintain the level of factor VIII up to 50% during operations and up to 30% in the postoperative period. One unit of factor VIII corresponds to 1 ml of fresh frozen plasma. Cryoprecipitate obtained from a single blood unit must contain at least 100 units of factor VIII.
Calculation of the need for transfusion of cryoprecipitate is made as follows:
Body weight (kg) x 70 ml/kg = blood volume (ml).
Blood volume (ml) x (1.0 - hematocrit) = plasma volume (ml)
Plasma volume (mL) x (factor VIII level required - factor VIII level present) = required amount of factor VIII for transfusion (u)
Required amount of factor VIII (U): 100 U = number of doses of cryoprecipitate needed for a single transfusion.
The half-life of a transfused factor VIII in the recipient's circulation is 8 to 12 hours, so repeated cryoprecipitate transfusions are usually necessary to maintain therapeutic levels.
In general, the amount of cryoprecipitate transfused depends on the severity of hemophilia A and the severity of bleeding. Hemophilia is regarded as severe at a level of factor VIII less than 1%, moderate - at a level in the range of 1 - 5%, mild - at a level of 6 - 30%.
The therapeutic effect of cryoprecipitate transfusions depends on the degree of distribution of the factor between the intravascular and extravascular spaces. On average, a quarter of the transfused factor VIII contained in the cryoprecipitate passes into the extravascular space during therapy.
The duration of therapy with cryoprecipitate transfusions depends on the severity and location of bleeding, the clinical response of the patient. For major surgeries or tooth extractions, factor VIII levels of at least 30% should be maintained for 10 to 14 days.
If due to some circumstances it is not possible to determine the level of factor VIII in the recipient, then indirectly it is possible to judge the adequacy of therapy by activated partial thromboplastin time. If it is within the normal range (30 - 40 s), then factor VIII is usually above 10%.
Another indication for the appointment of cryoprecipitate is hypofibrinogenemia, which is extremely rarely observed in isolation, more often being a sign of acute DIC. One dose of cryoprecipitate contains, on average, 250 mg of fibrinogen. However, large doses of cryoprecipitate can cause hyperfibrinogenemia, which is fraught with thrombotic complications and increased erythrocyte sedimentation.
The cryoprecipitate must be AB0 compatible. The volume of each dose is small, but the transfusion of many doses at once is fraught with volemic disorders, which is especially important to consider in children who have a smaller blood volume than adults. Anaphylaxis, allergic reactions to plasma proteins, and volemic overload may occur during cryoprecipitate transfusion. The transfusiologist must constantly be aware of the risk of their development and, if they appear, conduct appropriate therapy (stop transfusion, prescribe prednisolone, antihistamines, adrenaline).Journal number: August 2012
O.V.Vozgoment
Department of Anesthesiology and Resuscitation, Perm State Medical Academy named after A.I. acad. E.A. Wagner
The article presents the results of an expert assessment of the quality of medical care for 3 patients who experienced blood transfusion complications in the course of treatment due to the introduction of fresh frozen plasma, which led to an unfavorable outcome. On the basis of clinical analysis, a conclusion was made about the allergic nature of these complications, and the possibility of their development as anaphylactic shock or acute lung injury was shown. The problems of prevention and treatment of such complications are discussed.
Key words: transfusion, fresh frozen plasma, complication, allergy, diagnostics, examination, prevention, treatment.
Fresh frozen plasma as a cause of severe allergic complications, according to medicine care quality expert survey
O.V.Vozgoment
Anesthesiology and Reanimatology Department, E.A. Vagner Perm State Medicine Academy
The article presents the expert survey of 3 cases, in which hemotransfusion complication followed by unfavorable outcome after fresh frozen plasma injections have developed. Clinical analysis shows an allergic origin of these complications, as well as their developing in anaphylactic shock or acute lung lesion way. Problems of such complication prevention and treatment are discussed.
Keywords: transfusion, fresh frozen plasma, complication, allergy, diagnostics, expert survey, prevention, treatment.
Transfusions of fresh frozen plasma (FFP) are widely used in clinical practice, especially in critically ill patients. FFP serves as a source of missing coagulation factors that are eliminated during blood loss and consumed during rapid and significant formation of blood clots in other pathological conditions. Deficiency of platelets and plasma coagulation factors can lead to the development of disseminated intravascular coagulation (DIC), which is characterized by the consumption of coagulation factors, the occurrence of consumption coagulopathy and activation of fibrinolysis, clinical manifestation which is increased bleeding and hemorrhagic syndrome. Thus, conceptually, FFP transfusion is indicated only for replenishment of plasma coagulation factors, i.e. in order to correct hemostasis disorders. However, the use of FFP, like other components of donated blood, is associated with the risk of infectious complications, allergic reactions, immunosuppression, etc., some of which may be potentially life-threatening. This report presents the results of an examination of clinical cases associated with the development of severe allergic reactions to the infusion of FFP and erythromass.
Clinical case 1. Patient B., 18 years old, was delivered to the gynecological department of the city hospital by an ambulance team on 16.12. V
9 hours 31 minutes with a diagnosis: ovarian apoplexy? uterine bleeding. BP - 140/90 mm Hg. Art. Heart rate -
120 bpm From the anamnesis: from 13.12. runny nose and cough. Then there were abundant bloody issues(last menstruation at the end of November). Upon admission, the state of moderate severity, consciousness is clear, the skin is pale. Heart rate - 108 beats / min, blood pressure - 80/50 mm Hg. Art. The diagnosis was established: Violation of the menstrual cycle against the background of
SARS? Posthemorrhagic anemia, severe.
In the OAK dated December 16: Erythrocytes - 1.42¥1012 / l, Hb -
51 g/l, Ht - 12%, L - 15¥109/l, s/i - 7%, s/i - 67%, lymphocytes - 29%, monocytes - 6%, ESR - 13 mm/h, time coagulation - 6 min 45 s.
Conservative hemostatic therapy was started, 400.0 ml of 5% glucose solution was injected intravenously. Due to ongoing bleeding 16.12. at 12 noon
30 min produced curettage of the uterine cavity under intravenous ketamine anesthesia. Introduced oxytocin. The bleeding has stopped. With a substitution purpose, 250.0 ml of refortan and 400.0 ml of gelatinol were introduced intravenously. At 13:00: a state of moderate severity, heart rate - 106 beats / min, blood pressure - 110/60 mm Hg. st, there is no discharge from the genital tract. After determining the blood group (Rh-factor - doubtful) at 13:20, transfusion of FFP A (II) gr., Rh (+) - 200.0 ml was started. The biological test is negative. The patient's Rh factor was also negative. At 14:00, by the end of the transfusion of the first vial of FFP, the patient experienced difficulty in breathing and coughing. Auscultation revealed wheezing in the lungs. At 2 pm
35 minutes examined by a resuscitator. The condition is extremely difficult, the consciousness is clear. A sharp cough, a sharp pallor of the skin with an icteric tinge. Heart rate - 120 beats / min, blood pressure - 110/80 mm Hg, respiratory rate - 24 / min. In all fields - wet rales.
At 15:00 the patient was transferred to the intensive care unit. Preliminary diagnosis: PE? Air embolism? X-ray shows pulmonary edema. At 15:30 hemotransfusion of 300.0 er was started. mass A (II) gr., Rh (-). At 15:55, tracheal intubation, transfer to mechanical ventilation with positive expiratory pressure, and alcohol inhalation were performed. The condition is extremely difficult. Pulmonary edema, which qualifies as non-cardiogenic, progresses. Through the endotracheal tube, sputum is foamy with an admixture of blood. At 16.12: HR - from 116 to 145 beats / min, BP - 100/60–140/80 mm Hg, Sa02 - from 50 to 99%, CVP - 210–120 mm of water. Art. Diuresis - 3400 ml. Diagnosis. hemorrhagic shock. Posthemorrhagic anemia. Pulmonary edema. rdsv?
Inotropes, morphine, diuretics, antibiotics were prescribed: cefazolin + gentamicin, glucocorticoids and (?!) massive infusion-transfusion therapy. For 17 hours, 1770 ml er were introduced. mass, 1850 ml FFP. The total amount of fluid injected was 5340 ml.
17.12. at 6 o'clock: the condition is extremely serious. Located on IVL. Clinic of pulmonary edema is growing. 1500 ml (!) of liquid stood out from the trachea. On the R-gram - negative dynamics. SaO2 - 56%. Consciousness is absent. The volume of infusion therapy is reduced to 1100.0 ml. Changing antibiotics. Instead of gentamicin, abactal and metagyl are prescribed. The introduction of inotropes, vasodilators, hormones continues. Appointed counter-critical. During 17.12. the condition is extremely difficult. Unconscious. A large amount of mucus-viscous sputum is aspirated. Solitary moist rales. Heart rate - 96-124 beats / min, blood pressure - 90/60-140/80 mm Hg. Art. CVP - 140–210 mm of water. Art. Sa02 - up to 85%. Daily diuresis - 2850 ml. In OAK, there is a sharp neutrophilic shift (p / o - 47%), leukocytosis - up to 18.8¥109 / l. On the R-gram (18.12.) - pulmonary edema in the resolution stage. Body temperature - 38–38.2 ° С. Started tube feeding. Positive neurological symptoms. stable hemodynamics. The skin is pink. IN biochemical analysis blood: hypoproteinemia, hypernatremia up to 223 mmol/l, hypokalemia. In the future, stabilization of the state is noted, hyperthermia persists. In OAK: Ht - 44-35%, leukocytosis - up to 16.1¥109 / l, neutrophilic shift - up to melocytes, lymphopenia progresses - up to 2%. In OAM - moderate proteinuria, hematuria, leukocyturia. In the biochemical analysis, hypoproteinemia. By 24.12. – normalization of indicators of sodium and potassium. The patient is consulted by a general practitioner, pulmonologist, neurologist, ophthalmologist.
21.12. the patient is conscious, spontaneous breathing through the endotracheal tube. Extubated. 22.12. due to the increase in respiratory failure, she was again intubated and transferred to mechanical ventilation. 23.12. re-extubated. 24.12. again an increase in respiratory failure and again intubation and transfer to mechanical ventilation. Pastosity is noted lower extremities, swelling of the feet, more on the right. 28.12. due to anemia 3-4 tbsp. (OAK 27.12.: er. - 3.6¥1012 / l, Hb -
76 g/l, Ht - 29%)
640.0 ml of one-group erythromass without reactions and complications. 29.12. purulent hemorrhagic sputum is separated in large quantities. A tracheostomy was placed. In connection with the diagnosed DIC, 550.0 ml of FFP was transfused. The condition is extremely difficult. In the lungs, a large number of dry and wet rales. Infusion therapy continues: per day i/v 2100.0 and 600.0 ml through a probe. Inotropic support with dopamine and adrenaline. 30.12. against the background of mechanical ventilation, circulatory arrest occurred. Resuscitation measures are ineffective.
final diagnosis. Main: dysfunctional uterine bleeding.
Complication: severe posthemorrhagic anemia. Hypovolemic and anemic shock. Respiratory distress syndrome. Pulmonary edema. Bilateral pneumonia. DIC syndrome. Sepsis. Multiple organ failure. Related: Chronic pyelonephritis. P / a main diagnosis: Dysfunctional uterine bleeding against the background of sclero-cystic changes in the ovaries. Complications: Hemorrhagic shock. Severe post-hemorrhagic anemia. Foci of damage in the myocardium of the left ventricle of the heart and papillary muscles of the mitral valve with the development of small necrosis, myocytolysis; severe dystrophy of cardiomyocytes and small hemorrhages. Membraneogenic pulmonary edema 4 tbsp. Acute purulent-obstructive tracheobronchitis, bronchiolitis with the development of acute 2-sided focal purulent-destructive bronchopneumonia. Sepsis. Septicopyemia. Metastatic abscesses of the kidneys. DIC syndrome. Hemorrhages in serous and mucous membranes, adrenal medulla. Thrombosis of the right subclavian vein at the site of its catheterization. Hemorrhagic erosions of the stomach. Edema internal organs. Dropsy of serous cavities (pleural - 1000 ml each, abdominal - 1500 ml, pericardium - 100 ml). Cerebral edema. Parenchymal degeneration and venous plethora of internal organs. Operations: 16.12.01 - curettage, uterine cavity, 29.12 tracheostomy. Companion: 1. Diffuse fibrocystic disease of the mammary glands with a predominance of fibrosis. 2. Cholesterosis of the gallbladder. 3. Atherosclerosis of the ascending aorta, stage of lipoidosis.
A comment. It is clear that the cause of death in this case was severe sepsis and multiple organ failure. But this is the ultimate reason. Initiate pathological process, of course, it could well be hemorrhagic shock. But there were no serious circulatory disorders in the patient upon admission to the gynecological department. The level of Hb and erythrocytes is not an indicator of a state of shock, especially since blood loss occurred within three days and the anamnesis indicates that within three recent years the patient has hyperpolymenorrhea. In addition, high CVP and polyuria noted in the patient are not typical for hypovolemic shock. The condition worsened on the background of infusion of 200 ml of FFP. The patient developed symptoms resembling an allergic reaction (cough, shortness of breath, pulmonary edema). It could have been anaphylactic shock. According to
P. Marino, the most common anaphylactogens are drugs,
R-contrast agents and preparations of plasma and its proteins. Allergic reactions to donor plasma proteins occur in 1–3% of recipients. Moreover, in patients with immunoglobulin A deficiency, allergic reactions can occur without prior sensitization. But anaphylactic shock is primarily a circulatory disorder. Nothing about this is noted in the record of the gynecologist, except for violations in the respiratory system. The record of the resuscitator, made after 35 minutes, provides satisfactory indicators of central hemodynamics and noted a pronounced pallor of the skin, shortness of breath, as well as a sharp cough and wet rales in the lungs, which fit into the picture of anaphylactic shock in the asphyxial variant, the possibility of which in 20% patients are indicated by A.S. Lopatin. It is possible that the pathological process developed in our patient according to this variant. Variety allergic reaction there may be acute lung injury, which is a fairly rare complication of blood transfusion. The pathogenesis of ARF is associated with the ability of donor blood antileukocyte antibodies to interact with the recipient's granulocytes. The complexes enter the lungs, the released mediators of the inflammatory cascade damage the capillary wall, and pulmonary edema develops. The picture is reminiscent of rdsv.
Unfortunately, a post-transfusion complication was not diagnosed. The diagnosis emphasizes the role of hemorrhagic shock and the patient undergoes super-energetic intensive therapy: respiratory support, inotropes, peripheral vasodilators, hormones, diuretics, combined antibiotic therapy and excessive infusion-transfusion therapy. This is evidenced by the indicators of CVP, forced diuresis, progressive pulmonary edema. 1.5 l of fluid was released in 17 hours through the endotracheal tube(!). Polyuria, despite the restriction of infusion, persisted on the second day. Severe, dangerous dyselectrolytemia developed (Na - up to 240 mmol/l). Restriction of infusion and holding complex therapy, including adequate antibacterial, led to some stabilization of the condition. But 21.12. the patient is prematurely transferred to spontaneous breathing and 22.12. in connection with the growing respiratory failure again transferred to the ventilator. A similar precedent also occurs on December 23–24. The patient has edema. Hypoproteinemia in the blood. However, the volume of hydration is not corrected. Every day from 19.12. injected, more than three liters of fluid, which clearly exceeds the amount of fluid released. It is delayed, aggravating hemodilution and hyperhydration. 28.12. in connection with anemia of 3–4 degrees, with generally acceptable blood parameters for this condition, a hemotransfusion of 640 ml of erythromass is performed. Respiratory failure worsens. A tracheostomy is placed and 550 ml of FFP is infused. Again a picture of wet lungs and a fatal outcome.
Thus, in this case, we are dealing with a severe post-transfusion complication that arose after the infusion of FFP against the background of severe post-hemorrhagic anemia and a respiratory viral infection, and not quite adequate, although vigorous intensive care.
Case 2. Patient G., 24 years old, had a second pregnancy (the first 2 years ago ended in a miscarriage at 4 weeks). Pregnancy proceeding against the background of anemia of the 1st degree was complicated by fetoplacental insufficiency. On the 23rd–24th week, she suffered from pneumonia, was treated in the therapeutic department, on the 33rd–34th week, on 22.02. hospitalized in the department of pathology of pregnancy due to aggravated fetoplacental insufficiency (up to stage IV), chronic intrauterine hypoxia of the newborn to moderate severity. Appropriate examination and treatment were prescribed. 05.03. the woman arbitrarily left the department, returned on 06.03. On examination at 13:15, pale skin and weakness were noted. The pregnant woman complained of deterioration of health, dizziness, pain in the lower abdomen. As a result of the examination, antenatal fetal death was diagnosed due to total placental abruption, hemorrhagic shock of the 1st stage. According to emergency indications, a lower median laparotomy was performed, a caesarean section in the lower segment according to Gusakov, followed by extirpation of the uterus with tubes (Kuveler's uterus), drainage abdominal cavity. During the operation, with a substitution purpose, the following was introduced: infucol - 500 ml, physical. solution - 1200 ml and FFP - 850 ml. 08.03. due to severe anemia (er. - 2.5 × 1012/l, Hb - 68 g/l, Ht - 20%), hemotransfusion (erythromass) was performed in the amount of 213.0; 213.0 and 213 ml. According to the records in the medical documentation, the patient's blood type and Rh factor, as well as erythromasses in hemacones, were determined before the blood transfusion, tests for group and Rh compatibility, a biological test were carried out, and then post-transfusion monitoring was carried out in order to prevent post-transfusion complications.
08.03. appeared Clinical signs post-transfusion complications (jaundice of the sclera, hemoglobinemia, hemoglobinuria). ABO incompatibility is suspected. A therapy was prescribed to correct homeostasis during transfusion of incompatible blood - infusion therapy, including sodium bicarbonate 4% - 200 ml, stimulation of diuresis, glucocorticoids, etc. 9.03. condition was classified as moderate. It deteriorated sharply on the background of fractional plasmapheresis on 9.03. at 22:00. Replacement of the exfused blood was carried out with FFP. After the second blood sampling and the introduction of FFP, difficulty breathing, acrocyanosis, bradycardia, and then tachycardia - up to 160 beats / min, arterial hypertension appeared. Transferred to IVL. In the future, the condition remained difficult. The phenomena of renal and multiple organ failure increased. 11.03. in connection with the negative dynamics of purification indicators for hemodialysis, it was decided to transport the patient to the regional hospital. The patient's condition was regarded as conditionally transportable. She was taken to the emergency department in a terminal condition. The ongoing resuscitation measures were ineffective.
The diagnosis is clinical. Main: late postpartum period (5th day after the first urgent surgical delivery). Total detachment of a normally located placenta, antenatal fetal asphyxia. Cuweler's mother. Complication: hemorrhagic shock. Post-transfusion hemolytic complication. Multiple organ failure. Edema of the brain. Coma. Operations and benefits: laparotomy, n / median laparotomy. Cesarean section in the lower segment. Extirpation of the uterus with tubes. Drainage of the abdominal cavity (06.03.). Hemotransfusion - 08.03. Plasmapheresis. IVL. Checkpoint - 08.03. Cardiopulmonary resuscitation. The diagnosis is forensic. Primary: transfusion of erythrocyte mass (08.03–09.03.). Complication: acute renal failure: anemia of the glomeruli, necrosis. Bilateral hypostatic purulent pneumonia. Catarrhal laryngotracheobronchitis. Background: pregnancy II. First premature operative birth (35–
36 weeks). Fetoplacental insufficiency. Chronic intrauterine fetal hypoxia. Cervicitis. Hypertensive angiopathy. Community-acquired pneumonia on the left in 8, 9, 10 segments on the left and 5–8 on the right of moderate severity. Premature total detachment of a normally located placenta. hemorrhagic shock. Intrauterine fetal death. Cuweler's mother. Operation: laparotomy, n / median laparotomy. Cesarean section in the lower segment. Extirpation of the uterus with tubes. Drainage of the abdominal cavity - 06.03. Hemotransfusion - 08.03. Plasmapheresis. IVL. Checkpoint - 08.03. Cardiopulmonary resuscitation – 11.03.
A comment. Thus, the leading factor of thanatogenesis can be considered a hemolytic post-transfusion reaction, which served as a trigger for all subsequent complications leading to death. The mechanism of this post-transfusion reaction is not entirely clear. It is unlikely that this is the result of blood incompatibility for ABO or Rh-factor, since all the necessary tests before blood transfusion, according to the documentation provided, were performed. At the same time, during the control check of the content of hemacones by a laboratory doctor and head. The SPK revealed that the erythromass in one of the gemacons was hemolyzed, and the blood group and Rh-affiliation could not be determined. So, the nature of hemolysis in the patient is probably due to the introduction of hemolyzed blood. If we exclude dishonesty when performing tests for blood compatibility, which would necessarily have revealed the initial hemolysis, then it can be assumed that hemolysis occurred after all tests for compatibility were carried out. The cause of hemolysis could be overheating of the erythromass before blood transfusion. The possibility of thermal hemolysis is indicated by Yu.L. Shevchenko, V.N. Shabalin and others. Hemolysis, however, was not accompanied by severe systemic disorders, diuresis persisted. A sharp deterioration in the condition occurred against the background of plasmapheresis. The clinical situation described at the same time was very reminiscent of an anaphylactic reaction, apparently, to the protein of the transfused plasma. The patient received blood components from 10 donors in 3 days, so the probability, including cross-anaphylaxis, is very high. In the future, the condition remained severe, the patient was on mechanical ventilation, hyperthermia, hypoxemia (SaO2 - 86%), the clinic of cerebral edema, the R-gram showed interstitial pulmonary edema, that is, acute lung injury syndrome. Conducted infusion therapy, inotropic support, stimulation of diuresis, prescribed antibacterial drugs- klaforan and metrogil. The diuresis of the patient was sufficient, for 10.03. it amounted to 1440 ml. At the same time, the purification rates increased, which forced the decision to transfer the patient to the regional hospital, which, unfortunately, turned out to be fatal.
In this case, the incorrect formulation of the forensic medical diagnosis should be noted. RBC transfusion is not a pathology. Causes doubt and diagnosis community-acquired pneumonia in a patient who has been on the inpatient treatment and was on a ventilator for 2 days.
Clinical case 3. Patient U., 31 years old, was taken to the obstetric department by an ambulance team on 10.05. at 20:26 with a diagnosis: Pregnancy 40-41 weeks. Burdened obstetric anamnesis. Harbingers of childbirth. Chronic IUI. Vegetovascular dystonia, compensated. Large fruit. In order to prevent fetal hypoxia, Actovegin was administered intravenously. Oxytocin was administered to induce labor. At 16:25, a full-term boy was born according to Apgar score 5–6. Short-term chills were noted immediately after delivery and headache who bought themselves. Blood loss was 200 ml (BP - 120/80 mm Hg,
HR - 78 beats / min, NPV - 18 / min). Diagnosis: Childbirth
3 urgent giant fruit. OAA. Low water. Chronic IUI. Vegetovascular dystonia. SARS. The entanglement of the umbilical cord around the neck of the fetus. 11.05. V
At 18:00, one-stage bleeding from the birth canal with a volume of 500 ml was recorded, the blood does not clot. The condition of the mother is satisfactory. BP -120/70–130/70 mm Hg. Art. Heart rate - 88 beats / min. NPV - 18 / min. Diuresis through the catheter - 200 ml. (urine is light). A manual examination of the uterine cavity was performed, the remnants of placental tissue were removed. The uterus has contracted, moderate bleeding continues. In / in the jet introduced 400.0 ml of physical. solution, then 400.0 ml of physical. solution +1.0 ml of oxytocin, then 200.0 ml of physical. solution + 10.0 ml of tranexam and ceftriaxone. Clamps were placed on the uterine vessels to stop the bleeding. The recorded blood loss was 1500 ml. At 06:40 pm FFP transfusion was started in the amount of 1 liter, after which at 07:00 pm the bleeding stopped. At 19:40, a control blood test was performed: er. –3.07¥1012/l, Hb – 86 g/l, Ht – 28%, Tg. – 160¥109/l. At 20:00 after the transfusion of 150 ml of erythromass, the patient's condition deteriorated sharply, weakness, headache, coughing, and a drop in blood pressure to 70/30 mm Hg were noted. Art. Moist rales are heard in the lungs. Diagnosis: Early postpartum period after the third birth of a giant fetus. Early postpartum hemorrhage 1-2 class. Early transfusion response to FFP transfusion. Transfusion shock. Amniotic fluid embolism? Alveolar pulmonary edema. Manual examination of the uterine cavity, isolation of the remains of placental tissue, additional placenta. At 20:15 she was examined by the resuscitator on duty. The patient is conscious, but inhibited. Complaints of weakness, difficulty breathing. Cyanosis of the nasolabial triangle. Tachypnea - up to 30 in 1 min, wheezing in the lungs on both sides. BP - 90/50 mm Hg. Art., tachycardia up to 100 beats / min. In/in introduced dexamethasone - 16 mg, aminophylline - 240 mg and 1.0 adrenaline s / c. At 20:40, the puerperal was transferred to the ICU, against the background of oxygen insufflation through a nasal catheter, the patient's condition continued to worsen: tachypnea - up to 40 bpm, SaO2 - 70%. At 21:05, she was intubated and put on a ventilator. After 1 hour 20 minutes, the patient's condition with negative dynamics: a critical decrease in blood pressure - up to 40/0 mm Hg. Art., progressive clinic of pulmonary edema (harsh breathing, wet bilateral rales, abundant serous sputum), diuresis after drug stimulation was 100 ml. 12.05. at 02:10 was examined by the resuscitator of the air ambulance service. Diagnosis: Amniotic fluid embolism? Shock. Multiple organ dysfunction. Then, over the course of two days, against the background of ongoing therapy, the patient's condition continued to worsen: coma, constant hyperthermia (up to 41.2°C), tachycardia (up to 160–170 beats/min), acute respiratory distress syndrome (ARDS), increased clinic of multiple organ failure.
In the KLA: an increase in leukocytosis - from 11¥109 / l (11.05) to 40.9¥109 / l (14.05), shift p / l - from 8 to 34%. 05/14/2011 at 06:25 against the background of unstable hemodynamics, mechanical ventilation, cardiac arrest was recorded, resuscitation measures had no effect. Biological death was declared.
Therapeutic measures included mechanical ventilation in the SIMV mode, corrective infusion therapy, further in the mode of dehydration, inotropic support, antibacterial, hormone therapy, diuretics, morphine. Final clinical diagnosis. Main: Births 3 urgent, large fruit. Complication: Amniotic fluid embolism. Early transfusion reaction to fresh frozen plasma transfusion? Transfusion shock? Beginning fetal asphyxia. Early postpartum hemorrhage, grade 2. ICE syndrome. Alveolar pulmonary edema. Multiple organ dysfunction. Accompanying: NJO 2–3 tbsp. Chronic intrauterine infections without exacerbation.
The diagnosis is pathoanatomical. Primary: Early postpartum hemorrhage after 3 term deliveries with a large fetus. DIC syndrome. Manual examination of the uterine cavity. Massage of the uterus on the fist. The imposition of clamps on the parameters according to Baksheev, clamping of the abdominal aorta, transfusion of FFP. Delivery with oxytocin. Anaphylactoid reaction. Complications: Shock of combined genesis: shock lungs with the development of alveolar pulmonary edema, tubular necrosis in the kidneys, centrilobular necrosis of hepatocytes in the liver, severe cerebral edema, cerebral coma. Multiple organ failure. Concomitant: Interstitial fibromyoma of the uterus (subserous nodes in the bottom, submucosal in the right corner of the uterus with a diameter of 3.5 cm, intramural on the side wall on the left and right in diameter up to 1 cm).
