Conditions and shelf life of fresh frozen plasma. Features of FFP transfusion Plasma transfusion

  Indications for transfusion of fresh frozen plasma (FFP), cryoprecipitate and cryosupernatant plasma are very limited. They may cause unpredictable adverse effects. The risk of transmission of infection is approximately the same as with transfusion of other blood components unless pathogen-reduced plasma (PRP) is used. Specific adverse reactions include allergic reactions and anaphylaxis, transfusion-related acute lung injury, and hemolysis due to the administration of antibodies to blood group antigens, especially A and B. FFP is not indicated for disseminated intravascular coagulation without bleeding and is recommended as a plasma exchange medium only in thrombotic thrombocytopenic purpura (cryosupernatant is a possible alternative in this case), should never be used to treat warfarin overdose in the absence of serious bleeding, and is only of very limited value as prophylaxis before liver biopsy. The use of FFP and cryoprecipitate for surgical or traumatic bleeding should be based on data from coagulation studies, which may include bedside tests. FFP is not indicated for the treatment of vitamin K deficiency in neonates or patients in intensive care units. PRP can be used as an alternative to FFP. In the UK, PRP from countries where BSE is rare is recommended by the Department of Health for transfusion in children born after 1 January 1996. A commercial preparation of PRP from US donors (Octaplas) is licensed and available in the UK. FFP should be thawed using a technique that does not pose the risk of bacterial contamination. Plastic bags containing any of the plasma products are frozen and must be handled with care.

Key words: fresh frozen plasma, clinical use, guideline.

Clinical indications for the use of fresh frozen plasma (FFP), cryoprecipitate and cryosupernatant (see Section 10),

Single coagulation factor deficiency (Section 10.1)

Multiple clotting factor deficiencies (Section 10.2); disseminated intravascular coagulation (DIC) (Sections 10.3 and 10.4)

Thrombotic thrombocytopenic purpura (TTP) (Section 10.5)

Reversing the effects of warfarin (Section 10.6)

Vitamin K deficiency in the intensive care unit (ICU) (Section 10.7)

Liver diseases (Section 10.8)

Surgical bleeding and massive transfusion (Section 10.9)

Use of FFP in pediatrics (Section 11.0) (see BCSH, 2004)

Selection of SWP

Table I. Principles for selecting fresh frozen plasma according to the blood type of the donor and recipient (AB0).

Use of FFP, cryoprecipitate and cryosupernatant

The purpose of this guideline

Methods

1. Introduction

1.1. Historical and current use of NWS

1.2. Issues with variant Creutzfeldt-Jakob disease (vCJD) and the use of non-UK plasma (see vCJD position in the UK Transfusion Service document library; http://www.transfusionguidelines.org.uk)

1.3. The problem of transfusion-associated acute lung injury (TRALI) and the use of plasma from male donors (see Section 9.2),

2. Specifications, preparation, storage and handling of FFP and cryoprecipitate

2.1. SZP

  These values ​​were determined in the pathology laboratories of the University Hospital of Southampton. High levels of sodium, glucose, citrate and phosphate are associated with the use of a preservative anticoagulant mixture, and low levels of ionized calcium are also associated with this.
  The prepared plasma is quickly frozen to -30 degrees C, the recommended temperature for storage. The interval between collection and freezing is not specified in current guidelines (United Kingdom Blood Transfusion Services/National Institute for Biological Standards and Control, 2002).
  Frozen plastic bags containing FFP become relatively brittle and must be handled with care.
  Immediately after thawing, standard FFP should contain at least 70 IU/ml FVIII in at least 75% of the packages. This requirement has been relaxed for the PDP (see Section 3, and Table III).
  Packages should be inspected immediately before infusion. If any unexpected changes are observed in them, such as flaking, discoloration or obvious packaging defects, it is necessary to refrain from transfusion or observe these bags for a while to make a decision further. Other details of quality control requirements are also specified in the guidelines (United Kingdom Blood Transfusion Services/National Institute for Biological Standards and Control, 2002).

Recommendation
  Fresh frozen plasma produced by centrifugation of whole blood units and plasmapheresis is therapeutically equivalent in its effect on hemostasis and side effect profile (grade of recommendation A, level of evidence I).

2.2. Cryoprecipitate and cryosupernatant (‘cryo-depleted plasma’)

3. Pathogen-reduced plasma (PRFFP and PRP)

3.1. PRP manufacturing methods: quality control

3.1.1. MBFFP. Blood transfusions in the UK

  At the time of writing (December 2003) the supply of various types of MBFFP was being done in various regions of the UK and no non-UK plasma was available. Although harvesting FFP from male donors may reduce the risk of developing TRALI, such separation is not universally available. MBFFP obtained from AB male donors is sometimes available in packets containing 50-75 ml. During 2004, the supply of plasma obtained from donors from regions with a low incidence of BSE and pathogen-reduced using the MB process will be established for children born after 1996.

3.1.2. SDFFP.

3.1.3. Pathogen-reduced cryoprecipitate and cryosupernatant

3.1.4. Quality control.

3.2. Efficiency and safety

3.2.1. MBFFP and SDFFP.

3.2.2. MBFFP

3.2.3. SDFFP.

Recommendation
  Any patient prescribed PRP must weigh the risk of HAV and parvovirus B19 transmission and their possible complications against the likely clinical benefit (grade of recommendation, B evidence level II/III).

4. Selection of FFP based on blood type

4.1. Blood compatibility according to AB0 group (see Table I),

Recommendation
  Regarding AB0 blood groups, the first choice for prescription is FFP of the same group as the patient. If this is not available, an FFP of another A0 group can also be used if it is not tested to have anti-A or anti-B activity above the “high titer” threshold. Group 0 FFP should only be given to group 0 donors (grade of recommendation B, level of evidence III).

  Plasma prescribed to infants and newborns should not contain a clinically significant amount of irregular blood group antibodies. FFP from group AB donors contains neither anti-A nor anti-B antibodies and is often preferred.

Recommendation
  Group 0 FFP should not be used in non-group 0 infants or newborns because the relatively large volumes required may result in passive immune hemolysis (grade of recommendation B, level of evidence III).

4.2. Rh blood group compatibility

Recommendation
  Fresh frozen plasma, MBFFP and SDFFP of any Rh group can be administered regardless of the recipient's Rh group. No anti-D prophylaxis is required if Rh D negative patients receive Rh D positive FFP (grade of recommendation B, level of evidence IIa).

5. Dosage

6. Defrosting and storing melted product

6.1. Thawing FFP, cryoprecipitate and cryosupernatant

6.1.1. Dry ovens (incubator with temperature control and fan).

6.1.2. Microwaves.

6.1.3. Water baths.

6.2. Storage after defrosting

Recommendation
  After thawing, if replacement is not required, FVIII, FFP and cryosupernatant can be stored at 4° C in a special blood storage refrigerator until administered to the patient within 24 hours (grade of recommendation B, level of evidence III).

7. Control of receipt and transfusion

8. Response to FFP transfusion

9. Adverse effects

9.1. Allergy

9.2. TRALI

9.3. Complications associated with white blood cell depletion

9.4. Infection

Recommendation
  For patients likely to receive multiple doses of FFP units, such as those with congenital coagulopathy, vaccination against hepatitis A and B should be considered (grade of recommendation C, level of evidence IV).

9.5. Graft versus host disease (GvHD)

9.6. VTE

9.7. Reports of Adverse Reactions

10. Clinical indications for the use of FFP, cryoprecipitate and cryosupernatant

10.1. Single factor deficiency

10.2. Multiple coagulation factor deficiencies

10.3. Hypofibrinogenemia

10.5. TTP (Machin, 1984; BCSH, 2003)

Recommendation
  Daily single plasma volume replacement procedures should ideally be started immediately upon presentation (grade of recommendation A, level of evidence Ib), and preferably within 24 hours of presentation (grade of recommendation C, level of evidence IV). Daily plasma replacement should be continued for at least 2 days after remission is achieved (grade of recommendation C, level of evidence IV).

10.6. Reversing the effect of warfarin (see BCSH, 1990b; BCSH, 1998; Baglin, 1998; Makris and Watson, 2001)

Recommendation
  Fresh frozen plasma should not be used to reverse the anticoagulant effects of warfarin unless there is evidence of severe bleeding (grade of recommendation B, level of evidence IIa).

10.7. Policy for the use of vitamin K in the ICU

Recommendation
  Intensive care unit patients should receive vitamin K routinely; 10 mg three times a week for adults and 0.3 mg per kg for children (grade of recommendation B, level of evidence IIa).

10.8. Liver diseases

Recommendation
  Available data indicate that patients with liver disease and an increase in PTW of more than 4 seconds compared with controls are unlikely to benefit from FFP (grade of recommendation C, level of evidence IV).

10.9. Surgical bleeding

10.9.1. Coronary artery bypass graft (CABG) surgeries.

10.9.2. Massive transfusion.

Recommendation
  Whether and how much FFP should be used to treat a patient with apparent blood loss should be based on data from timely coagulation tests (including bedside tests). The prophylactic regimen should not be used (grade of recommendation B, level of evidence IIb).

11. Use of FFP in pediatrics (see BCSH, 2004),

11.1. Hereditary deficiency of clotting factors

11.2. Hemorrhagic disease of the newborn (HDN)

11.2.1. Management of acute bleeding. SZP

PCC (see Section 10.6).

Recommendation
  Although the coagulation defect in HDN can be completely corrected by PCC, there are no data to guide the dosage in this situation (grade of recommendation C, level of evidence IV).

11.3. Neonates with coagulopathy and bleeding, or risk of bleeding due to the use of aggressive procedures

Recommendation
Neonates with significant coagulopathy and risk of bleeding, or those about to undergo aggressive procedures, should receive approximately 15 ml/kg FFP as well as vitamin K (grade of recommendation C, level of evidence IV). The reduction in clotting time is unpredictable and should be monitored after administration.

11.4. Prevention of intraventricular hemorrhage in premature infants

11.5. Polycythemia in infants

11.6. T antigen activation by red cells

Recommendations
  In the absence of specific data, each clinical department should formulate its own policies and protocols for investigating any unexpected hemolysis associated with plasma transfusion in a child with NEC or similar infection. A selective testing strategy and transfusion protocol may also be required in such cases (grade of recommendation C, level of evidence IV).
  If there is a high suspicion of T-activated hemolysis, exchange transfusion using plasma products and red blood cells with a low titer of anti-T may be indicated. In this situation, (washed/resuspended) low titer anti-T platelet concentrate may also be indicated (grade of recommendation C, level of evidence IV). It should be taken into account that avoiding transfusion of plasma-containing blood components in infants with T-activated red cells may be an inappropriate policy for patients who require correction of hemostasis (grade of recommendation B, level of evidence II/III).

12. Additional instructions for patients who, for various reasons, refuse transfusion

13. No indications for the use of FFP

13.1. Hypovolemia

13.2. Plasma exchange (except TTP)

13.3. Correction of increased INR in the absence of bleeding

Legal Disclaimer
  While the recommendations and information in this guide are believed to be true and accurate at the time of publication, neither the authors nor the publishers can accept any legal liability or responsibility for any omissions or errors that may be made.

Links

Atance, R., Pereira, A. & Ramirez, B. (2001) Transfusing methylene blue – photoinactivated plasma instead of FFP is associated with an increased demand for plasma and cryoprecipitate. Transfusion, 41, 1548–1552.

Baglin, T. (1998) Management of warfarin (coumarin) overdose. Blood Review, 12, 91–98.

BCSH (1988) Guidelines for transfusion for massive blood loss. Clinical Laboratory Hematology, 10, 265–273.

BCSH (1990a) Guidelines on hospital blood bank documentations and procedures. Journal of Clinical Laboratory and Hematology, 12, 209–220.

BCSH (1990b) Guidelines on oral anticoagulation: second edition. Journal of Clinical Pathology, 43, 177–183.

BCSH (1992) Guidelines for the use of fresh frozen plasma. Transfusion Medicine, 2, 57–63.

BCSH (1994) Guidelines for administration of blood products, transfusion of infants and neonates. Transfusion Medicine, 4, 63–69.

BCSH (1998) Guidelines on oral anticoagulation: third edition. British Journal of Haematology, 101, 374–385.

BCSH (1999) Guidelines for administration of blood products, and management of transfused patients. Transfusion Medicine, 9, 227–238.

BCSH (2003) Guidelines on the diagnosis and management of the thrombotic microangiopathic haemolytic anemias. British Journal of Haematology, 120, 556–573.

BCSH (2004) Guidelines on the transfusion of neonates and older children. British Journal of Haematology, 124, 433–453.

Bjerrum, O.S. & Jersild, C. (1971) Class specific anti-IgA associated with severe anaphylactic transfusion reactions in a patient with pernicious anemia. Vox Sanguinis, 21, 411–424.

Bull, B.S., Huse, W.M., Brauer, F.S. & Korpman, R.A. (1975) Heparin therapy during extracorporeal circulation: II. The use of a dose-response curve to individualize heparin and protamine dosage. Journal of Thoracic and Cardiovascular Surgery, 69, 686–689.

Carson, J.L., Poses, R.M., Spence, R.K. & Bonavita, G. (1988) Severity of anemia and operative mortality and morbidity. Lancet, 331, 727–729.

Ciavarella, D., Reed, R.L., Counts, R.B., Pavlin, E., Baron, L., Heimbach, D.M. & Carrico, J. (1987) Clotting factor levels and the risk of diffuse microvascular bleeding in the massively transfused patient. British Journal of Haematology, 67, 365–368.

Cohen, H. (1993) Avoiding the use of FFP. British Medical Journal, 307, 395–396.

College of American Pathologists Practice Guidelines Development Task Force (1994) Practice parameters for the usage of FFP, cryo and platelets. Journal of the American Medical Association, 271, 777–781.

Council of Europe (2004) Guide to the Preparation, Use and Quality Assurance of Blood Components, 10th edn. Council of Europe Publishing, Strasbourg.

De la Rubia, J., Arriaga, F., Linares, D., Larrea, L., Carpio, N., Marty, M.L. & Sanz, M.A. (2001) Role of methylene blue treated of fresh frozen plasma in the response to plasma exchange in patients with thrombotic thrombocytopic purpura. British Journal of Haematology, 114, 721–723.

Department of Health (1998) Vitamin K for New Born Babies. PL/CMO/98/3, PL/CMO/98/4. Department of Health, London.

Det Norske Veritas (1999) Assessment of the Risk of Exposure to vCJD Infectivity in Blood and Blood Products. A Report to Spongiform Encephalopathy Advisory Committee. Det Norske Veritas, London.

Dyer, C. (2003) Second vCJD patient to receive experimental treatment. British Medical Journal, 273, 886.

Eagleton, H., Benjamin, S. & Murphy, M.F. (2000) Audits of appropriate use of FFP. Bloods Matters, 4, 5–8.

Eder, A.F. & Manno, C.S. (2001) Does red cell activation matter? British Journal of Haematology, 114, 25–30.

vans, G., Llewelyn, C., Luddington, R., Baglin, T.P. & Williamson, L.M. (1999) Solvent/detergent fresh frozen plasma as primary treatment of acute thrombotic thrombocytopenic purpura. Clinical and Laboratory Hematology, 21, 119–123.

Food Standards Agency (2003) OTM Rule Review: Core Stakeholder Group Report. WWW document. URL: http://www.foodstandards.gov.uk.

Furlan, M., Robles, R., Galbusera, M., Remuzzi, G., Kyrle, P. A., Brenner, B., Krause, M., Scharrer, I., Aumann, V., Mittler, U., Solenthaler , M. & Lammle, B. (1998) Von Willebrand factor cleaving protease in thrombotic thrombocytopenic purpura and the haemolytic uraemic syndrome. New England Journal of Medicine, 339, 1578.

Garwood, M., Cardigan, R.A., Drummond, O., Hornsey, V., Turner, C.P., Young, D., Williamson, L.M. & Prowse, C.V. (2003) The effect of methylene blue photoinactivation and methylene blue removal on the quality of fresh-frozen plasma. Transfusion, 43, 1238–1247.

Goodnough, L.T. (1999) Transfusion Medicine 2nd of 2 parts. New England Journal of Medicine, 340, 525–533.

Green, G., Dymock, I.W., Poller, L. & Thomson, J.M. (1975) Use of factor VII-rich prothromin complex concentrate in liver disease. Lancet, 1, 1311–1314.

Harke, H. & Rahman, S. (1980) Haemostatic disorders in massive transfusion. Biblioteca Haematologica, 46, 179–188.

Harrison, C.N. Lawrie, A.S., Iqbal, A., Hunter, A. & Machin, S.J. (1996) Plasma exchange with solvent/detergent plasma of resistant thrombotic thrombocytopenic purpura. British Journal of Haematology, 94, 756–758.

Hellstern, P. & Haubelt, H. (2002) Indications for plasma in massive transfusion. Thrombosis Research, 107(Suppl. 1), S19–S22.

Hett, D.A., Walker, D., Pilkington, S.N. & Smith, D.C. (1995) Sonoclot analysis. British Journal of Anaesthesia, 75, 771–776.

Hewitt, P.E. & Machin, S.J. (1990) Massive blood transfusion. British Medical Journal, 300, 107–109.

Hiippala, S.T., Myllyla, G. & Vahtera, E.M. (1995) Hemostatic factors and replacement of major blood loss with plasma-poor red cell concentrates. Anesthesia and Analgesia, 81, 360–365.

Hilton, D.A., Ghani, A.C., Conyers, L., Edwards, P., McCardle, L., Penney, M., Ritchie, D. & Ironside, J.W. (2002) Accumulation of prion protein in tonsil and appendix: review of tissue samples. British Medical Journal, 325, 633–634.

Horrow, J.C., Hlavecek, J., Strong, M.D., Collier, W., Brodsky, I., Goldman, S.M. & Goel, I.P. (1990) Prophylactic tranexamic acid decreases bleeding after cardiac operations. Journal of Thoracic and Cardiovascular Surgery, 99, 70–74.

Houston, F., Foster, J.D., Chong, A., Hunter, N. & Bostock, C.J. (2000) Transmission of BSE by blood transfusion in sheep. Lancet, 356, 999–1000.

Hunt, B.J. (1991) Modifying periperative blood loss. Blood Reviews, 5, 168–176.

Hunter, N., Foster, J., Chong, A., McCutcheon, S., Parnham, D., Eaton, S., MacKenzie, C. & Houston, F. (2002) Transmission of prion diseases by blood transfusion. Journal of General Virology, 83, 2897–2905.

Jain, N., Kirschbaum, N., Gaines, A., Coignard, B., Jarvis, W. & Silverman, T. (2003) Pulmonary embolism in liver transplant setting associated with the use of solvent detergent plasma. Journal of Thrombosis and Haemostasis, 1(Suppl. 1), abstract no. OC159.

Kopto, P.M. & Holland, P.V. (1999) Transfusion related acute lung injury. British Journal of Haematology, 105, 322–329.

Lakkis, N.M., George, S., Thomas, E., Ali, M., Guyer, K. & Carville, D. (2001) Use of ICHOR-platelet works to assess platelet function in patients treated with GP IIb/IIIa inhibitors . Catheterization and Cardiovascular Interventions, 53, 346–351.

Laupacis, A. & Fergusson, D. for the International Study of PeriOperative Transfusion (ISPOT) Investigators (1997) Drugs to minimize perioperative blood loss in cardiac surgery: meta-analyses using perioperative blood transfusion as the outcome. Anaesthesia and Analgesia, 85, 1258–1267.

Levi, M. & ten Cate, H. (1999) Disseminated intravascular coagulation. New England Journal of Medicine, 341, 586–592.

MacGregor, I., Hope, J., Barnard, G., Kirby, L., Drummond, O., Pepper, D., Hornsey, V., Barclay, R., Bessos, H., Turner, M. & Prowse, C. (1999) Application of a time-resolved fluoroimmunoassay for the analysis of normal prion protein in human blood and its components. Vox Sanguinis, 77, 88–96.

Machin, S.J. (1984) Thrombotic thrombocytopenia purpura. British Journal of Haematology, 56, 191–197.

Makris, M. & Watson, H.G. (2001) The management of coumarin induced over anticoagulation. British Journal of Haematology, 114, 271–280.

Makris, M., Greaves, M., Phillips, W.S., Kitchen, S., Rosendaal, F.R. & Preston, F.E. (1997) Emergency oral anticoagulant reversal: the relative efficacy of infusions of fresh frozen plasma and clotting factor concentrate on correction of the coagulopathy. Thrombosis and Haemostasis, 77, 477–480.

Male, C., Johnston, M., Sparling, C., Brooker, L., Andrew, M. & Massicotte, P. (1999) The influence of developmental haemostasis on the laboratory diagnosis and management of haemostatic disorders during infancy and childhood . Clinics in Laboratory Medicine, 19, 39–69.

Mannucci, P.M., Franchi, F. & Diaguardi, N. (1976) Correction of abnormal coagulation in chronic liver disease by combined use of fresh frozen plasma and prothrombin complex concentrates. Lancet, 2, 542–545.

Mannucci, P.M., Federici, A.B. & Sirchia, G. (1982) Haemostasis testing during massive blood replacement. A study of 127 cases. Vox Sanguinis, 42, 113–123.

Mansouri, A. & Lurie, A.A. (1993) Consise review: metaemoglobinaemia. American Journal of Haematology, 42, 7–12.

McClelland, D.B.L. (ed.) (2001) The Handbook of Transfusion Medicine, 3rd edn. HMSO, London. http://www.thestationeryoffice.co.uk/nbs/handbook2001/index.htm.

Mollison, P. L. (1972) Blood Transfusion in Clinical Medicine, 5th edn. Blackwell Scientific Publications, Oxford, p. 188.

Murphy, M.F. (1999) NV CJD, the risk of transmission by blood transfusion and potential benefit of leucocyte reduction of blood components. Transfusion Medicine Reviews, 13, 75–83.

Murphy, M.E. (2001) Febrile reactions and TRALI. In: Practical Transfusion Medicine (ed. by Murphy, M.F. & Pamphilon, D.H.), pp. 157–163. Blackwell Science, Oxford.

Northern Neonatal Nursing Initiative Trial Group (1996) Randomized trial of prophylactic early fresh-frozen plasma or gelatin or glucose in preterm babies: outcome at 2 years. Lancet, 348, 229–232.

O'Shaughnessy, D.F. (2000) Communication theory in the setting of blood transfusion in a DGH, MBA thesis. Oxford Brookes University.

Osborn, D.A., Lui, K., Pussell, P., Jana, A.K., Desai, A.S. & Cole, M. (1999) T and Tk antigen activation in necrotizing enterocolitis: manifestations, severity of illness and effectiveness of testing. Archives of Diseases in Childhood, Fetal and Neonatal Edition, 80, 192F–197F.

Palfi, M., Berg, S., Ernerudh, J. & Berlin, G. (2001) A randomized controlled trial of transfusion-related acute lung injury: is plasma from multiparous blood donors dangerous? Transfusion, 41, 317–322.

Pamphilon, D.H. (2000) Viral inactivation of FFP. British Journal of Haematology, 109, 680–693.

Peters, D.C. & Noble, S. (1998) Aprotinin: an update of its pharmacology of therapeutic use in open heart surgery and coronary artery bypass surgery. Drugs, 57, 233–260.

Pincock, S. (2004) Patient's death from vCJD may be linked to blood transfusion. Lancet, 363, 43.

Popovsky, M.A., Chaplin, Jr, H.C. & Moore, S.B. (1992) Transfusion related acute lung injury a neglected, serious complication of haemotherapy. Transfusion, 32, 589–592.

Rock, G., Shumak, K.H., Sutton, D.M.C., Buskard, N.A., Nair, R.C., Michelson, A.D. & Members of the Canadian Apheresis Group (1996) Cryosupernatant as repalcement fluid for plasma exchange in the thrombotic thrombocytopenic purpura. British Journal of Haematology, 39, 1227–1234.

Sandler, G.S., Mallory, D., Malamui, D. & Eckrich, R. (1995) IgA anaphylactic transfusion reactions. Transfusion Medicine Reviews, 9, 1–8.

Sazama, K. (1994) Bacteria in blood for transfusion: a review. Archives of Pathology Laboratory Medicine, 118, 350–365.

Serious Hazards of Transfusion (2001) Annual Report 1999–2000. ISBN 0 9532 789 3 X.

Serious Hazards of Transfusion (2002) Annual Report 2000–2001. ISBN 0 9532 789 4 8.

Serious Hazards of Transfusion (2003) Annual Report 2001–2002. ISBN 0 9532 789 5 6.

Shehata, N., Blajchman, M. & Heddle, N. (2001) Coagulation factors in FFP and cryosupernatant. Transfusion Medicine, 11, 391–401.

Shore-Lesserson, L., Manspeizer, H.E., DePerio, M., Francis, S., Vela-Cantos, F. & Ergin, M.A. (1999) Thromboelastography-guided transfusion algorithm reduces transfusions in complex cardiac surgery. Anaesthesia and Analgesia, 88, 312–319.

Silliman, C.C., Boshkov, L.K., Mehdizadehkashi, Z. Elzi, D.J., Dickey, W.O., Podlosky, L. Clarke, G. & Ambruso, D.R. (2003) Transfusion-related acute lung injury: epidemiology and a prospective analysis of etiologic factors. Blood, 101, 454–462.

Solheim, B.G. & Hellstern, P. (2003) Composition, efficacy, and safety of S/D-treated plasma (letter). Transfusion, 43, 1176–1178.

Solheim, B.G., Rollag, H., Svennevig, J., Arafa, O., Fosse, E. & Bergerud, U. (2000) Viral Safety of solvent/detergent treated plasma. Transfusion, 40, 84–90.

Stainsby, D. & Burrowes-King, V. (2001) A National Audit of the Use of Fresh Frozen Plasma. NBS. WWW document. URL: http://www.nbsweb/med/ca/pf/ffprep.pdf

Stainsby, D., MacLennan, S. & Hamilton, P.J. (2000) Commentary. Management of massive blood loss: a template guideline. British Journal of Anaesthesia, 85, 487–491.

Stanworth, S.J., Brunskill, S.J., Hyde, C.J., McClelland, D.B.L. & Murphy, M.F. (2004) Is FFP clinically effective? A systematic review of randomized controlled trials. British Journal of Haematology, in press.

Turner, M. L. & Ironside, J.W. (1998) New variant CJD: the risk of transmission via blood products. Blood Reviews, 12, 255–268.

United Kingdom Blood Transfusion Services/National Institute for Biological Standards and Control (2002) Guidelines for the Blood Transfusion Services in the United Kingdom, 6th edn. TSO. WWW document. URL: http://www.thestationeryoffice.com.nbs/rdbk2001/guidelines.htm and http://www.transfusionguidelines.org.uk.

United Kingdom Haemophilia Center Directors’ Organization (1997) Guidelines on therapeutic products to treat haemophilia and other hereditary coagulation disorders. Haemophilia, 3, 63–77.

United Kingdom Haemophilia Center Directors’ Organization (2003) Guidelines on the selection and use of therapeutic products to treat haemophilia and other hereditary bleeding disorders. Haemophilia, 9, 1–23.

Will, R.G., Ironside, J.W., Zeider, M., Cousens, S.N., Estiberio, K., Alperovitch, A., Poser, S., Pocchiari, M., Hofman, A. & Smith, P.G. (1996) A new variant of Creutzfeldt–Jakob disease in the UK. Lancet, 347, 921–925.

Williamson, L.M. (2001) Storage of blood components. In: Practical Transfusion Medicine (ed. by M.F. Murphy & D.H. Pamphilon), pp. 231–243. Blackwell Science, Oxford.

Williamson, L.M., Llewelyn, C.A., Fisher, N.F., Allain, J.-P., Bellamy, M.C., Baglin, T.P., Freeman, J., Klinck, J.K., Ala, F.A., Smith, N., Neuberger, J. & Wreghitt, T.G. (1999) A randomized trial of solvent/detergent and standard fresh frozen plasma in the coagulopathy of liver disease and liver transplantation. Transfusion, 39, 1227–1234.

Wuillemin, W.A., Gasser, K.M., Zeerleder, S.S. & Lammle, B. (2002) Evaluation of a platelet function analyzer (PFA 100) in patients with a bleeding tendency. Swiss Medical Weekly, 132, 443–448.

Yarranton, H., Cohen, H., Pavord, S.R., Benjamin, S., Hagger, D. & Machin, S.J. (2003) Venous thromboembolism associated with the management of acute thrombotic thrombocytopenic purpura. British Journal of Haematology, 121, 778–785.

Zeigler, Z.R., Shadduck, R.K., Gryn, J.F., Rintels, P.B., George, J.N., Besa, E.C., Bodensteiner, D., Silver, B., Kramer, B.E. & The North American TTP Group (2001) Cryoprecipitate poor plasma does not improve early response in primary adult thrombotic thrombocytopenic purpura. Journal of Clinical Apheresis, 16, 19–22. Zipursky, A. (1998) Prevention of vitamin K deficiency. Bleeding in newborns. British Journal of Haematology, 104, 430–437.

Appendix A

Points of evidence

Translation and web design -

Exam questions on professional retraining

"Transfusiology"

1. Bacteriological study of the air environment of boxed premises involves determining:

b) the total content of microbes and the amount of Staphylococcus aureus and streptococcus;

c) the amount of Staphylococcus aureus, mold and yeast fungi

The most dangerous biological fluids for HIV

c) blood

d) sperm

3. Blood substitutes with hemodynamic action are:

A ). Reopoliglyukin

b). Acesol

V). Polidez

G). Glucose

Human blood antigens include:

A. Erythrocyte and leukocyte

B. Erythrocyte, leukocyte, platelet

B. Simple and complex

G. Erythrocyte, leukocyte, platelet, serum

The instructions on the drug packaging “store in a cool place” correspond to the parameters

A). 2 to 8 °C;

b). 8 to 15 °C;

V). 18 to 20 °C;

G). 15 to 25 °C.

Time the tourniquet is on the limb

A). in summer no more than 30 minutes, in winter 40 minutes

b). in summer no more than 60 minutes, in winter 90 minutes

V). in summer no more than 15 minutes, in winter 30 minutes

G). can stay indefinitely

What class of waste do expired medicines belong to?

a) Class A

b) Class B

c) Class G

d) Class B

A specialist in the field of nursing organization must have a certificate in the specialty

a) "Nursing"

b) "Medicine"

c) "Midwifery"

d) "Organization of nursing"

d) "Medical and preventive care"

Which of the following methods is aimed at preventing HIV infection, hepatitis B and C?

a) Deratization

b) Pest control

V) Disinfection

d) All of the above

Founder of nursing development

A). Ekaterina Mikhailovna Bakunina

b). Dasha Sevastopolskaya

V). Florence Nightingale

G). Virginia Henderson

11. National Donor Day is celebrated in Russia every year:

12. Responsibility for the state of labor protection in the institution lies with:

a) Chairman of the occupational safety commission;

b) Manager;

V ) OSH Commissioner.

13. Disinfection of boxes in which material is tested for sterility is carried out:

a) when mold fungi are detected in the air or on the surface;

b) daily before the start of work;

c) at least once a week

Control of sterilization regimes by biological method is carried out:

a) 2 times a month;

b) 2 times a week;

c) 2 times a year

Incubation period for HIV infection

a) up to 7 days

b) up to 30 days

V) from 3 weeks to 3 months, sometimes up to a year

Duration of virus carriage

a) no more than 20-30 days

b) up to several months

c) for life

Causes of immunodeficiency in HIV

a) damage to B cells

b) damage to T cells

c) damage to erythrocytes

The most common opportunistic infections in HIV

a) flatulence

b) Kaposi's sarcoma

c) pneumocystosis

Incubation period for viral hepatitis B

b) 6 months

c) 2 months

Routes of transmission of viral hepatitis B

a) parenteral

b) sexual

c) fecal-oral

Storage conditions for sera for ELISA

a) at t 0ºC – up to 2 days

b) at t 4ºC – up to 7 days

c) at t 6ºC – up to 3 days

Laboratory research methods for diagnosing HIV infection

a) complement fixation reaction

c) immunoblot

What does ELISA detect when testing for HIV?

a) antigen

b) antibodies

c) p24 antigen and total HIV antibodies 1,2

24. Preparations for parenteral nutrition are:

A). Gelatinol

b). Amino acid mixtures

V). Perftoran

G). Lactosol

25. Blood products with complex action are:

A ). Albumin solution and fresh frozen plasma

b). Protein and red blood cell mass

V). Cryoprecytpitate

G). Albumin and protein solution

26. Conditions and shelf life of red blood cells prepared with the preservative “CPDA-1”:

A). At a temperature of 4±2 °C, 21 days

b). At a temperature of 4±2 °C, 35 days

V). At a temperature of 4±2 °C, 42 days

G). At a temperature of 4±2 °C, 50 days

Conditions and shelf life of platelet concentrate

A). At a temperature of 4±2 °C, 2 hours if continuous stirring is not possible

b). At a temperature of 20±2 °C, 5 days with continuous stirring

V). At a temperature of 20±2.2 days if continuous stirring is impossible

G). At a temperature of 20±2.6 hours if continuous stirring is impossible

28. Blood components include:

A). Erythrocyte mass, fresh frozen plasma, immunoglobulins, antistaphylococcal human plasma

b). Erythrocyte suspension, albumin, platelet concentrate

V). Red blood cell mass, filtered, fresh frozen plasma, cryoprecipitate

G). Washed erythrocytes, thrombin, erythrocyte suspension thawed and washed

Conditions and shelf life of fresh frozen plasma

A). At a temperature of minus 18 °C, 3 years

b). At a temperature of minus 25 °C, 3 years

V). At a temperature of minus 30 °C, 5 years

G). At a temperature of minus 20 °C, 1 year

30. Quarantine of fresh frozen plasma is carried out:

A). For a period of no more than 180 days from the date of study at a temperature of minus 25 °C

b). For a period of at least 180 days from the moment of freezing at a temperature of minus 25 ° C

V). For a period of no more than 90 days from the moment of fractionation at a temperature of minus 30 °C

G). For a period of no more than 90 days from the moment of inactivation at a temperature of minus 30 ° C

31. After quarantine of fresh frozen plasma, the following is carried out:

A). Use for the production of blood components and preparations

b). Use for transfusion to recipients

V). Repeated examination of the donor’s health status and laboratory testing of his blood for blood-borne infections

G ). Repeated laboratory testing of donor blood for blood-borne infections and norms for the composition of biochemical parameters of peripheral blood

32. Regulatory documents regulating the quarantine method:

A). Order of the Ministry of Health of the Russian Federation No. 193 dated 05/07/2003

b). Order of the Ministry of Health of the Russian Federation No. 363 dated November 25, 2002.

V). Decree of the Government of the Russian Federation dated January 26, 2010. No. 29

G). SANPIN 2.1.7.2790-10

33. The main sections of transfusiology are:

A). General transfusiology, blood service organization, clinical transfusiology,

b). Blood service, transfusion immunology, clinical transfusiology, industrial transfusiology

V). Theoretical transfusiology, practical transfusiology

G). Industrial transfusiology, theoretical transfusiology, clinical transfusiology

34. The main tasks of the SEC are:

A). Acquisition, registration and medical examination of donors, procurement and storage of donor blood and its components, organization of donated blood testing, control over the organization of transfusion therapy in medical organizations

b). Procurement, processing, storage, transportation and ensuring the safety of donor blood and its components in order to meet the needs of medical organizations for blood components

V). Planning, recruitment and medical examination of donors, control of the process of plasma procurement using plasmapheresis, ensuring the safety of collected plasma at all stages of the production process

G). Organization of provision of medical departments with blood components for the provision of transfusion assistance, storage of blood components, participation in the investigation of post-transfusion reactions and complications

35. The staffing levels of blood service institutions should be determined in accordance with the order:

A). Ministry of Health of the USSR No. 155 (1990)

b). Ministry of Health of the Russian Federation No. 278n (2012)

V). Ministry of Health of the USSR No. 1055 (1985)

G). Ministry of Health of the Russian Federation No. 183n (2013)

36. Documents required for the effective organization of production of blood components:

A). External (laws, orders, instructions, etc.)

b). Standard Operating Procedures

V). Records (quality data)

G). All listed

37. Resources of the quality management system in a blood service institution:

a) - Occupational health and safety, information resources

b) - Personnel, donors, premises

c) – Equipment, production environment

d) - All of the above

Clinically significant antigens of the Rhesus system:

b. Rh(D), rhC, rhE

V. Rh(D), rhC, rhc, rhE, rhe

G . Rh(D), rhC, rhc, rhE, rhe, Kell

The ABO antigenic system includes:

A. Antigens A and B

b. Antigens A and B, antibodies α and β

V. Antigens A and antibodies α

G. Antibodies α and β

Before donation, blood donors are determined:

A . Blood type and hemoglobin content

b. ALT activity and blood group

V. Hemoglobin content, number of leukocytes, platelets, ESR

G. Blood type, hemoglobin content, anti-erythrocyte antibodies

Normal ALT activity is:

A. no more than 40 U/l

b. no more than 31 U/l

V. Men no more than 40 U/l, Women no more than 31 U/l

G. Men no more than 31 U/l, Women no more than 40 U/l

After plasma donation, plasma donors are examined for:

A. ALT activity, total protein content, blood group, Rhesus affiliation, anti-erythrocyte antibodies

b. ALT activity, total protein content, blood group, Rhesus affiliation, anti-erythrocyte antibodies, microprecipitation reaction to Lues

V. ALT activity, blood group, Rhesus affiliation, anti-erythrocyte antibodies, microprecipitation reaction to Lues

G. ALT activity, total protein content, protein fractions (after 5 plasma doses), blood group, Rhesus affiliation, anti-erythrocyte antibodies, microprecipitation reaction to Lues

Immunohematological studies of donor blood include:

A. – determination of blood group according to the ABO system

- definition of rhesus - belonging

- determination of the phenotype of erythrocyte antigens using the Rhesus and Kell systems

- screening of anti-erythrocyte antibodies

b.– determination of blood group

Definition of Rhesus - belonging

V.– determination of hemoglobin

Blood group determination

Definition of Rhesus - belonging

Equipment required to determine blood group according to the ABO system using the cross method:

A .

- 0.9% NaCl solution

- tablets

- pipettes

- stirring sticks

b.– Coliclones anti-A, anti-B, anti-AB

Standard red blood cells O(I), A(II), B(III)

0.9% NaCl solution

V.– Coliclones anti-A, anti-B, anti-AB

0.9% NaCl solution

Tablets

Pipettes

Stirring sticks

Hourglass at 3 and 5 minutes

G.– Coliclones anti-A, anti-B, anti-AB

Standard red blood cells O(I), A(II), B(III)

Tablets

Pipettes

Stirring sticks

Hourglass at 3 and 5 minutes

How long does it take to monitor the progress of the reaction when determining Rhesus status?

A. 3 minutes

b. 5 minutes

V. 2 minutes

Causes of errors when determining blood group:

A.– incorrect labeling of tubes

Incorrect order of applying reagents to the plate

Individual characteristics of blood

b . - incorrect labeling of tubes

- incorrect order of applying reagents to the tablet

- incorrect ratio of reagents and test blood

- reduction of reaction observation time

- temperature violation

- individual characteristics of the blood being tested

V.– presence of an anticoagulant in the blood being tested

Low ambient temperature

Use of capillary blood

The main document regulating the conduct of immunohematological studies of donor blood:

A. Decree of the Government of the Russian Federation of December 31, 2010 No. 1230 “On approval of the rules and methods of research and rules for the selection of donor blood samples necessary for the application and implementation of technical regulations on the safety requirements of blood, its products, blood replacement solutions and technical means used in transfusion and infusion therapy "

b . Order of the Ministry of Health of the Russian Federation dated January 09, 1998 No. 2 “On approval of instructions for immunoserology.”

V. Order of the Ministry of Health of the Russian Federation No. 364 of September 14, 2001. “On approval of the procedure for medical examination of blood donors and its components.”

First aid for frostbite

A. remove the impact of the damaging factor

b . apply an aseptic bandage and wrap the affected part of the body

V. Give a hot drink

d. administer anesthesia

d. immobilize injured limbs

i.e. all of the above

Principles of cardiopulmonary resuscitation

A. restoration of airway patency

b. emergency mechanical ventilation and oxygenation

V. Maintaining circulation

G . all of the above

Classification of burns by degree

b. 1,2,3a,3b,4

First aid for acute coronary syndrome

A . provide the patient with rest, give him an aspirin tablet to chew, 1-2 tablets of nitroglycerin under the tongue, heparin 10,000-15,000 units subcutaneously, call an ambulance.

b. call an ambulance and try to distract the sick person by talking, give a validol tablet

V. Invite the patient to walk to improve blood circulation.

Plasma, frozen no later than two hours after taking blood from donors, has the working name antihemophilic plasma, since it contains clotting factor VIII - antihemophilic globulin in higher concentrations than FFP obtained at a later date (there is no blood product under this name in OK KKChiK ). In clinical practice it can be replaced by cryoprecipitate.

SZP can be stored at a temperature of -30 °C for 12 months from the date of vein puncture, provided that the packaging is sealed. In accordance with Order No. 193 of the Ministry of Health of the Russian Federation dated 05/07/2003, quarantined fresh frozen plasma is allowed storage mode 24 months at temperatures below -30 °C. Then order N 170 of March 19, 2010 was issued, in which the storage period for plasma was extended up to 36 months and a temperature not lower than -25 °C.

Selection donor-recipient pairs produced according to the AB0 system. Plasma of group AB(FV) in emergency cases can be transfused to a patient with any blood group.
Directly before transfusion of FFP thaw at a temperature of +37-38 °C. In the absence of special equipment for defrosting FFP, you can use water baths (with strict control over the water temperature - overheating is not allowed). After thawing, plasma is allowed to be stored for a short time before transfusion (no more than 1 hour at +1-6). The content of fibrin flakes in thawed plasma does not prevent transfusion through standard plastic systems with filters. Re-freezing and use of thawed plasma is not permitted.

If canned blood has not been deleukocyted before separation into components, it is recommended to transfuse FFP through special filters that retain leukocytes.
Thawed FFP is usually administered intravenously. According to certain indications, in case of massive surgical bleeding - intraarterially. Plasma can be injected into the bone marrow, subcutaneously.

SZP used primarily to replenish coagulation factors. For replacement purposes, FFP is injected in large volumes, usually in combination with polyglucin.
FFP dosages depend on the clinical situation and course of the disease and can range from 250-300 ml to 1000 ml per day. Administration is by drip or jet, depending on the indications for use. For the treatment of most diseases, a standard dose of FFP is recommended - 15 ml/kg. In cases where FFP transfusions are combined with platelet concentrate transfusions, it should be taken into account that with every 5-6 doses of platelet concentrate the patient receives a volume of plasma equivalent to 1 dose of FFP.

For achievement hemodynamic effect the total dose of infused FFP should ensure a sustained increase in blood pressure above the critical level (90 mm Hg).
In order to dehydration in patients with signs of cerebral edema, pulmonary edema in the absence of albumin, administration of native plasma concentrate is indicated.

Indications for FFP transfusion are steadily expanding without sufficient reason. There are two main reasons contributing to this: high cost and the lack of sufficient quantity and assortment (at least for domestic clinics) of specific concentrates of coagulation factors that could replace FFP, and, very importantly, the current lack of unified recommendations and clear indications for FFP transfusions.

Application of FFP indicated for the following clinical conditions:
lack of a specific drug for the treatment of isolated deficiency of blood coagulation factors (II, V, VII, IX, X, XI and XIII) or inhibitors (antithrombin III, proteins C and S, C1-esterase);
acute DIC syndrome;
thrombotic thrombocytopenic purpura;
sepsis (including neonatal sepsis);
patients after open heart surgery;
extracorporeal circulation;

The need for urgent neutralization of an oral anticoagulant in cases of overdose (in the absence of appropriate antidotes or their ineffectiveness);
vitamin K deficiency (in newborns);
hemophilia A and B, accompanied by bleeding;
correction of blood volume in case of massive blood loss, external and internal bleeding;
burn disease - plasma volume replacement;
purulent-septic processes of various etiologies - replacement of plasma volume and as a detoxification agent;
cerebral edema - for the purpose of dehydration. Plasma should be used to replace plasma volume, as a detoxification agent and for the purpose of dehydration only in the absence of appropriate blood substitutes.

Pre- and post-transfusion assessment patient's coagulation state- the most important component of transfusiological tactics when using FFP. It should be carried out on the basis of a set of clinical and laboratory data.

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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 its fluid state. Plasma proteins determine its colloid-oncotic pressure and balance with hydrostatic pressure; They also maintain a balanced state of the blood coagulation and fibrinolysis systems. 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.

PLASMA FRESH FROZEN

Under fresh frozen plasma refers to plasma that, within 4-6 hours after blood exfusion, is separated from red blood cells by centrifugation or apheresis and placed in a low-temperature refrigerator, ensuring complete freezing to a temperature of -30°C in an hour. This mode of plasma procurement 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 an optimal ratio.

It is desirable that fresh frozen plasma meets the following standard quality criteria: protein amount not less than 60 g/l, hemoglobin amount less than 0.05 g/l, potassium level less than 5 mmol/l. Transaminase levels should be within normal limits. The results of tests for markers of syphilis, hepatitis B and C, and HIV are negative.

Fresh frozen plasma volume, obtained by centrifugation from one dose of blood, is 200-250 ml. When performing double donor plasmapheresis, the plasma yield can be 400-500 ml, while hardware plasmapheresis can be no more than 600 ml.

Xhurt at a temperature - 20°WITH. At this temperature, PSZ can be stored up to 1 year. During this time, labile factors of the hemostatic system remain in it. Immediately before transfusion, the PSZ is thawed in water at a temperature +37 - +38°WITH. Fibrin flakes may appear in thawed plasma, which does not prevent transfusion through standard plastic systems with filters. The appearance of significant turbidity and massive clots indicate poor quality plasma, and it cannot be transfused.

Thawed plasma can be stored prior to transfusion no more than 1 hour. Re-freezing it is unacceptable.

The transfused fresh frozen plasma must be of the same group as the recipient according to the AB 0 system. Compatibility according to the Rh system is not mandatory, since fresh frozen plasma is a cell-free medium, however, with volume transfusions of fresh frozen plasma (more than 1 liter), Rh compatibility is required. Compatibility for minor erythrocyte antigens is not required. When transfusing PSZ, a group compatibility test is not performed. (?)

In emergency cases, in the absence of single-group fresh frozen plasma, transfusion of group AB(IV) plasma is allowed to a recipient with any blood group.

Indications and contraindications for transfusion of fresh frozen plasma:

Acute disseminated intravascular coagulation (DIC), complicating the course of shocks of various origins (septic, hemorrhagic, hemolytic) or caused by other causes (amniotic fluid embolism, crash syndrome, severe injuries with crushing tissue, extensive surgical operations, especially on the lungs, blood vessels, brain brain, prostate), massive transfusion syndrome;

Acute massive blood loss (more than 30% of circulating blood volume) with the development of hemorrhagic shock and disseminated intravascular coagulation syndrome;

Liver diseases accompanied by a decrease in the production of plasma coagulation factors and, accordingly, their deficiency in the circulation (acute fulminant hepatitis, cirrhosis of the liver);

Overdose of indirect anticoagulants (dicoumarin and others);

When performing therapeutic plasmapheresis in patients with thrombotic thrombocytopenic purpura (Moschkowitz disease), severe poisoning, sepsis, acute disseminated intravascular coagulation syndrome;

Coagulopathies caused by a deficiency of plasma physiological anticoagulants.

For burn disease in all clinical phases;

With purulent-septic processes;

Not recommended transfuse fresh frozen plasma to replenish the volume of circulating blood (there are safer and more economical means for this) or for parenteral nutrition purposes. Caution should be exercised in prescribing fresh frozen plasma transfusions in persons with a significant transfusion history or in the presence of congestive heart failure.

Features of fresh frozen plasma transfusion. Transfusion of fresh frozen plasma is carried out through a standard blood transfusion system with a filter, depending on clinical indications - in a stream or drip; in acute DIC with severe hemorrhagic syndrome - in a stream. It is prohibited to transfuse fresh frozen plasma to several patients from the same container or bottle.

When transfusing fresh frozen plasma, it is necessary to perform a biological test (similar to transfusion of blood gas carriers). The first few minutes after the start of the infusion of fresh frozen plasma, when a small amount of the transfused volume has entered the recipient's circulation, are decisive for the occurrence of possible anaphylactic, allergic and other reactions. fresh frozen plasma native cryoprecipitate

Transfused volumeSZP depends on clinical indications. For bleeding associated with DIC syndrome administration of at least 1000 ml of fresh frozen plasma at a time under the control of hemodynamic parameters and central venous pressure is indicated. It is often necessary to re-administer the same volumes of fresh frozen plasma under dynamic monitoring of the coagulogram and clinical picture. In this condition, the administration 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 disseminated intravascular coagulation syndrome, the amount of transfused fresh frozen plasma should be at least 25-30% of the total volume of transfusion media prescribed to replenish blood loss, i.e. at least 800-1000 ml.

For chronic DIC syndrome, as a rule, they combine transfusion of fresh frozen plasma with the prescription of direct anticoagulants and antiplatelet agents (coagulological control is required, which is a criterion for the adequacy of the therapy). In this clinical situation, the volume of fresh frozen plasma transfused once is at least 600 ml.

For severe liver diseases accompanied by a sharp decrease in the level of plasma coagulation factors and the development of bleeding or the threat of bleeding during surgery, transfusion of fresh frozen plasma at the rate of 15 ml/kg body weight is indicated, followed, after 4-8 hours, by repeated transfusion of plasma in a smaller volume (5-10 ml /kg).

The possibility of long-term storage of fresh frozen plasma allows it to be accumulated from one donor in order to implement the “one donor - one recipient” principle, which allows to sharply reduce the antigenic load on the recipient.

Reactions during transfusion of fresh frozen plasma. The most serious risk when transfusing fresh frozen plasma is the possibility 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, it is potentially possible immunological reactions associated with the presence of antibodies in the plasma of the donor and recipient. The most severe of them is anaphylactic shock, clinically manifested by chills, hypotension, bronchospasm, and chest pain. As a rule, such a reaction is caused by IgA deficiency in the recipient. In these cases, it is necessary to stop the plasma transfusion and administer adrenaline and prednisolone. If there is a vital need to continue therapy using fresh frozen plasma transfusion, it is possible to prescribe antihistamines and corticosteroids 1 hour before the start of the infusion and re-administer them during the transfusion.

Absolute contraindications to FFP transfusions:

* hypercoagulation;

* sensitization to parenteral administration of protein. It must be remembered that plasma is the main carrier of markers of infectious diseases.

Technology for obtaining and preparing plasma. Plasma can be collected using several methods:

· centrifugation of a dose of preserved blood and isolation of native plasma from it;

· plasmapheresis method - repeated taking of a dose of blood from one donor, centrifugation of it, isolation of plasma and return of red blood cells to the donor;

· method of automatic plasmapheresis - separation of plasma from a continuous flow of donor blood entering an automatic separator

Currently, blood service institutions can stock several types of plasma:

· native plasma - isolated from donor canned blood within the permissible storage period;

· fresh frozen plasma (FFP);

· factor VIII-depleted plasma (plasma remaining after cryoprecipitate is isolated);

· cell-depleted plasma (remaining after harvesting QDs and CLs from LTS).

From 500 ml. 250-300 ml of canned blood is obtained. native plasma. Containers containing red blood cells and plasma are aseptically separated, sealed and labeled. Plasma is sent: for processing into medicines; frozen or used for transfusion to patients.

Obtaining blood components using plasmacytopheresis methods by qualified, specially trained personnel is a safe procedure. The plasmapheresis operation consists of a number of stages: preparation of equipment, equipment and polymer double containers; taking blood from a donor into a polymer container; centrifuging a polymer container with blood; plasma separation; reinfusion of autologous red blood cells to the donor. After the donor returns his own red blood cells, the single plasmapheresis procedure is stopped. The collected plasma must be transferred to the clinic for transfusion within the first 3 hours after the end of plasmapheresis or no later than 4 hours, after which the plasma must be frozen.

Automatic hardware plasmapheresis is carried out by a plasma production system of a Gemanetic device, which is fully automated and computerized. She receives whole blood from a donor; mixes it with an anticoagulant, separates the plasma from the globular mass and returns the unused cellular elements to the donor.

The prepared plasma is collected in plastic containers. A larger amount is frozen, and some is sent for clinical use.

NATIVE PLASMA

Native plasma is obtained under sterile conditions from whole donor blood after centrifugation.

After separation of water from plasma, the concentration of total protein and plasma coagulation factors, in particular IX, increases significantly - such plasma is called plAzma native concentrated.

Concentrated native plasma (NCP) contains all the main components of freshly prepared plasma (except for the reduced content of factor VIII), but in a 2.5-4 times smaller volume (80 ± 20 ml). The concentration of total protein is higher than in native plasma and should be at least 10% (100 g/l). Possesses increased hemostatic and oncotic properties due to an increase in plasma proteins and coagulation factors (except factor VIII).

Indications for use. PNK is intended for the treatment of patients with severe deficiency of various procoagulants, hypo- and afibrinogenemia; as a dehydrating and detoxifying agent; for the treatment of diseases accompanied by protein deficiency, the development of edematous-ascitic and hemorrhagic syndromes.

Directions for use and doses. For bleeding caused by congenital or acquired deficiency of procoagulants, PNA is administered at a dose of 5-10 ml/kg per day until the bleeding stops completely.

In case of protein deficiency with the development of ascitic syndrome, it is possible to use the drug in a dose of 125-150 ml per day at intervals of 2-3 days, on average 5-6 transfusions per course.

Contraindications. PNC should not be used in severe renal impairment with anuria. After administration of the drug, allergic reactions may develop, which can be controlled by the administration of antihistamines.

Storage conditions. The drug is stored frozen. Shelf life - 3 months at a temperature of -30 °C.

CRYOPRECIPITATE

If cryoprecipitate is removed from plasma during fractionation, the remaining part of the plasma is the supernatant fraction of plasma (cryosupernatant), which has its own indications for use.

Last time cryoprecipitate, being a medicinal product obtained from donor blood, it is considered not so much as a transfusion medium for the treatment of patients with hemophilia A, von Willebrand disease, but as a starting material for further fractionation in order to obtain purified factor VIII concentrates.

For hemostasis, it is necessary to maintain factor VIII levels 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 one unit of blood must contain at least 100 units of factor VIII.

Requirement calculation in transfusion of cryoprecipitate is carried out 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 (required factor VIII level - available factor VIII level) = required amount of factor VIII for transfusion (units).

Required amount of factor VIII (units): 100 units = number of doses of cryoprecipitate required for a single transfusion.

The half-life of transfused factor VIII in the recipient's circulation is 8–12 hours, so repeat transfusions of cryoprecipitate 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 when the level of factor VIII is less than 1%, moderate - when the level is in the range of 1-5%, mild - when the level is 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, one fourth 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 and the patient's clinical response. For major surgeries or dental extractions, it is necessary to maintain factor VIII levels of at least 30% for 10-14 days.

If, due to some circumstances, it is not possible to determine the level of factor VIII in the recipient, then the adequacy of therapy can be indirectly judged by the 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 use of cryoprecipitate is hypofibrinogenemia, which is extremely rarely observed in isolation, more often as a sign of acute disseminated intravascular coagulation. 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 sedimentation of erythrocytes.

Cryoprecipitate must be compatible according to the AB 0 system. The volume of each dose is small, but transfusion of many doses at once is fraught with volemic disturbances, which is especially important to consider in children who have a smaller blood volume than adults. Anaphylaxis, allergic reactions to plasma proteins, and volume overload may occur with cryoprecipitate transfusion. The transfusiologist must constantly remember the risk of their development and, if they appear, carry out appropriate therapy (stop transfusion, prescribe prednisolone, antihistamines, adrenaline).

PLASMA PREPARATIONS

Antihemophilic plasma- plasma from freshly citrated donor blood, obtained 30 minutes after its collection. Contains unchanged antihemophilic globulin and other easily inactivated blood clotting factors. Dried antihemophilic plasma can be stored at room temperature for a year.

Fibrinogen-specific plasma protein takes part in blood clotting. It is obtained from plasma (1 g from 1 liter of plasma). Used to stop bleeding caused by afibrinogenemia and fibrinolysis. Antihemophilic globulin - factor VIII concentrate (dry or cryoprecipitate); 20 ml of cryoprecipitate corresponds to 250 ml of antihemophilic plasma. Used for hemophilia (hemophilia A) as a hemostatic agent. Can be stored for 6 months at a temperature of -30°C.

Clotting factor concentrate (PPSB)- prothrombin, proconvertin, Stewart factor and antihemophilic factor B. Used for hemorrhagic diathesis caused by a lack of these factors.

Fibrinolysin- a plasma enzyme preparation with high thrombolytic activity. Before use, the dry powder is dissolved in an isotonic sodium chloride solution and administered intravenously in combination with heparin for several hours. Used for vascular thrombosis and embolism. Streptase, cabinase, streptodecase are more effective.

Protein- a protein preparation obtained from hemolyzed blood, containing 75-80% albumin and 20-25% globulins. The protein concentration in the preparation is about 4.5-6%. It has a hemodynamic and detoxification effect due to the rapid increase in blood volume, dilution and binding of toxins. Used for traumatic, hemorrhagic, dehydration and other types of shock, as well as sepsis, hypoproteinemia of various origins. Administered intravenously (from 250 to 1000 ml). It is stored for about 3 years at a temperature of 4 "C.

Albumen 5, 10, 20% is obtained by ethanol fractionation of donor plasma. Shelf life - 3 years at a temperature of 4-8 °C. It has a pronounced therapeutic effect in cases of shock, blood loss, hypoproteinemia, cerebral edema, hepatic-renal failure, etc. It quickly increases blood pressure. Administered by drip. A single dose of a 10% solution is about 100-300 ml.

IMMUNE PLASMA

The most in demand at present is PI of the following specificity: antistaphylococcal plasma, antipseudomonal plasma, antiprotean plasma. At the same time, using modern diagnostic kits, it is possible to obtain PIs of a different specificity (anti-escherichiosis, etc.).

The main stages of obtaining (production) of IP are:

* selection and recruitment of immune plasma donors;

* examination of donor blood samples for the presence of antibodies to opportunistic microorganisms and determination of their titer;

* documenting research results in the Laboratory Research Registration Book? and ?Donor card? ;

* selection of plasma samples containing antibacterial antibodies (ABA) in therapeutic titers and suitable for transfusion;

* applying markings to the labels of selected donor plasma samples that correspond to the established specificity of AAA with an indication of the titer;

* registration (documentation) of receiving IP in the “Register of the procurement of blood and its components”? and transfer for storage;

* release of IP suitable for transfusion.

To study natural AAA, labeled samples of donor serum are used, remaining after the completion of immunohematological studies, stored at a temperature of +2 °C ... +6 °C in the absence of signs of poor quality (infection, hemolysis, etc.). The timing of screening should not exceed 3 days after taking blood from donors. If long-term storage is necessary, donor serum can be frozen at -20°C and below in special sealed plastic tubes.

Antistaphylococcal human plasma and antipseudomonas human plasma. Transfusions ASP or ASGP are indicated for the treatment or prevention of purulent-septic complications caused by the corresponding bacterial agent (sepsis, wound infection, burn disease, abscess pneumonia, hemoblastosis, etc.).

Plasma administered intravenously daily or every other day - depending on the severity of the disease - 200-300 ml or 3-5 ml/kg body weight (at least 18 IU). Course: 3-5 times or more in accordance with the severity of the disease and therapeutic effect. Children of the period newborns, including premature infants, transfusion of antistaphylococcal plasma is carried out at the rate of 10 ml/kg body weight (at least 60 IU). For each type of plasma, the indications for transfusion will be different.

Antistaphylococcal hyperimmune plasma. Currently, anti-staphylococcal plasma is obtained at blood transfusion stations from donors immunized with staphylococcal toxoid. After immunization (1.0-1.0-2 ml) and the appearance of specific antibodies in the blood at a titer of 6.0-10 IU/l, donors undergo plasmapheresis. It should be emphasized that one of the conditions for obtaining immune plasma is the use of plasmapheresis.

When carrying out treatment with this immune drug, it is necessary to take into account that a significantly greater clinical effect is achieved not with its single administration, but with a course of treatment, which consists of 3-5 intravenous infusions of anti-staphylococcal hyperimmune plasma of 150-200 ml per day.

Sources

1. http://ksmu.org.ru/library/surgery/536.html.

2. http://arenmed.org/ob10006.php.

3. http://spbgspk.ru/index.php?option=com_content&view=article&id=178&Itemid=21.

4. Production and clinical use of immune plasma in military medical institutions. Guidelines.

5. http://www.medskop.ru/antistafilokokkovaya_plazma/.

6. http://meduniver.com/Medical/Xirurgia/1024.html.

7. http://www.vrachebnye-manipulyacii.ru/vm/18.html.

8. http://www.transfusion.ru/doc/3638.htm.

9. Instructions for the use of blood components (approved by order of the Ministry of Health of the Russian Federation dated November 25, 2002 N 363).

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Magazine issue: August 2012

O.V.Vozgoment
Department of Anesthesiology and Reanimatology, Perm State Medical Academy named after. acad. E.A. Wagner

The results of an expert assessment of the quality of medical care for 3 patients who, during treatment, experienced blood transfusion complications due to the administration of fresh frozen plasma, which led to an unfavorable outcome, are presented. Based on the 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 preventing and treating such complications are discussed.
Key words: transfusion, fresh frozen plasma, complication, allergy, diagnosis, 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 complications prevention and treatment are discussed.
Keywords: transfusion, fresh frozen plasma, complication, allergy, diagnostics, expert survey, prevention, treatment.

Fresh frozen plasma (FFP) transfusions are widely used in clinical practice, especially in critically ill patients. FFP serves as a source of missing coagulation factors that are released during blood loss and consumed during the 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, the clinical manifestation of which is increased bleeding and hemorrhagic syndrome. Thus, conceptually, FFP transfusions are only indicated to replenish plasma coagulation factors, i.e. for the purpose of correcting hemostasis disorders. However, the use of FFP, like other components of donor blood, is associated with the risk of infectious complications, allergic reactions, immunosuppression, etc., some of which can 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 December 16. V
9 hours 31 minutes with a diagnosis: ovarian apoplexy? uterine bleeding. Blood pressure – 140/90 mm Hg. Art. Heart rate –
120 beats/min. From the anamnesis: from 13.12. I'm bothered by a runny nose and cough. At the same time, heavy bleeding appeared (last menstruation at the end of November). Upon admission, the patient was in a moderate state, consciousness was clear, the skin was pale. Heart rate – 108 beats/min, blood pressure – 80/50 mmHg. Art. A diagnosis was made: Menstrual irregularities due to
ARVI? Posthemorrhagic anemia, severe.
In OAK from 16.12: Red blood cells – 1.42¥1012/l, Hb –
51 g/l, Ht – 12%, L – 15¥109/l, p/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 administered intravenously. Due to ongoing bleeding on 16.12. at 12 o'clock
The uterine cavity was curetted for 30 minutes under IV ketamine anesthesia. Oxytocin was introduced. The bleeding stopped. For replacement purposes, 250.0 ml of refortan and 400.0 ml of gelatinol were administered intravenously. At 13:00: moderate condition, heart rate – 106 beats/min, blood pressure – 110/60 mm Hg. Art., no discharge from the genital tract. After determining the blood group (Rh factor is doubtful), at 13:20 a transfusion of FFP A(II) gr., Rh(+) – 200.0 ml was started. Biological test is negative. The patient's Rh factor also turned out to be negative. At 14:00, towards the end of the transfusion of the first bottle of FFP, the patient experienced difficulty breathing and coughing. On auscultation, wheezing appeared in the lungs. At 2 p.m.
She was examined by a resuscitator for 35 minutes. The condition is extremely serious, consciousness is clear. Sharp cough, severe pallor of the skin with a jaundiced tint. Heart rate – 120 beats/min, blood pressure – 110/80 mm Hg, respiratory rate – 24/min. There are wet rales across all fields.
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 a blood transfusion of 300.0 er was started. mass A(II) gr., Rh(-). At 15:55, tracheal intubation was performed, transfer to mechanical ventilation with positive expiratory pressure, and alcohol inhalation. The condition is extremely serious. Pulmonary edema, which is classified as non-cardiogenic, progresses. Foamy sputum mixed with blood is released through the endotracheal tube. At 16.12: heart rate – from 116 to 145 beats/min, blood pressure – 100/60–140/80 mm Hg, Sa02 – from 50 to 99%, CVP – 210–120 mm H2O. 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. Over 17 hours, 1770 ml of air was administered. mass, 1850 ml FFP. The total amount of fluid administered was 5340 ml.
17.12. at 6 o'clock: the condition is extremely serious. He is on a ventilator. The clinical picture of pulmonary edema is growing. 1500 ml (!) of fluid was released from the trachea. The R-gram shows negative dynamics. SaO2 – 56%. There is no consciousness. The volume of infusion therapy is reduced to 1100.0 ml. Changing antibiotics. Instead of gentamicin, abactal and metragil are prescribed. The administration of inotropes, vasodilators, and hormones continues. A counterman has been appointed. During 17.12. the condition is extremely serious. Unconscious. A large amount of mucous-viscous sputum is aspirated. Single moist rales. Heart rate – 96–124 beats/min, blood pressure – 90/60–140/80 mm Hg. Art. CVP – 140–210 mm water. Art. Sa02 – up to 85%. Daily diuresis – 2850 ml. In OAK there is a sharp neutrophil shift (p/i – 47%), leukocytosis – up to 18.8¥109/l. The R-gram (December 18) shows pulmonary edema in the resolution stage. Body temperature – 38–38.2°C. Tube feeding started. Positive neurological symptoms. Stable hemodynamics. The skin is pink. Biochemical blood test: hypoproteinemia, hypernatremia up to 223 mmol/l, hypokalemia. Subsequently, the condition stabilizes and hyperthermia persists. In OAK: Ht – 44–35%, leukocytosis – up to 16.1¥109/l, neutrophil shift – up to melocytes, lymphopenia progresses – up to 2%. In OAM – moderate proteinuria, hematuria, leukocyturia. Biochemical analysis showed hypoproteinemia. By 12/24. – normalization of sodium and potassium levels. The patient consults a therapist, pulmonologist, neurologist, and ophthalmologist.
21.12. The patient is conscious, breathing spontaneously through the endotracheal tube. Extubated. 22.12. due to increasing respiratory failure, she was again intubated and transferred to mechanical ventilation. 23.12. extubated again. 24.12. again an increase in respiratory failure and again intubation and transfer to mechanical ventilation. Pastyness of the lower extremities and swelling of the feet are noted, more so on the right. 28.12. due to grade 3–4 anemia. (OAK 27.12.: air – 3.6¥1012/l, Нb –
76 g/l, Ht – 29%) blood transfusion is performed
640.0 ml of single-group erythromass without reactions or complications. 29.12. purulent hemorrhagic sputum is released in large quantities. A tracheostomy was performed. Due to the diagnosed DIC syndrome, 550.0 ml of FFP was transfused. The condition is extremely serious. There are a large number of dry and moist rales in the lungs. Infusion therapy continues: 2100.0 ml intravenously and 600.0 ml via tube per day. 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. Associated: Chronic pyelonephritis. P/a main diagnosis: Dysfunctional uterine bleeding against the background of sclerocystic changes in the ovaries. Complications: Hemorrhagic shock. Severe posthemorrhagic anemia. Foci of damage in the myocardium of the left ventricle of the heart and the papillary muscles of the mitral valve with the development of minor necrosis and myocytolysis; severe degeneration of cardiomyocytes and minor hemorrhages. Membranogenic pulmonary edema grade 4. Acute purulent-obstructive tracheobronchitis, bronchiolitis with the development of acute 2-sided focal purulent-destructive bronchopneumonia. Sepsis. Septicopyemia. Metastatic kidney abscesses. DIC syndrome. Hemorrhages in the serous and mucous membranes, the adrenal medulla. Thrombosis of the right subclavian vein at the site of catheterization. Hemorrhagic erosions of the stomach. Swelling of internal organs. Dropsy of the serous cavities (pleural - 1000 ml, abdominal - 1500 ml, pericardial - 100 ml). Brain swelling. Parenchymal dystrophy and venous congestion of internal organs. Operations: 12/16/01 - curettage, uterine cavity, 12/29/tracheostomy. Associated: 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 final reason. Of course, hemorrhagic shock could also initiate the pathological process. But the patient did not experience any serious circulatory disorders upon admission to the gynecology department. The level of Hb and red blood cells is not an indicator of a state of shock, especially since the blood loss occurred within three days and the history indicates that the patient has had hyperpolymenorrhea for the last three years. In addition, the high central venous pressure and polyuria noted in the patient are not characteristic of hypovolemic shock. The condition worsened due to the infusion of 200 ml of FFP. The patient developed symptoms reminiscent of an allergic reaction (cough, difficulty breathing, 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 was noted in the gynecologist’s note, except for disturbances in the respiratory system. The resuscitator's note, made after 35 minutes, shows satisfactory indicators of central hemodynamics and notes pronounced pallor of the skin, shortness of breath, as well as a sharp cough and moist rales in the lungs, which fits into the picture of anaphylactic shock according to the asphyxial variant, the possibility of which is in 20% patients are indicated by A.S. Lopatin. Perhaps this is precisely how the pathological process developed in our patient. A type of allergic reaction can also be acute lung injury, which is a fairly rare complication of blood transfusion. The pathogenesis of ARF is associated with the ability of anti-leukocyte antibodies from donor blood to interact with granulocytes of the recipient. 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 the RDSV.
Unfortunately, the post-transfusion complication was not diagnosed. The diagnosis emphasizes the role of hemorrhagic shock and the patient is given ultra-vigorous intensive therapy: respiratory support, inotropes, peripheral vasodilators, hormones, diuretics, combination antibacterial therapy and excessive infusion-transfusion therapy. This is evidenced by CVP indicators, forced diuresis, and progressive pulmonary edema. 1.5 liters of fluid was released in 17 hours through the endotracheal tube(!). Polyuria, despite the limited infusion, persisted on the second day. Severe, dangerous dyselectrolythemia developed (Na - up to 240 mmol/l). Limiting the infusion and carrying out complex therapy, including adequate antibacterial therapy, led to some stabilization of the condition. But 21.12. the patient is prematurely transferred to spontaneous breathing and 22.12. Due to increasing respiratory failure, he is again transferred to mechanical ventilation. A similar precedent occurs on December 23–24. The patient has swelling. Hypoproteinemia in the blood. However, the volume of hydration is not corrected. Every day, starting from 19.12. more than three liters of fluid are introduced, which clearly exceeds the volume of fluid released. It lingers, aggravating hemodilution and overhydration. 28.12. in connection with grade 3–4 anemia, with blood levels generally acceptable for this condition, a blood transfusion of 640 ml of red blood cell mass is performed. Respiratory failure worsens. A tracheostomy is performed and 550 ml of FFP is infused. Again the 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 posthemorrhagic anemia and respiratory viral infection, and not entirely adequate, although vigorous, intensive care.

Clinical case 2. Patient G., 24 years old, had a second pregnancy (the first 2 years ago ended in a miscarriage at 4 weeks). The pregnancy, which occurred against the background of grade I anemia, was complicated by placental insufficiency. At 23–24 weeks she suffered from pneumonia, was treated in the therapeutic department, at 33–34 weeks, 22.02. hospitalized in the pregnancy pathology department due to severe placental insufficiency (up to stage IV), chronic intrauterine hypoxia of the newborn to moderate severity. Appropriate examination and treatment were prescribed. 05.03. the woman left the department without permission and returned on 03/06. When examined at 1:15 p.m., pale skin and weakness were noted. The pregnant woman complained of deterioration in health, dizziness, and pain in the lower abdomen. As a result of the examination, antenatal fetal death due to total placental abruption and stage I hemorrhagic shock were diagnosed. 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), and drainage of the abdominal cavity. During the operation, for replacement purposes, the following was administered: infucol - 500 ml, saline. solution – 1200 ml and FFP – 850 ml. 08.03. due to severe anemia (er. - 2.5 × 1012/l, Hb - 68 g/l, Ht - 20%) a blood transfusion (erythromass) was performed in a volume of 213.0; 213.0 and 213 ml. According to the records in the medical documentation, before the blood transfusion, the patient’s blood type and Rh factor, as well as the erythromass in the hemacons, were determined, group and Rh compatibility tests were carried out, a biological test was carried out, and then post-transfusion observation was carried out in order to prevent post-transfusion complications.
08.03. clinical signs of post-transfusion complications appeared (yellowness of the sclera, hemoglobinemia, hemoglobinuria). ABO incompatibility is suspected. 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. the condition was classified as moderate. It worsened sharply during fractional plasmapheresis on March 9. at 10 p.m. Replacement of exfused blood was carried out by FFP. After the second blood draw and administration of FFP, difficulty breathing, acrocyanosis, bradycardia, and then tachycardia - up to 160 beats/min, and arterial hypertension appeared. Transferred to mechanical ventilation. Subsequently, the condition remained serious. The phenomena of renal and multiple organ failure increased. 11.03. Due to 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 brought to the emergency department in terminal condition. The resuscitation measures taken were ineffective.
The diagnosis is clinical. Main: late postpartum period (5th day after the first urgent surgical birth). Total detachment of a normally located placenta, antenatal fetal asphyxia. Cuveler's uterus. Complication: hemorrhagic shock. Post-transfusion hemolytic complication. Multiple organ failure. Brain swelling. Coma. Operations and benefits: laparotomy, midline laparotomy. Caesarean section in the lower segment. Extirpation of the uterus with tubes. Drainage of the abdominal cavity (06.03.). Blood transfusion – 08.03. Plasmapheresis. Ventilation KPV – 08.03. Cardiopulmonary resuscitation. The diagnosis is forensic. Main: red blood cell transfusion (03/08–03/09). Complication: acute renal failure: glomerular anemia, necronephrosis. 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 segments 8, 9, 10 on the left and 5–8 on the right of moderate severity. Premature total abruption of a normally located placenta. Hemorrhagic shock. Intrauterine fetal death. Cuveler's uterus. Operation: laparotomy, midline laparotomy. Caesarean section in the lower segment. Extirpation of the uterus with tubes. Drainage of the abdominal cavity – 06.03. Blood transfusion – 08.03. Plasmapheresis. Ventilation KPV – 08.03. Cardiopulmonary resuscitation – 11.03.
A comment. Thus, the leading factor in 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 a control check of the contents of the hemacons by the laboratory doctor and the head. The SPK revealed that the erythromass in one of the hemacons 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 administration of hemolyzed blood. If we exclude dishonesty in performing blood compatibility tests, which would necessarily have revealed initial hemolysis, then we can assume that hemolysis occurred after all compatibility tests were performed. 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, and diuresis was maintained. A sharp deterioration in the patient's condition occurred during plasmapheresis. The clinical situation described was very reminiscent of an anaphylactic reaction, apparently to the protein of the transfused plasma. The patient received blood components from 10 donors over 3 days, so the likelihood of cross-anaphylaxis is very high. Subsequently, the condition remained serious, the patient was on mechanical ventilation, hyperthermia, hypoxemia (SaO2 - 86%), clinical signs of cerebral edema remained, and the R-gram showed interstitial pulmonary edema, that is, acute lung injury syndrome. Infusion therapy, inotropic support, stimulation of diuresis were carried out, and antibacterial drugs were prescribed - claforan and metrogil. The patient's diuresis was sufficient at 10.03. it amounted to 1440 ml. At the same time, the clearance rates increased, which forced the decision to transfer the patient to a regional hospital, which, unfortunately, turned out to be fatal.
In this case, it should be noted that the forensic medical diagnosis was formulated incorrectly. Transfusion of red blood cells is not a pathology. The diagnosis of community-acquired pneumonia in a patient who was hospitalized for 5 days and on mechanical ventilation for 2 days also raises doubts.
Clinical case 3. Patient U., 31 years old, was delivered to the obstetric department by an ambulance team on May 10. at 20:26 with a diagnosis: Pregnancy 40–41 weeks. Complicated obstetric history. Harbingers of childbirth. Chronic IUI. Vegetative-vascular dystonia, compensated. Large fruit. To prevent fetal hypoxia, Actovegin was administered intravenously. Oxytocin was administered to induce labor. At 16:25 a full-term boy was born with Apgar scores of 5–6. Immediately after birth, short-term chills and headache were noted, which resolved on their own. Blood loss was 200 ml (BP – 120/80 mm Hg,
Heart rate – 78 beats/min, respiratory rate – 18/min). Diagnosis: Childbirth
3 urgent giant fruit. OAA. Low water. Chronic IUI. Vegetovascular dystonia. ARVI. The umbilical cord is entwined around the fetal neck. 11.05. V
At 18:00 a simultaneous bleeding from the birth canal with a volume of 500 ml was recorded, the blood did not clot. The mother's condition is satisfactory. Blood pressure –120/70–130/70 mm Hg. Art. Heart rate – 88 beats/min. NPV – 18/min. Catheter diuresis – 200 ml. (urine is light). A manual examination of the uterine cavity was performed, and the remaining placental tissue was removed. The uterus has shrunk and moderate bleeding continues. 400.0 ml of saline was injected intravenously. solution, then 400.0 ml saline. solution +1.0 ml oxytocin, then 200.0 ml saline. solution + 10.0 ml tranexam and ceftriaxone. To stop bleeding, clamps are applied to the uterine vessels. The recorded blood loss was 1500 ml. At 18:40, transfusion of 1 liter of FFP was started, after which the bleeding stopped at 19:00. At 19:40 a control blood test was performed: er. –3.07¥1012/l, Нb – 86 g/l, Нt – 28%, Тg. – 160¥109/l. At 20:00 after transfusion of 150 ml of erythromass, the patient’s condition sharply worsened, weakness, headache, coughing, and a drop in A/D to 70/30 mm Hg were noted. Art. Moist rales are heard in the lungs. Diagnosis: Early postpartum period after the third birth with a giant fetus. Early postpartum hemorrhage grade 1–2. Early blood transfusion reaction to FFP transfusion. Blood transfusion shock. Amniotic fluid embolism? Alveolar pulmonary edema. Manual examination of the uterine cavity, isolation of remnants of placental tissue, additional placenta. At 20:15 she was examined by the resuscitator on duty. The patient is conscious, but lethargic. Complaints of weakness, difficulty breathing. Cyanosis of the nasolabial triangle. Tachypnea - up to 30 per minute, wheezing in the lungs on both sides. Blood pressure – 90/50 mm Hg. Art., tachycardia up to 100 beats/min. Dexamethasone - 16 mg, aminophylline - 240 mg and 1.0 adrenaline s.c. were administered intravenously. At 20:40, the postpartum woman was transferred to the ICU, against the background of oxygen insufflation through a nasal catheter, the patient’s condition continued to deteriorate: tachypnea - up to 40 beats/min, SaO2 - 70%. At 21:05 she was intubated and transferred to mechanical ventilation. After 1 hour 20 minutes, the patient’s condition showed negative dynamics: a critical decrease in blood pressure - up to 40/0 mm Hg. Art., progressive clinical picture of pulmonary edema (hard breathing, moist bilateral rales, copious serous sputum), diuresis after drug stimulation was 100 ml. 12.05. at 02:10 a.m. she was examined by a resuscitator from the air ambulance service. Diagnosis: Amniotic fluid embolism? Shock. Multiple organ dysfunction. Then, over the course of two days, against the background of the therapy, the patient’s condition continued to deteriorate: coma, constant hyperthermia (up to 41.2°C), tachycardia (up to 160–170 beats/min), clinical signs of acute respiratory distress syndrome (ARDS) were increasing. Clinic of multiple organ failure.
In the UAC: an increase in leukocytosis - from 11¥109/l (11.05) to 40.9¥109/l (14.05), p/i shift - from 8 to 34%. On 05/14/2011 at 06:25, cardiac arrest was recorded against the background of unstable hemodynamics, mechanical ventilation, and resuscitation measures were without effect. Biological death was declared.
Treatment measures included mechanical ventilation in the SIMV mode, corrective infusion therapy, then in the dehydration mode, inotropic support, antibacterial therapy, hormone therapy, diuretics, and morphine. The clinical diagnosis is final. Main: 3 urgent births, large fetus. Complication: Amniotic fluid embolism. Early blood transfusion reaction to fresh frozen plasma transfusion? Transfusion shock? Incipient fetal asphyxia. Early postpartum hemorrhage, grade 2. DIC syndrome. Alveolar pulmonary edema. Multiple organ dysfunction. Accompanying: VJO 2–3 tbsp. Chronic intrauterine infections without exacerbation.
The diagnosis is pathological. Main: Early postpartum hemorrhage after 3 term deliveries of a large fetus. DIC syndrome. Manual examination of the uterine cavity. Massage of the uterus on a fist. Application of clamps to the parametrium according to Baksheev, clamping of the abdominal aorta, transfusion of FFP. Labor enhancement with oxytocin. Anaphylactoid reaction. Complication: Shock of combined origin: 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. Associated: Interstitial fibroids of the uterus (subserous nodes in the fundus, submucous in the right corner of the uterus with a diameter of 3.5 cm, intramural on the side wall on the left and right with a diameter of up to 1 cm).