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gadaudebeli da masiuri transfuziebi

gadaudebeli da masiuri transfuziebi. Brian Poirier, MD UCDavis Medical Center 2010. miznebi. masiuri transfuziis gansazRvreba Sokis tipebis CamoTvla. sisxlis kargvisa da siTxis aRdgenis Sefaseba. eriTrocitebis, Trombocitebis da plazmis Cvenebebis ganxilva, masiuri transfuziebisas.

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gadaudebeli da masiuri transfuziebi

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  1. gadaudebelidamasiuritransfuziebi Brian Poirier, MD UCDavis Medical Center 2010

  2. miznebi • masiuri transfuziis gansazRvreba • Sokis tipebis CamoTvla. • sisxlis kargvisa da siTxis aRdgenis Sefaseba. • eriTrocitebis, Trombocitebis da plazmis Cvenebebis ganxilva, masiuri transfuziebisas. • sisxlis kargvis riskebis mixvedra.

  3. masiuri transfuziebi • 10 an meti pRBC erTeuli (TBV) < 24 saaTSi. • sxva: • 50% TBV-s Canacvleba 3 saaTSi. • sisxlis kargva >150 ml/min.

  4. masiuri transfuziebi • travmebi • qirurgia (e.g. RviZli, gulsisxlZarRvovani) • GI sisxldena • meanoba

  5. mTa Storm KingColorado

  6. Soki

  7. Sokistipebi • kardiogenuli – MI, kardiomiopaTia • obstruqciuli – tamponada, PE (pulm. embol.) • distribuciuli – sefsisi, anafilaqsia • hipovolemiuri – sisxldena

  8. I klasi • <750ml sisxlis kargva, 10-15% • pulsi <100, BP normaluri • pulsuri wneva normaluri an momatebuli • respiracia 14-20 • Sardis gamoyofa >30ml/hr • CNS: odnav aforiaqebuli • siTxis Canacvleba - kristaloidebi

  9. II klasi • 750-1500ml sisxlis kargva 15%-30% • pulsi >100, BP normaluri • pulsuri wneva daqveiTebuli • respiracia 20-30 • Sardis gamoyofa 20-30ml/hr • CNS saSualod aforiaqebuli • siTxis Canacvleba- kristaloidebi

  10. III klasi • 1500-2000ml • 30%-40% sisxlis kargva • pulsi >120, BP daqveiTebuli • pulsuri wneva daqveiTebuli • respiracia 30-40 • Sardis gamoyofa 5-15ml/hr • CNS aforiaqebuli da daTrgunuli • siTxis Canacvleba - kristaloidebi da sisxli

  11. IV klasi • >2000ml • 40% an meti sisxlis kargva • pulsi >140, BP daqveiTebuli • pulsuri wneva daqveiTebuli • respiracia >35 • Sardis gamoyofa umniSvnelo • CNS daTrgunuli da leTargiuli • siTxis Canacvleba- kristaloidebi da sisxli

  12. sisxliskargvisSefasebanakadurgadasxmazereaqciiT?

  13. laboratoriulimaCveneblebitravmismonitoringisaTvis • Hgb/Hct • INR/PTT • fibrinogeni • Trombocitebis raodenoba • sisxlis gazebi • eleqtrolitebi

  14. sisxlis produqti • eriTrocitebi • plazma • Trombocitebi • krioprecipitati

  15. sisxlis produqti

  16. sisxlismoTxovna • Tu aris pacientis sisxlis nimuSi • tipireba da skriningi • tipireba da SeTavseba • Tu ar aris pacientis sisxlis nimuSi • saswrafo miwodeba (universaluri donori/Pink Sheet) • masiuri transfuziis gaidlaini

  17. sisxlissaswrafomiwodeba- universaluridonori • O, RhD neg/pos ermasa – 5 wT. • AB an A plazma/Trombocitebi

  18. tipirebadaskriningi • pirveladi nimuSi mowmdeba ABO, Rh da antisxeulebze. • dro ~ 40 wT. • sisxlis moTxovnisas keTdeba “Crossmatching”-i. • dro ~ 10-15 wT.

  19. tipirebadacrossmatching-i • pirveladi nimuSi mowmdeba ABO, Rh da antisxeulebze da keTdeba crossmatching-i • dro ~ 60 wT. • sisxlis moTxovnisas yvelaferi gakeTebulia • dro ~ 5 wT.

  20. usafrTxotransfuziisalbaToba

  21. saswrafo RBC-ssxvaproblemebi • SeTavsebis arasruli testi • moulodneli antisxeulebis aRmoCena • Tavsebadi sisxlis ararseboba

  22. Washoutmrudi Y/Y0= e-x Y = nivTierebis saboloo koncentracia Y0 = nivTierebis sawyisi koncentracia X = Canacvlebuli moculobis sruli odenoba D erksen 1984

  23. hemostazisaTvissaWiroSededebisfaqtorebis-% • I 12-50% • II 10-25% • V 10-30% • VII >10% • VIII 30-40% • IX 15-40% • X 10-40% • XI 20-30%

  24. Reed 1985 • aCvena, rom Trombocitebis raodenoba sisxlis masiuri kargvis Semdeg ar ewinaaRmdegeboda standartuli aferezis gamorecxvis gantolebas ??? • fiziologiurad meti Trombociti gaCnda • SesaZlo elenTis rezervuari

  25. Trombocitebidasisxlismasiurikargva(Toy 1991) • pacientebi masiuri transfuziiT • mxolod RBC-sda kristaloidebis aRdgena • 20 erTeulis Semdeg 75% Trombocitebis raodenobisa < 50K • mikrovaskularuli sisxldena ar aRiniSneba

  26. UCD Trombocitebisgamoyeneba1992 • travmiani pacientebis 1.5% sWirdeba Trombocitebi. • blagvi travmebis 1.43% • Wrilobiani pacientebis 2.3%

  27. UCDMC CvenebebiTrombocitebisadahemostazisfaqtorebisaTvis • FFP Tu INR> 1.5 an PT >1.5 X Normal • Trombocitebi, Tu raodenoba <50K-100K • krioprecipitati, Tu fibrinogeni <100mg/dl (TiToeuli erTeuli Seicavs ~250 mg)

  28. “is bevrad met sicocles ixsnis, vidre Sen warmogidgenia” Gen. George S Patton

  29. sisxlis masiuri gamoSveba (kargva)“sikvdilis triada” • acidozi • hipoTermia • koagulopaTia

  30. sisxlisgamaTbobeli

  31. masiuritransfuziisprotokoli • sikvdilianoba masiuri transfuziebisas maRalia 57% (pacients esxmeba >50 RBC erTeuli) • koagulopaTia vlindeba adreve, da ara rogorc mxolod hemodiluciis faqtori (Gonzalez et al 2007) • bolo retrospeqtulma kvlevebma aCvena gadarCenis sixSiris mateba – • plazma : Trombocitebi : RBC-s 1:1:1 Sefardebisas

  32. masiuri transfuziis kvleva(Holcomb 2008)

  33. masiuri transfuziis kvleva (Holcomb 2008)

  34. masiuri transfuziis kvleva (Holcomb 2008)

  35. masiuri transfuziis kvleva (Holcomb 2008)

  36. masiuritransfuziisprotokoli • axali mimarTuleba – gadavusxaT RBCs, FFP da Trombocitebi, mTliani sisxlis gadasxmis simulaciisTvis • gamoqveynebuli tipiuri Sefardebebi RBC:FFP:Tromb. tipiuri produqtis gamoyenebiT • 6 erTeuli RBC (250ml/unit) • 6 erTeuli FFP (~250ml/unit) • 6 erTeuli Tromb. koncentrati (50ml/unit)

  37. UCDMC masiuritransfuziisgaidlaini(miRebuli 2008 wels) • mozrdilTaTvis CanacvlebiTi moculobebi ganisazRvra mwvave sisxldenaze (50%) dayrdnobiT da • RBC : FFP : Platelet-is mTliani sisxlis proporciebis dacviT, UCDMC – Si xelmisawvdomi produqtis gamoyenebiT • 6 units RBC Adult (250ml/unit) • 3 units FFP Jumbo (400ml/unit) • 1 unit Plateletpheresis (250ml/unit)

  38. Massive Transfusion ProtocolExample

  39. masiuritransfuziisgaidlaini(MTG) pediatriaSi • gamoiyenes bavSvebis “zrdis grafikebi” sxvadasxva asakobrivi jgufebSi sxeulis wonis dasadgenad, da mozrdilTa dozebi proporciulad Seamcires. • MTG uCvenebs ras miviRebT jamSi, da ara aucileblad zust dozebs pacientisaTvis. • TiToeul bavSvs sWirdeba dozis gamoTvla faseba, maTi zomidan da hemoragiis xarisxidan gamomdinare.

  40. MTG-s problemebi • SeiZleba amis gadatana samoqalaqo praqtikaSi? yvela pacientisaTvis aris saWiro, Tu, mxolod Zalian mZime dazianebebisas? • AB plazmis uyairaTo xarjva. • SeiZleba gaizardos filtvis mwvave SemTxvevebi - TACO & TRALI?

  41. masiuritransfuziispotenciuriukuefeqtebi • metaboluri darRvevebi • transfuziis reaqciebi • infeqciuri daavadebis riski

  42. masiuritransfuzia • citratuli toqsiuroba • hiperkaliemia • Jangbadis gadatanis daqveiTeba • hipoTermia

  43. transfuziismwvavereaqciebi • mwvave hemolizuri reaqciebi • sisxlis produqtebis baqteriuli dabinZureba • anafilaqsia • TRALI • mZime febriluri reaqciebi • TACO (Transfusion Associated Circulatory Overload) • masiuri transfuziis metaboluri problemebi • aerovani da mikro - emboliebi • hipotenzia

  44. FDA transfuziulisikvdilianobisangariSi

  45. Secdomiswyaro(NY monacemebi1999) • 58% sisxlis bankis gareT • 17% sisxlis bankSi da bankis gareT • 25% sisxlis bankSi

  46. Secdomiswyaro • 58% sisxlis bankis gareT • 43% Secdoma pacientis identifikaciisas • 11% Secdoma flebotomiisas • 3% araswori SekveTa

  47. Secdomiswyaro • 17% sisxlis bankSi da bankis gareT • 15% sisxli gacemuli iyo sxva pacientze/ar gadaamowmes gadasxmiswin (bedside) • 2% gaigzavna Seusabamo SekveTa/sisxlis bankSi ver SeamCnies

  48. Secdomiswyaro • 25% sisxlis bankSi • 1% gamoiyenes sxvisi sisxlis nimuSi • 11% gaica sxva jgufis sisxli • 7% araswori tipireba – teqnikuri mizeziT • 6% araswori tipireba – Secdoma Cawerisas

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