手术室疑似温差致一过性输液反应21例分析

Analysis of 21 eases of transient transfusion reaction during operation caused by temperature difference

目的探讨引起手术室一过性输液反应的原因并制定对应措施，防范类似事件发生。方法对手术室21例一过性输液反应患者临床资料进行回顾性分析，包括输入的液体、临床表现、处理过程及结果等。结果21例一过性输液反应患者中，13例患者输注平衡液，5例输注生理盐水，3例输注等渗糖。21例输液反应发生在输液后2～15min内，主要临床表现为：面部潮红，胸闷，皮疹等，予吸氧、静脉注射地塞米松、更换输液及管道能完全缓解，有5例患者未做处理，症状在2-15min内亦缓解。予保暖升温措施后460例手术患者无一例发生一过性输液反应。结论加强手术室环境控制及病人保暖措施，改进手术液体存放环境，改进输液流程，减少一过性输液反应发生。

Objective To investigate the causes of transient transfusion reaction during operation and develop measures to avoid the occurrence of it. Method Retrospectively analyzed clinical materials of 21 cases of transient transfusion reaction in operating room, including types of injection, clinical manifestations, treatment process and effect. Results Lactated Ringer＇s solution was used in 13 cases, normal saline was used in 5 cases, and isotonic glucose solution was used in 3 cases. Transient transfusion reaction occurred in 2-15 minutes after transfusion in 21 cases, with major clinical symptoms of flushing, chest distress, and rash, these symptoms completely remitted after oxygen inhalation, intravenous injection of dexamethasone, and replacement of injection and tube. Above clinical symptoms also remitted in 2-15 minutes in 5 cases without treatment. After raising the room temperature, transient transfusion reaction failed to be observed in 460 patients. Conclusion We should improve the environment and temperature control in operating room, the storage of operative liquid and transfusion procedure to decrease the occurrence of transient transfusion reaction.