1例Rh（D）阴性患者输血引发迟发性输血反应原因探讨

摘要

目的：探讨Rh(D)阴性患者误输Rh(D)阳性血液的原因，保障安全、有效输血。方法1例76岁Rh(D)阴性女性胆囊炎患者，术前血型鉴定失误，术中误输Rh(D)阳性悬浮红细胞4 U，引发迟发性输血反应。运用微柱凝胶卡式法，对患者血液标本进行血型鉴定、抗筛检查及交叉配血试验。结果患者血型为B型，Rh(D)阴性，术前抗体筛查及交叉配血结果均为阴性，出错原因为首次鉴定方法不敏感导致假阳性、错报及人员复核马虎。结论通过案例剖析，寻找原因，提高认识，使临床输血真正达到安全、有效。%Objective To investigate the cause of late-onset blood transfusion reaction caused by false transfusion of Rh ( D ) positive blood in 1 case of Rh ( D ) -negative patient to protect the safe and effective blood transfusion. Methods 1 case of 76-year-old Rh ( D ) -positive female with cholecystitis was misdiagnosed before operation. 4 U of Rh-D-positive suspension red blood cells was mistakenly transfused during the operation, causing the late-onset blood transfusion reaction. Blood sample identification, anti-screening test and cross-matching blood test were carried out by using microcolumn gel-card method. Results The blood type of the patients was B, Rh ( D ) negative. The result of antibody screening and cross matching was negative. The cause of the error was that the first identification method was insensitive, misstatement and malpractice of the medical staff. Conclusion Through case analysis, we should raise our awareness so that clinical transfusion can truly be safe and effective.