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本文报告一例成年、男性、B 型、脾切除患者,在术中和术后的三天内,共误输 A 型血三次,总血量达800毫升。虽未引起严重后果,但教训是深刻的。从本例吸取的教训是:在检定血型和配血试验时,应加强全心全意“为人民服务”的观点;在交叉配血中,若怀疑某例为冷凝集而需要排除时,为防止将特异性凝集误认为冷凝集,除严格控制加温的温度外,还应对疑有冷凝集素的血清加入自身的红细胞作对照,否则有可能会重犯本例所发生的严重错误;对同一位献血员和受血者,若要进行重复输血时,在每次输血前也应再做交叉配血,以防万一;在输血后,尤其是在短期内多次输血,若发现输血疗效不佳,而当时对此又无满意的解释时应警惕是否已误输异型血的可能性。此外,对本例未发生严重后果的机理,作了初步分析。
This article reports a case of adult, male, B-type, splenectomy patients, during and three days after surgery, a total of three cases of blood type A error, the total blood volume of 800 ml. Although it has not caused serious consequences, the lesson is profound. The lesson learned from this example is that there should be a stronger focus on serving the people wholeheartedly when testing for blood type and blood tests; in the case of cross-matching, if it is suspected that an example is cryocondensation and needs to be excluded, Agglutination mistaken for condensation, in addition to strictly control the temperature of the warm, but also should be suspected cold agglutinin serum added to its own red blood cells as a control, otherwise it may repeat the serious errors occurred in this case; the same blood donor And blood recipients, for repeated transfusions, blood transfusion should be done before each transfusion, just in case; after transfusion, especially in the short term multiple transfusions, transfusion if found to be ineffective, At the time, however, there was no satisfactory explanation for whether there was a possibility of misdiagnosis of heterosexual blood. In addition, a preliminary analysis of the mechanism of no serious consequences in this case was made.