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NOTES: Heme/Onc > 253/254 - Blood Transfusions: Indications and Compatibility > Flashcards

253/254 - Blood Transfusions: Indications and Compatibility Flashcards

1
Q

If a patient is acutely bleeding, what is “priority #1” to replace?

A

IV blood volume; use fluids

Goal is to avoid hypovolemia, hypoperfusion

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2
Q

Which of these infections is most frequently transmitted by blood transfusions?

  1. HCV
  2. HBV
  3. HIV
  4. Bacterial sepsis (platelets)
  5. West Nile virus
A

d. Bacterial sepsis (platelets)

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3
Q

A 72-year-old patient with metastatic breast cancer on chemotherapy is emergently transferred to your hospital with vertebral collapse and thoracic spinal cord compression. The neurosurgery service recommends immediate surgery. Her Hgb is 8.4 gm/dL, platelet count 55K/uL, PT 15.6 sec (normal 10-13) (INR 1.4), PTT 38.2 sec (normal 25-35), fibrinogen 160 mg/dL (normal 200-400).

Which blood component would be your highest priority for transfusion before surgery?

  1. None needed
  2. RBCs
  3. Platelets
  4. Plasma
  5. Cryoprecipitate
A

c. Platelets

  • Threshold to give platelets:
    • < 10K/uL for all
    • <50K/uL for bleeding/invasive procedure
    • <75-100K/uL for CNS bleeding/prodecure
  • Threshold to give RBCs: Hgb < 7 g/dL (<8 g/dL in cardiac issue)
  • Threshold to give plasma: INR > 1.7 (or PTT >1.5x normal)
  • Threshold to give cryoprecipitate: Fibrinogen <100 (<200 obstetric)
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4
Q

What is the highest infectious-disease risk from transfusions?

(Result and type of transfusion)

A

Bacterial sepsis from platelets

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5
Q

What is the normal immediate response to platelet transfusion?

What constitutes a refractory response?

A

Normal = platelets rise by 25-30k

Refractory = platelets rise by 10-15K/uL increment at 18-24 hr

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6
Q

1 dose of cryoprecipitate increases a patient’s fibrinogen level by how much…

on average?

Ideally?

A

Average: 40 mg/dL increase in fibrinogen

(if not consumed)

Ideally: 65 mg/dL

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7
Q

For which blood products (2) do we have pathogen inactivation methods?

A

Plasma and platelets

  • can give chemical treatment to disrupt pathogens or photochemical treatment to block nucleic acid replication
  • Still in development for RBCs*
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8
Q

What is the goal of giving cryoprecipitate to a patient?

A

Increase fibrinogen levels

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9
Q

List 4 key initial manifestations of transfusion reaction

A
  1. Fever
  2. Rash
  3. Hypotension
  4. Respiratory problems
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10
Q

What is the goal fibrinogen when you are giving cryoprecipitate?

A

>100 mg/dL in pts with bleeding or surgery

>200 mg/dL in obstetric pts

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11
Q

Which element of RBC compatibility testing is most critical?

A

ABO

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12
Q

What causes graft vs. host disease?

What is the treatment?

A
  • Donor lymphocytes attack host tissues
  • lack of normal rejection of transfused lymphocytes
  • occurs 3-30 days post transfusion most commonl in pts who are severely immunosupressed, or when there is very close HLA-matching
  • Host WBCs see donor WBCs as self and does not attack them, but the donor WBCs see host antigens and attack them
  • Treat with corticosteroids
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13
Q

1 unit of RBCs will increase a patient’s hemoglobin by how much?

A

1 g/dL

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14
Q

A 27-year-old motorcyclist suffers multiple injuries in a collision and is in trauma surgery. He has diffuse bleeding in the surgical fields and his plasma fibrinogen is 70 mg/dL despite numerous units of plasma. With an ideal response, how many doses of cryoprecipitate are needed to achieve the recommended fibrinogen level?

  1. None—no cryo needed
  2. One
  3. Two
  4. Five
A

b. One
* 1 dose = 40 mg/dL increase, target is >100 mg/dL*

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15
Q

The blood bank places a transfusion tag on each unit containing patient’s ID and unit number. Which one of the following pre-transfusion blood checks provides the most complete patient safety?

  1. Check the transfusion tag patient ID with the patient wristband ID
  2. Verify the transfusion tag unit # with the blood bag unit #.
  3. Compare the transfusion tag patient ID and unit # with the blood unit # and the patient wristband ID.
  4. Read the patient her name from the transfusion tag and her wristband
A

c. Compare the transfusion tag patient ID and unit # with the blood unit # and the patient wristband ID

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16
Q

What is the effect of plasma transfusion on INR?

A

Will normalize INR a bit if its really high

If INR is only moderately elevated, INR won’t change much

17
Q

Which patients are at highest risk of an anaphylactic transfusion reaction?

A

Patients with selective IgA deficiency

caused by host antibodies to an allergen in the donor plasma

18
Q

Describe the pathogenesis of acute hemolytic transfusion reaction

A

Host antibodies to donor ABO antigens (ABO incompatibility)

Can also be caused by host antibodies to non-ABO antigens in donor blood (missed in screening)

  • RBC-antibody immune complexes activate inflammation*
  • RBCs lyse -> lysed RBC membranes damage kidneys and activate clotting*
  • Symptoms: dark urine (hemoglobinuria), renal insufficiency (acute tubular necrosis), elevated PT & PTT*
19
Q

1 unit of plasma increased a patient’s plasma clotting factor levels by…

A

<6 percentage points

20
Q

Describe the pathogenesis of anaphylactic transfusion reaction

A

Pre-formed host antibodies to donor plasma proteins

Vs. acute hemolytic, where host antibodies are to donor RBC antigens

Most common in patients with selective IgA deficiency

Tx: antihistamines, epinephrine, corticosteroids

21
Q

Which preventive or therapeutic measure is incorrect for the adverse event shown?

  1. Acetaminophen for febrile reaction
  2. Leukoreduction for graft-vs-host disease
  3. Male plasma for transfusion-related acute lung injury
  4. Blood bank records for delayed hemolytic reaction
A

c. Male plasma for transfusion-related acute lung injury
* Give respiratory support; there is no TRALI-specific therapy*

22
Q

What is the hemoglobin threshold for transfusion?

A

7 g/dL

(8 g/dL in acute cardiac disease or thrombocytopenia pts)

23
Q

What is the treatment for transfusion-related lung injury?

A

Respiratory support

There is no specific treatment

Transfusion Related Acute Lung Injury (TRALI)

  • <6 hrs after transfusion
  • Caused by antibodies in donor plasma that attack host WBCs
  • antibody activated neutrophils damage pulmonary capillaries
24
Q

Which patients are at highest risk of having RBC antibodies?

A

Anyone who has been in contact with someone else’s blood

  • People who have been pregnant
  • People who have recieved blood transfusions

But 1-2% of patients who have not been pregnant or recieved a transfusion will have RBC alloantibodies

25
Q

What is the treatment for acute hemolytic transfusion reaction? (4)

A
  • Diuresis
  • Plasma and platelets as needed for bleeding
  • Blood pressure support
  • Compatible RBCs if necessary

Caused by host antibodies to donor RBCs

26
Q

What are the thresholds for giving plasma in a patient who is bleeding or about to undergo a procedure?

  • PT:
  • PTT:
A
  • Give platelets if:
  • PT: INR > 1.7
  • PTT: >1.5x normal PTT
27
Q

What is the universal plasma group?

A

AB

  • Does not have anti-A or anti-B antibodies
  • Opposite of universal RBC group*
28
Q

Describe the pathogenesis of transfusion-related acute lung injury

A

Donor plasma contains antibodies against host WBCs

Results in antibody-activated neutrophils that damage pulmonary capillaries

Tx = respiratory support

29
Q

A 67-yr-old man is receiving his initial therapy for chronic myelogenous leukemia. His Hgb is 6.3 gm/dL. He complains of chest pain and has ST segment elevation on his ECG. You consider whether to transfuse RBCs. Which option do you elect?

  1. No transfusion is needed.
  2. Give 1 unit to reach Hgb >7 gm/dL and recheck patient
  3. Give 1 unit to reach Hgb >8 gm/dL and recheck patient
  4. Give 2 units to reach Hgb >8 gm/dL and recheck patient
A

b. Give 1 unit to reach Hgb >7 gm/dL and recheck patient

“Transfusing RBCs 1 unit at a time with evaluation before next unit is recommended in non-acute patients.”

  • Usually Hbg increases 1 g/dL per unit of RBCs*
  • Target is >8 g/dL in acute cardiac disease, >7 g/dL otherwise*
30
Q

What level of blood loss constitutes need for transfusion?

A

Blood loss >30% of blood volume

“normal” blood volume = 5L of blood (in a 70 kg man)

So loss of 1.5L or more

31
Q

What is the preventative or therapeutic measure used to treat a febrile reaction?

A

Acetaminophen

32
Q

What is the preventative or therapeutic meausre used to treat graft vs. host disease?

A

Leukoreduction for graft-vs-host disease

33
Q

What is the preventative or therapeutic measure used to treat delayed hemolytic reaction?

A

Check the blood bank records

NOTES: Heme/Onc (36 decks)

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