blood

Question 2

The most appropriate order of blood products transfused sequentially through the
same blood administration set is:

A) RBC - plasma - plts
B) RBC - plts - plasma
C) Plasma - RBC - plts
D) Plts- RBC -plasma

Answer 2

D) Plts- RBC -plasma

according to Lifeblood guidelines, platelets MUST be given before RBC if in the same line, as red cell debris will trap platelets; platelets and plasma can be sequential through the same set; as platelets take a long time to transfuse, it makes sense to first transfuse plasma (fast), then platelets, then red cells

Question 3

A medication that would be acceptable to a patient who refuses all products derived
from human plasma is:

a) Prothrombinex
b) Activated factor 7
c) Fibrinogen concentrate
d) Albumin
e) anti-d

Answer 3

Factor 7 - Recombinant, made from baby hamster kidney cells

Albumin - Alburex® 5 AU (Human Albumin 50 g/L) is an Australian manufactured albumin product

Fib con - Lyophilised precipitate. manufactired from cryoprecipitate.

PCC - Prothrombinex-VF® is a lyophilised concentrate of human coagulation factors containing factors II, IX and X and a small amount of factor VII.

Red cross lifeblood.

Correct answer is rVIIa

Question 4

NP Once a unit of fresh packed red blood cells has been removed from controlled refrigeration the transfusion should be completed within

a) 2.5 hours
b) 3 hours
c) 3.5 hours
d) 4 hours

Answer 4

REPEAT

4 hours

As per Lifeblood

Start the transfusion as soon as possible after removing the blood component from approved temperature-controlled storage. Transfusion of each pack should be completed prior to the labelled expiry or within four hours, whichever is sooner.

Redcross: “Transfusion of each pack should be completed prior to the labelled expiry or within four hours, whichever is sooner. “

Shelf life of platelets: 5 days (Stored at 20-24 degrees, must be agitated gently and continuously)

FFP: Once FFP is thawed, must use within 24 hours.

Albumin administration: At RCH we allow the product to be administered within 6 hours of piercing the bottle. (from RCH.org)

Cryoprecipitate
Thawed cryoprecipitate should be maintained at 20°C to 24°C until transfused.
Once thawed, should be used within six hours if it is a closed single unit, or within four hours if it is an open system or units have been pooled.

Question 5

The correct blood collection tube for a mast cell tryptase test is a:

a. Potassium EDTA
b. serum separating tube
c. sodium citrate
d. sodium oxalate something

Answer 5

REPEAT

b. serum separating tube (gold top tube or red)

Potassium EDTA (purple)
-> FBC

sodium citrate (blue)
-> clotting screen/Rotem

sodium oxalate (green)
-> heavy metals (lead copper zinc)

Question 6

20.2 If group A Rh-ve fresh frozen plasma is not available for use in an A Rh-ve patient, of the following your next best choice should be

a. A+
b. B-
c. AB+
d. O+
e. O-

Answer 6

a. A+

Group A Plasma component preference
1st choice: A
2nd Choice: AB
3rd Choice: B

[a] If the patient is a female of childbearing potential, O RhD negative red cells should be used until the patient’s blood group is established.
[b] Group A platelets with the A2 subgroup don’t express significant amounts of A antigen and are therefore preferable to other group A platelets when transfusing group O and B recipients.
[c] Apheresis platelets that have a low titre anti-A/B or pooled platelets pose a lower risk of haemolysis when transfusing ABO incompatible components.
[d] Plasma components that have low titre anti-A/B pose a lower risk of haemolysis when transfusing ABO incompatible components.
[e] Group A plasma may be used as per local institutional policies. 

If no A, use AB Rh + cryo (Ie; no anti A or anti B)

Cryo incompatible can be given, but large volumes are high risk for DIC

https://litfl.com/cryoprecipitate/

Question 7

21.2 You have been asked to provide general anaesthesia for a complex thoracic endovascular aortic aneurysm repair. After the placement of a lumbar drain the recommended safe time before the administration of intravenous heparin is

a) 1 hour
b) 4 hours
c) 6 hours
d) 12 hours

Answer 7

1 hour

ASRA: 1 hour

Although the occurrence of a bloody or difficult neuraxial needle placement may increase risk, there are no data to support mandatory cancellation of a case. Direct communication with the surgeon and a specific risk-benefit decision about proceeding in each case are warranted.

Currently, insufficient data and experience are available to determine if the risk of neuraxial haematoma is increased when combining neuraxial techniques with the full anticoagulation of cardiac surgery. We suggest postoperative monitoring of neurologic function and selection of neuraxial solutions that minimise sensory and motor block to facilitate detection of new/progressive neurodeficits.

NYSORA:
Administration of intravenous heparin intraoperatively should be delayed for at least 1 hour after epidural placement; a delay before administration of subcutaneous heparin is not required. In cases of full heparinization for CPB, additional precautions include delaying surgery for 24 hours in the event of a traumatic tap, tightly controlling the heparin effect and reversal, and removing catheters when normal coagulation is restored.

Question 8

22.2 The medication most strongly associated with an acute primary hypotensive reaction following transfusion of blood products is
a. aspirin
b. celecoxib
c. hydralazine
d. metoprolol
e. labetalol
f. perindopril

Answer 8

f. perindopril

Hypotensive transfusion reactions, which account for almost 3% of all transfusion reactions, are associated with patients treated with angiotensin-converting enzyme inhibitors. The current hypothesis suggests that they are caused by bradykinin-induced vasodilation in the absence of allergic, hemolytic, or septic mechanisms. The hypotension observed frequently is unresponsive to conventional therapy with catecholamines. The suggested intraoperative management includes cessation of transfusion and washing red blood cells before blood replacement.

Hypotensive reactions to transfusion may not always be recognized. To prevent these reactions, clinicians have several options: they may discontinue the ACE inhibitor (elective transfusion), not use a leukoreduction filter (if the patient has no absolute requirement for leukoreduced blood components), use washed cellular components, or use components that have undergone leukoreduction at the collection facility or the hospital blood bank before transfusion (since bradykinin is degraded during storage).

Question 9

22.1 A patient in atrial fibrillation with a CHA2DS2-VASc score of 2 has presented for elective hip surgery. Warfarin had been ceased for four days preoperatively and on the day before surgery the international normalized ratio (INR) was 2.1. The best course of action at this point is to

a) Postpone surgery
b) Vitamin K 3mg IV
c) Prothrombinex 25IU/kg
d) Cell saver intraop
e) Proceed with surgery

Answer 9

Give 3mg of Vitamin K and re-check on day of surgery proceed if INR <1.5 on DOS

Question 10

21.2 In a patient with anaemia of chronic disease, of the following the most likely to be elevated is

a. MCV
b. transferrin saturation
c. Increased soluble Transferrin Receptor
d. Ferritin
e. Total iron binding capacity

Answer 10

d. Ferritin

ANZCA blue book:

ACD caused primarily by inflammation

Mechanism:
1. Iron
- Inflammation reduces Iron availabilty as a protective mechanism whereby Iron is sequestered and stored in macrophages to limit availability to microbial pathogens
- Hepcidin expression is increased, this prevents the release of Iron by reticuloendothelial system resulting in “functional iron deficiency” with reduced tissue availability of iron, despite apparently normal total body iron stores. (hence increased Ferritin)

2. Response to erythropoietin
   - mechanism not clear suspect blunting of response to erythropoietin
3. Therapeutic agents
   chemotherapies that impair bone marrow response to erythropoiesis
   65% of patients with lung and gynae cancer treated with platinum based drug develop anaemia

RCPA advice on interpretation of Soluble Transferrin Receptor:

Soluble transferrin receptor levels in plasma are elevated if there is increased iron demand due to Iron deficiency, increased erythropoiesis (eg, Haemolysis) or dyserythropoiesis (eg, Megaloblastic anaemia), regardless of other, coexistent states.

Thus, it can be used to demonstrate iron deficiency in patients who also have an acute phase response and it can distinguish Iron deficiency from the Anaemia of chronic disease.

Patients with an acute phase response have reduced plasma iron and transferrin with elevation of Ferritin, making these usual indicators unreliable.

Question 11

A previously healthy 22-year-old man is involved in an altercation and sustains a ruptured spleen. During splenectomy he is transfused with packed red blood cells. One hour into the transfusion his SpO2 rapidly decreases, his ventilator pressures
increase, frothy sputum appears in the endotracheal tube and he is febrile. The likely cause is:

a) TRALI
b) TACO

Answer 11

AT

a) TRALI

Both TACO and TRALI are characterised by:
- hypoxia
- acute dyspnoea
- diffuse bilateral infiltrates

However, presence of fever is more in keeping with TRALI.

Reference:
Distinguishing between transfusion related acute lung injury and transfusion associated circulatory overload Robert C. Skeatea and Ted Eastlund

Question 12

Kate A bleeding patient has ROTEM results including: [table attached]. The most
appropriate treatment is:

a) Fibrinolysis

Answer 12

LINDON

Question 13

20.2 If group A Rh-ve fresh frozen plasma is not available for use in an A Rh-ve patient, of the following your next best choice should be

a. A+
b. B-
c. AB+
d. O+
e. O-

Answer 13

a. A+

Group A Plasma component preference
1st choice: A
2nd Choice: AB
3rd Choice: B

[a] If the patient is a female of childbearing potential, O RhD negative red cells should be used until the patient’s blood group is established.
[b] Group A platelets with the A2 subgroup don’t express significant amounts of A antigen and are therefore preferable to other group A platelets when transfusing group O and B recipients.
[c] Apheresis platelets that have a low titre anti-A/B or pooled platelets pose a lower risk of haemolysis when transfusing ABO incompatible components.
[d] Plasma components that have low titre anti-A/B pose a lower risk of haemolysis when transfusing ABO incompatible components.
[e] Group A plasma may be used as per local institutional policies. 

If no A, use AB Rh + cryo (Ie; no anti A or anti B)

Cryo incompatible can be given, but large volumes are high risk for DIC

https://litfl.com/cryoprecipitate/

Question 14

22.1 A normal sized six-year-old girl has a haemoglobin of 70 g/L following surgery. The volume of packed red blood cells that you would plan to infuse to raise her haemoglobin to 80 g/L is

a. 80ml
b. 100ml
c. 120ml
d. 180ml
e. 200ml

Answer 14

b. 100ml

Paediatric weight estimation:
Luscombe: Weight (kg) = (age x 3) + 7
RCH: Weight (kg) = (age + 4) x 2

Formula for calculating transfusion volume (mL)
Children <20 kg:
PRBC (mL) = wt (kg) x Hb (g/L) rise (desired Hb – actual Hb) x 0.5 (transfusion factor)

Children >20 kg: 1 unit PRBC

Example:
6 + 4 x 2 = 20kg

20kg x 10g/l x 0.5 = 100ml

Question 15

22.1 In comparison with fresh frozen plasma, cryoprecipitate contains an increased concentration of factor

a. II
b. VII
c. XI
d. XIII

Answer 15

d. XIII

But Fibrinogen (I) is the most significant factor that

Question 16

20.2 The composition of Plasma-Lyte 148 (in mmol/l) includes

a Na 140 Mg 1.0 K 5.0 acetate 27 lactate 0
b Na 140 Mg 1.5 K 5.0 acetate 0 lactate 27
c Na 140 Mg 1.0 K 4.0 acetate 24 lactate 0
d Na 140 Mg 1.0 K 4.0 acetate 0 lactate 24
e Na 140 Mg 1.5 K 5.0 acetate 27 lactate 0

Answer 16

e Na 140 Mg 1.5 K 5.0 acetate 27 lactate 0

Question 17

20.1 What is the level below which we need to replace fibrinogen in a pregnant patient with a PPH

A. <1 g/L
B. <1.5 g/L
C. <2 g/L
D. <2.5 g/L
E. <3 g/L

Answer 17

<2g/L

Question 18

21.2 Cryoprecipitate contains all of the following EXCEPT

a) Factor I
b) Factor VII
c) Factor VIII
d) VWF
e) Fibronectin

Answer 18

b) Factor VII

Redcross:
Cryoprecipitate contains most of the following found in fresh frozen plasma:
1. factor VIII
2. fibrinogen
3. factor XIII
4. von Willebrand factor
5. fibronectin

Prothrombinex-VF® is a lyophilised concentrate of human coagulation factors it contains:

Factors:
II
IX
X
small amount of factor VII.

Also contains:
plasma proteins (human)
Antithrombin III (human)
Heparin sodium (porcine)
Sodium
Phosphate
Citrate
Chloride

Question 19

23.1 Cryoprecipitate contains coagulation factors

A. 2, 8, 13, von willebrands
B. 1, 7, 13 , von willebrands.
C. 1, 8, 13, von willebrands.
D. 2, 7, 13, von willebrands.

Answer 19

C.

Cryoprecipitate contains Factor VIII, XIII, fibrinogen (factor I), fibronectin, vWF

https://www.lifeblood.com.au/health-professionals/products/blood-components/cryoprecipitate

Question 20

22.1 When fresh frozen plasma is administered to treat hypofibrinogenaemia in a bleeding patient, the volume required to achieve an increase in plasma fibrinogen concentration of one gram per litre is

A. 5 ml/kg
B. 10 ml/kg
C. 20 ml/kg
D. 30 ml/kg
E. 50 ml/kg

Answer 20

D. 30 ml/kg

Identification and Management of Obstetric Hemorrhage
Anesthesiology Clinics - Obstetric Anesthesia (2017)
https://www.anesthesiology.theclinics.com/article/S1932-2275(16)30074-X/fulltext

Although FFP, cryoprecipitate, and fibrinogen concentrates can all be used to increase fibrinogen levels, the optimal strategy for managing hypofibrinogenemia in obstetric hemorrhage is unclear. The relatively low concentration of fibrinogen in FFP limits its usefulness in the treatment of significant hypofibrinogenemia. To increase fibrinogen plasma level by 1 g/L, 30 mL/kg of FFP is necessary, increasing the risk of pulmonary edema and other hypervolemic complications. Cryoprecipitate, which is a concentrated source of fibrinogen, factor VIII, fibronectin, von Willebrand factor (vWF), and factor XIII, will increase fibrinogen levels by ~0.7 to 1 g/L for every 100 mL given. Although cryoprecipitate is associated with a lower transfusion volume, the standard “dose” (10 U) is typically prepared by pooling concentrates from multiple donors. Given the risk of infectious disease transmission and/or an immunologic reaction from exposure to multiple donors, several countries preferentially use purified, pasteurized fibrinogen concentrate for the treatment of congenital and/ or acquired hypofibrinogenemia. Fibrinogen concentrates are also prepared from large donor pools, but subsequent processing removes or inactivates potentially contaminating viruses, antibodies, and antigens. Studies comparing cryoprecipitate and fibrinogen concentrates utilization in hemorrhage resuscitation suggest fibrinogen concentrates are associated with lower blood loss, decreased RBC transfusion, and greater increases in plasma fibrinogen levels. Although the most appropriate method of fibrinogen replacement is somewhat controversial, the critical role of fibrinogen in reversing the coagulopathy accompanying obstetric hemorrhage is clear. As such, close monitoring and replacement of fibrinogen are crucial in the management of the bleeding parturient.

Question 21

22.2 Normal (0.9%) saline has the physical properties of
a. Na 140, 280 mOsm/L
b. Na 148, 296 mOsm/L
c. Na 150, 300 mOsm/L
d. Na 154, 308 mOsm/L

Answer 21

D Na 154, 308 mOsm/L

Question 22

21.1 The composition of blood returned to the patient from intraoperative cell salvage shows

A. No evidence of haemolysis
B. Normal 2,3 DPG
C. Nil evidence of bone cement or some embolism type
D. Normal levels of coagulation factors

Answer 22

B. Normal 2,3 DPG

higher Hct-60%
No immunimodulation
require reinfusion within 6hrs
pause with sement, caution metal fragments

Question 23

20.2 Of the following, the agent that causes the LEAST prolongation of the Thrombin Clotting Time (or Thrombin Time) is

a) Heparin
b) LMWH
c) Bivalirudin
d) Warfarin
e) Dabigatran

Answer 23

d) Warfarin

Warfarin – no effect on thrombin time
Heparin - causes considerable prolongation of TT.

LMWH, fondaparinux or direct factor Xa inhibitors have no effect on TT as the predominantly inhibit factor Xa.
-> However LMWH in very high concentration can affect TT.

Dabigatran, Bivalirudin and other direct thrombin inhibitors prolong TT considerably.

The thrombin time (TT), also known as the thrombin clotting time (TCT) is a blood test that measures the time it takes for a clot to form in the plasma of a blood sample containing anticoagulant, after an excess of thrombin has been added. Warfarin prevents thrombin synthesis but does not inhibit it, therefore no effect on TT.

Question 24

21.2 A bleeding patient has ROTEM results including (results displayed) . The most appropriate treatment is

a) Cryoprecipitate
b) FFP
c) Platelets
d) TXA
e) Protamine

Answer 24

e) Protamine

The interpretation of this graph is not especially laborious. The cardinal abnormality is the massively prolonged CT and CF of the INTEM graph, which suggests that something has killed the intrinsic pathway of the clotting cascade. The CT returns to normal in the HEPTEM graph, which is essentially just an INTEM test with adde heparinase. The presence of heparinase seems to have reversed all of the coagulopathy - the CFT, alpha-angle and MCF have all returned to normal. Therefore, this patient has no coagulation problems other than the heparin.

https://derangedphysiology.com/main/required-reading/haematology-and-oncology/Chapter 1.2.0.1/intepretation-abnormal-rotem-data

Question 25

22.1 The EXTEM plot from a ROTEM sample is shown. The most appropriate treatment for this bleeding patient is

(EXTEM graph with low amplitude and hyperfibrinolysis)

a. Platelets
b. TXA
c. Fibrinogen
d. Coagulation factors

Answer 25

b. TXA

Question 26

23.1 Tranexamic acid is NOT useful for managing

A. Post cardiac bypass
B. Neurotrauma
C. PPH
D. Trauma
E. Upper GI bleed

Answer 26

E. Upper GI bleed

Incompressible sites, large volume blood loss and mortality risk are a few of the things that made GI bleeds seem like a natural fit for TXA administration. Early research seemed promising, but trials were small. The HALT-IT trial examined over 15,000 patients to see if TXA reduced death [14]. Not only did TXA have no effect on mortality, it increased the risk of seizure and thromboembolic events.

Take home: No demonstrated benefit with TXA in GI bleeding

https://www.ems1.com/research-reviews/articles/understanding-txa-AFkqRLajUv46X7xV/

Question 27

22.2 The composition of blood returned to the patient from intraoperative cell salvage shows

a) Normal plasma proteins
b) Normal platelets
c) Normal 23 DPG
d) Absence of fat emboli
e) Absence of haemolysed RBC

Answer 27

c) Normal 23 DPG

https://www.bjaed.org/article/S2058-5349(20)30157-8/fulltext

Advantages of Cell salvage:
1. reduction in need for donor blood transfusion

2. no restrictive transfusion triggers
3. superior oxygen delivery compared to donor blood
   -> red cells retain elliptical profiles and retain deformability
   -> increased concentrations of 2,3 DPG and ATP
   -> evidence supports early transfusion as oxygen carriage and deformability degrade over time
4. lack of adverse immunolgical effects
   -> no sensitisation to antigens; Kell, duffy or Lutheran
   -> donor blood transfusion causes dose-dependant transfusion related immunosupression (TRIM) this can lead to increased risk of post-op infection and posible increased risk of tumour growth in patients undergoing cancer surgery
5. Fulfills criteria for certain cultural groups to receive blood transfusion (JW)
6. Financial benefits despite equipment and staffing costs

Disadvantages:
1. The salvaged blood contains clinically insignificant concentrations of clotting factors and platelets, and when large volumes of blood are processed, the use of clotting factors, platelets, and calcium may be necessary.

2. High initial cost of equipment and training
3. Processing of blood requires a few minutes, blood may not be immediately available in time critical scenariois
4. REinfusion hypotension can occur and can be very marked requiring vasopressors
5. More labor intensive than donor blood, increased diligence required when collecting blood
6. May not be appropriate for all situations of operative blood loss
   ->Malignancy: use is controversial but supported in some instances (cystectomy radical prostatectomy, nephrectomy)
   ->Sepsis: not absolute contraindication but colume of contaminated material and pus must be limited
   ->Haemaglobonpathy: relative contraindication in sickle cell trait/disease and thalassaemia due to red cell fragility and potential for haemolysis

Question 28

23.1 A feature of citrate toxicity following massive blood transfusion is

a. Hypotension
b. Metabolic acidosis
c. Hypokalaemia

Answer 28

Hypotension

Citrate is the anticoagulant used in blood products. It is usually rapidly metabolised by the liver. Rapid administration of large quantities of stored blood may cause hypocalcaemia and hypomagnesaemia when citrate binds calcium and magnesium. This can result in myocardial depression or coagulopathy. Patients most at risk are those with liver dysfunction or neonates with immature liver function having rapid large volume transfusion

https://litfl.com/citrate-toxicity/

Hypocalcaemia resulting in
long QT,
reduced inotropy,
hypotension
systemic hypocoag

Metabolic
Met alk with HCO3 formation
HAGMA with citrate accumulation
Hypernatraemia from Na citrate
Hypomag due to citrate chelation
Hypokalaemia due to low mag and met alk

Question 29

23.1 You are using intraoperative cell salvage during a high-risk caesarean section. The salvaged blood has been washed and reinfused through a leukodepletion filter. This process should remove all of the following EXCEPT

A. Vernix
B. Alpha fetoprotein
C. Foetal RBC
D. Amniotic fluid
E. Foetal squamous cell

Answer 29

c) Foetal RBC

All others removed with leukodepletion filter

Question 30

20.1 A patient with von Willebrand deficiency Type 1 presents with mild but persistent epistaxis.

First-line medical therapy should include:

a) Factor VII
b) Factor VIII
c) Recombinant von Willebrand factor
d) TXA
e) FFP

Answer 30

d) TXA

VWD Types:
1 - quantitative - minor effect on bleeding - DDAVP useful
2 - qualitative - spectrum of effects on bleeding - (2a,2b,2m,2n) - DDAVP may be useful in consult with haem
3 - absence - major bleeding - no effect of DDAVP

factors not recommended in Type 1
TXA and DDAVP are recommended but DDAVP not in list
TXA 10mg/kg IV q8h
DDAVP 300mcg intranasal 90-120 mins preop
(DDAVP increases factor VIII levels 2-5x via release of VWF which binds VIII and prevents its clearance)

Treatment of bleeding in an individual with von Willebrand disease (VWD) depends on:
1. Severity of bleeding
2, Site of bleeding
3. the type of VWD
4. the previous responses to therapy.

The two main approaches:
1. Increasing the level of normal von Willebrand factor (VWF) activity via DDAVP
2. Replacing the defective VWF with VWF concentrates

VWF concentrates have been demonstrated to provide excellent to good hemostasis in a number of patient populations and a number of bleeding types.

DDAVP is only effective in some individuals, produces a smaller increase in VWF activity, and has a later onset and shorter duration of action.

Question 31

23.1 Three-factor prothrombin complex concentrate reverses warfarin therapy within

A. 5 mins
B. 15 mins
C. 60 mins
D. 120 mins

Answer 31

a) 15 mins

50UI/kg,
Prothrombinex-VF is able to completely reverse a supratherapeutic INR within 15 minutes however, vitamin K is also required to sustain the reversal effect as the half-lives of the infused clotting factors are similar to endogenous factors.

https://www.mja.com.au/journal/2013/198/4/update-consensus-guidelines-warfarin-reversal#:~:text=Prothrombinex%2DVF%20is%20able%20to,similar%20to%20endogenous%20clotting%20factors.

Question 32

20.2 Prothrombinex VF is a factor concentrate. It is indicated for the management of bleeding caused by

a Von Willebrand disease
b Haemophilia a
c Haemophilia b
d Haemophilia c
e Congenital fibrin deficiency

Answer 32

c Haemophilia b

Question 33

20.1 The threshold plasma fibrinogen level at which you should start replacement during postpartum haemorrhage is

a. 1.0
b. 1.5
c. 2.0
d. 2.5
e. 3.0

Answer 33

C

https://ranzcog.edu.au/wp-content/uploads/2022/05/Prevention-and-Management-of-Postpartum-Haemorrhage.pdf

Question 34

23.1 A 25-year-old woman has critical bleeding following major trauma. Her blood group is unknown. Fresh frozen plasma that she receives should ideally be from

A. Any
B. A
C. B
D. AB
E. O

Answer 34

D - AB
Group AB plasma or group A plasma that is high-titre negative can be given in an emergency when the blood group is unknown. Group AB plasma is universal but in short supply.

Question 35

21.2 The use of erythropoietin before major surgery results in
a) Less transfusion, same thrombosis
b) Less transfusion, more thrombosis
c) No change in transfusion or thrombosis
d) No change in transfusion, more thrombosis

Answer 35

a) Less transfusion, same thrombosis

●A 2019 meta-analysis of randomized trials comparing preoperative administration of EPO versus placebo (32 trials; 4750 patients, mostly orthopedic and cardiac surgery) found reduced blood transfusions in the EPO groups. Decreased blood transfusions were seen in the entire population (RR 0.59, 95% CI 0.47-0.73; 28 trials), as well as the subgroups undergoing cardiac surgery (RR 0.55, 95% CI 0.47-0.73; nine trials) and major orthopedic surgery (RR 0.36, 95% CI 0.28-0.46; five trials). In addition, the EPO group had increased hemoglobin levels. There was no increase in the incidence of thromboembolic events with EPO.

Question 36

22.1 When using ROTEM thromboelastometry, the APTEM test is used to assess

a. Fibrinolysis
b. Platelet function
c. Coagulation factors

Answer 36

Fibrinolysis

In APTEM, coagulation is also activated as in EXTEM. By the addition of aprotinin or tranexamic acid in the reagent, fibrinolytic processes are inhibited in vitro.

The comparison of EXTEM and APTEM allows for a rapid detection of fibrinolysis. Furthermore, APTEM enables the estimation if an antifibrinolytic therapy alone normalises the coagulation or if additional measures have to be taken (e.g. administration of fibrinogen).

Question 37

23.1 The medication most strongly associated with an acute primary hypotensive reaction following transfusion of blood products is

A. Aspirin
B. Metoprolol
C. Hydralazine
D. perindopril

Answer 37

D. perindopril

Acute hypotensive transfusion reaction (AHTR) is characterized by the abrupt onset of hypotension immediately after the start of transfusion and usually resolves when transfusion ceases. Recent studies have shown an association with pre-operative treatment with an angiotensin-converting enzyme (ACE) inhibitor

https://www.lifeblood.com.au/health-professionals/clinical-practice/adverse-events/hypotension

Question 38

22.1 Extended life plasma is thawed fresh frozen plasma which can be stored at 2 to 6 C for a
maximum period of

a. 2 days
b. 3 days
c. 5 days
d. 7 days

Answer 38

5 days

Previous MCQ2015A – cryoprecipitate once thawed must use within 4 hours.

Previous MCQ2015B – FFP must be transfused within 4 hours once thawed, or stored at 2-6 degrees for 5 days.

Question 39

22.2 A patient is bleeding and her ROTEM displays a Fibtem A5 of 2 mm (normal > 4 mm). The most appropriate treatment is

a. FFP
b. fib conc
c. cryoprecipitate
d. TXA

Answer 39

b) fibrinogen concentrate

bleeding and low fib = concentrate
not bleding and low = cryo

Question 40

22.2 The amount of fresh frozen plasma that needs to be administered (in mL/kg) to increase plasma fibrinogen levels by 1 g/L is

a) 10ml/kg
b) 20ml/kg
c) 30ml/kg
d) 40ml/kg
e) 50ml/kg

Answer 40

c) 30ml/kg

After a dose of 10 to 15 mL/kg of FFP, plasma clotting factors rise about 15%, and the fibrinogen level rises by 40 mg/dL (0.4g/l)

https://www.sciencedirect.com/topics/medicine-and-dentistry/fresh-frozen-plasma

1g/0.4g= 2.5
2.5 x 10ml/kg= 25ml/kg
2.5 x 15ml/kg= 37.5ml/kg
30ml/kg best answer

For cryoprecipitate:

One unit of Cryo is 15-20 mL in volume and contains 150-250 mg of fibrinogen. Cryo is generally transfused in pools of 10 units, which should increase an adult recipient’s fibrinogen level by 50-100 mg/dL. (0.5-1g/l)

10 units of cryo= 200-300ml
200ml/70kg= 2.8ml/kg
300ml/70kg= 4.2ml/kg

Question 41

21.2 Intraoperative cell salvage is contraindicated in

a) LSCS
b) Revision of infected THR
c) Heparin allergy
d) Severe coagulopathy
e) Phaeochromocytoma

Answer 41

phaeochromatoma

Question 42

A bleeding patient has ROTEM results including (ROTEM results shown). The most
appropriate treatment is

a) Plts
b) FFP
c) Cryo
d) TXA

Answer 42

c) Cryo

Cryo or TXA,

TXA first line treatment however patient has low fibrinogen and requires fibrinogen replacement.

Question 43

Assuming a blood volume of 70 ml/kg, a massive transfusion in a 20 kg, 5-year-old child is
defined as a three-hour packed red blood cell (PRBC) transfusion volume of

a) 250ml
b) 500ml
c) 700ml
d) 1000ml

Answer 43

700ml
50% of blood volume in 3 hours

S Blaine. BLAE Paediatric massive transfusion