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Fundamentals 3- Heme > Blood Component Therapy > Flashcards

Blood Component Therapy Flashcards

1
Q

What are the two types of blood donation?

A
  1. Whole blood donation where a single unit of WB is collected in a plastic bag and then separated into components
  2. Apheresis- where the donor is connected to an instrument that can selectively collect RBC, platelets or plasma.
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2
Q

What are the four components of blood?

How are they separated and prepared?

A
  1. PRBC (packed RBC)
  2. platelets
  3. cryoprecipitate
  4. plasma

Each is prepared by centrifuging at various speeds and temperatures

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3
Q

What is the only real situation that would warrant the transfusion of whole blood?

A

Military operations where the storage facilities are shitty.
If a soldier has rapid, massive blood loss on the battle field, whole blood is given because it improves O2 carrying capacity and volume expansion

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4
Q

If you need to increase Hb levels, what type of blood transfusion should be given?

How do you know what Hb levels are adequate for O2 carrying capacity (compensatory mechanisms should be used and not transfusion?)

Hb of what level or above should never be transfused bc risks of transfusion outweigh benefits of increased O2 capacity?

A

PRBCs
Healthy individual- O2 capacity may be adequate at 7g/L
Decreased cardiopulmonary function- Hb concentration should be slightly higher.

NEVER transfuse a patient if Hb is above 10g/L

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5
Q

One unit of RBCs increases an average adult’s Hb by___________?

A

1g/L or Hct of 3%

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6
Q

A patient is volume depleted. What should you transfuse?

A

Saline, ringer lactate, occasionally 5% albumin

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7
Q

What tests are run in pre-transfusion testing when you plan to give a patient PRBCs?

A
  1. ABO blood group
  2. RhD type
  3. antibody screen for unexpected RBC antibodies (if the Ab test is positive, red cell elution to determine the antigenic specificity)
  4. Crossmatch- where donor RBC is mixed with patient plasma are mixed. If agglutination or hemolysis occurs, the donor and recipient are NOT compatible
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8
Q

How does computerized crossmatching occur? What is the benefit of computer crossmatching?

A

If the antibody screen is negative, computer crossmatching is done because it is much faster turn around time.
It compares ABO/RhD type of the patient with the unit getting ready for transfusion.

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9
Q

As a rule, blood for transfusion should be the same _______ type as the recipient. In urgent situations, type _____/______ PRBCs can be given.

A

The donor should be the same ABO as the recipient.

In urgent situations, O/Rh- PRBCS can be given because anti-A, anti-B and Rh antibodies will not react with the RBCs

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10
Q

When would you use a type and screen? When would you use a type and cross?

Why don’t we just always test and cross?

A

type and screen when you don’t know if you need to transfuse or not (patient going into minor surgery like a tonsillectomy, don’t know if they will bleed out or not)

Type and cross when the transfusion is eminent like in total hip replacement surgery

You don’t defer to test and cross because crossing requires using a unit of blood to do the mixing which is wasteful

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11
Q

When you are centrifuging whole blood, what is the step by step for generating the different blood components?

A
  1. Whole blood–>PRBC + PRP (platelet rich plasma)
  2. PRBC + 110ml additive solution. Done.
  3. PRP hard spin –> Platelets + Fresh frozen plasma
  4. FFP thawed = cryoprecipitate
  5. FFP–> CPP
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12
Q

What does Rh typing determine?
Rh negative patients should always receive blood from ______________ donors.
If this is unavailable, _______________ should be given.

A

It determines whether RhD is present (+) or absent (-)
Rh- patients should always receive Rh- blood.
If it is unavailable, they can receive Rh+ blood

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13
Q

If an Rh- patient had to be given blood from an Rh+ donor, what should happen once the patient is stabilized?

A

A female should go through red cell exchange using Rh- cells and treatment with anti-D immunoglobulin to prevent alloimmunization

A male should be observed to manage delayed hemolysis of the newly made anti-D Ab against the transfused RhD RBC

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14
Q

For plasma and platelet transfusions, what information about the patients blood type needs to be known?

A

ABO blood type is required.

Antibody screening and ABO crossmatching are not required

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15
Q

What are leukoreduced PRBCs?
What 3 situations would it be used in?
Roughly how much does a unit cost? What would increase the price?

A

RBCs are run through special filters to remove >99.99% of WBCs.

This is indicated for patients who:

  1. had non-hemolytic febrile transfusions
  2. exchange transfusions
  3. patients who need CMV - blood when CMV- blood is unavailable

A unit is roughly $300 but additional charges are added for antigen - units for recipients that have antibodies

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16
Q

What is red cell washing?

A

It removes plasma and plasma constituents but is time consuming and reduces the PRBC shelf life to 24 hours instead of 42 days

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17
Q

What is FFP?
How does it differ from FP?

Which one would you be more likely to use to correct coagulopathy?

A

Fresh frozen plasma has all the clotting factors without the platelets. -18degrees celcius
Fresh plasma has all the clotting factors except 8 because it is heat labile and denatures at 4 degrees celcius

FP would be justified due to the fact that 8 would be increased anyway because it is an acute phase reactant

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18
Q

What is TP?

A

Thawed plasma is when FFP has been thawed and stored at 4degrees C for up to 5 days.
Has all clotting factors except 8

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19
Q

What are the indications for plasma therapy? (FFP or TP)

A
  1. correct secondary hemostasis issue when specific factor replacement isn’t available
  2. DIC, liver failure
  3. warfarin reversal in the case of an OD
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20
Q

What are two treatment options for warfarin reversal?

Which is preferred at Parkland?

A

TP or Prothrombin complex (vitamin K dependent factors in inactive form)
Parkland uses prothrombin complex

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21
Q

Why should FFP not be used for volume expansion?

A

It causes many adverse effects including TRALI (transfusion related Acute lung injury)

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22
Q

What 5 things should you NOT use FFP for?

A
  1. Heparin reversal
  2. Volume
  3. Prolonged PT/PTT due to lupus anticoagulant
  4. 8, 9, or vWF deficiencies
  5. DIC with no bleeding
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23
Q

What are platelet concentrates used for?

A
  1. prevent bleeding in asymptomatic severe thrombocytopenia (when platelet count is below 10x10^9)
  2. bleeding patients with less severe thrombocytopenia (below 50)
  3. Bleeding patients with platelet disfunction due to ASA or clopidogrel, but normal platelet count
  4. patients receiving massive transfusions that cause dilution thrombocytopenia
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24
Q

How much does one platelet concentrate from a whole blood donation raise the platelet count?
How many concentrates are needed to transfuse an average adult?

A

10x10^9 platelets

5-6 pooled random donor platelet concentrations

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25
Q

What are the two numerical ways platelet counts are reported?

A 
# x 10^9/L
or 
#x1000/mL
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26
Q

What technique can be used instead of the random pooling of platelets from 5-6 donors?
What is the drawback of this technique?

A

Apheresis where enough platelets are taken from one donor.

This reduces chance for immune rejection but it increases risk of TRALI and it takes 1-2 hours

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27
Q

What temperature are platelets stored at?

What is the benefit and drawback?

A 
room temp (20-24 degrees)
At 4 degrees (the temperature of thawed plasma) the platelets become dysfunctional and ineffective due to membrane and granular changes.

The problem with storing platelets at room temperature is that they are at an increased risk of bacterial infection. This is why it can only be stored 5 days.

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28
Q

What is the most expensive blood product?

A

Platelet concentrates cost $800 to $1200 a unit

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29
Q

What are 3 circumstances that would not allow the platelet count to rise after a platelet concentrate transfusion?

A
  1. splenic sequestration of the platelets in patients with splenomegaly (usually due to cirrhosis)
  2. Alloantibodies against platelets
  3. Platelet consumption by HLA-directed platelet destruction

Patients should try to be ABO and HLA matched and should be transfused with leukoreduced RBCs and leukoreduced platelets.

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30
Q

What is cryoprecipitate?

How is it made and what factors are in it?

A 
It is prepared by gradually thawing FFP from -18 to 4 degrees celcius. 
As the temperature is slowly raised, certain proteins precipitate out.
It contains:
1. factor 8
2. vWF
3. fibrinogen
4. fibronectin
5. factor 13
31
Q

What is cryoprecipitate used to treat?

A 
vWF disease
Hemophilia A
Acute DIC with bleeding (source of fibrinogen)
Massive transfusion during trauma
Uremic bleeding 
cardiothoracic surgery
obstetric emergency 
Factor 13 deficiency
32
Q

How many units of cryoprecipitate are needed to treat one patient?

A

10

33
Q

What is transfused if there is sepsis?

A

Granulocytes if the patient has profound neutropenia and are not responding to antibiotics

Seldom used!

34
Q

What are the most common complications of transfusions?

What are the most SERIOUS complications?

A 
Common:
1. Febrile, non-hemolytic 
2. Chill rigor reactions
Serious:
1. Acute hemolytic reaction due to ABO incompatability
2. TRALI
35
Q

What are the symptoms suggestive of a transfusion reaction?

What should be done if these symptoms are seen?

A
  1. Fever
  2. Chills
  3. Rigors
  4. shortness of breath
  5. lightheaded
  6. rash/itching
  7. flank pain
  8. STOP the transfusion and keep the IV line on with normal saline
  9. send the remainder of the unit to the blood bank for investigation
  10. If the need to continue transfusion is urgent, use type O/Rh- RBCs
36
Q

What are the 3 main things that can trigger a hemolytic reaction?

A
  1. ABO/Rh donor and recipient incompatability
  2. Plasma Ab against the donor RBC antigens
  3. Hemolyzed or fragile RBCs due to overwarming of stored blood or contact with hypotonic IV solutions
37
Q

Acute hemolytic transfusion reactions usually result from recipient __________________ to donor_________________.
What two pathologies develop?

What are the 3 main symptoms?

A

recipient Ab attack antigens on the donors RBCs.
This can lead to immediate intravascular hemolysis and acute renal failure.

Symptoms: dyspnea, fever, low back pain

38
Q

How is acute hemolytic transfusion reactions confirmed?

A

Finding free Hb in blood and urine, Hemosiderin in the renal tubule cells, and a low haptoglobin level

39
Q

What is the most common cause of AHTR?

A

ABO incompatability.
This transfusion occurs due to human error: mislabeling the sample at the time of collection, failure to match intended recipient, etc)

40
Q

What four things determine the severity of the AHTR?

A
  1. degree of incompatability
  2. amount of blood given
  3. rate of administration
  4. integrity of the person’s kidney, liver, heart
41
Q

What are the only real symptoms if AHTR occurs under general anesthesia?

A

hypotension, uncontrolled bleeding from incision and mucous membranes, dark urine

42
Q

What determines the prognosis after the acute phase of AHTR?

A

the BUN and creatinine levels which tell you the degree of kidney damage

43
Q

If AHTR is suspected, what should be done?

A
  1. stop transfusion immediately
  2. maintain adequate BP and RBF with IV saline and furosemide
    Antihypertensives can be given as needed.
    NO PRESSORS (*if you must–> dopamine)
44
Q

When does DHTR occur? What is the cause?

What are the symptoms?

A

It usually occurs 3-7 days after the transfusion.
A patient who has been previously sensitived to an RBC antigen, but had really low levels of Ab will reactivate the Ab with the transfusion.

Asymptomatic or slight fever
Decreased Hct, Hb
Rise in LDH, UCB

45
Q

What is febrile, non-hemolytic transfusion reaction?

A

FNHTR is a fever without intravascular hemolysis.

  1. Ab are directed against WBC HLA from an otherwise compatible donor (most common).
  2. Cytokines get released from WBCs during storage
46
Q

What temperature change constitutes a febrile reaction?

A

an increase in 1 or more degrees celcius.

47
Q

How are febrile transfusion reactions treated?

A

Acetominophen and diphenhydramine if necessary

48
Q

What are the two possible causes of an allergic reaction during a transfusion?
What are the symptoms?

A
  1. Ab react to an allergen in the donors plasma
  2. Antibodies from an allergic donor

Rash, edema, dizziness, headache treat with corticosteroids

49
Q

What can you do prophylactically for a patient that is known to have allergic reactions?

A

give antihistamine just before the transfusion.
NEVER mix the medication with the blood.

If the allergy is moderate(bronchospasm/generalized rash) give hydrocortisone
If the reaction is severe–> epi

50
Q

If a patient has an IgA deficiency, what is required for their donors blood?

A

Red cell washing, platelets and plasma from IgA deficient donor because IgE antibodies are developed in the deficient patient against IgA

51
Q

What is circulatory volume overload?
What transfusions are contraindicated?
How should transfusions be administered?

A

High osmotic load of blood products (specifically whole blood and plasma) draw volume into the intravascular space which can cause volume overload (specifically in patients with cardiac or renal insufficiency)

Whole blood is contraindicated.
Infuse RBCs slowly and observe the patients for signs of heart failure. If they occur, treat with furosemide diuretic to reduce volume

52
Q

What is the cause of TRALI?

A

Transfusion related acute lung injury.
Anti-HLA and anti-granulocyte Ab in the donor plasma agglutinate/degranulate WBC within the lung capillaries releasing cytokines

  • most common cause of death from transfusions since 2004
53
Q

What are the symptoms that develop with TRALI?

A

Dyspnea, hypoxemia, hypotension, fever.

Chest X-ray shows a bilateral pulmonary edema within 6 hours of transfusion

54
Q

What treatment is contraindicated with TRALI?

What SHOULD be given though?

A

Diuretics because the patient is not volume overloaded (the edema in the lungs is due to cytokine release, not fluid production)

Patients can be given steroids (hydrocortisone) to stabilize the endothelial leak

55
Q 
What is TA-GVHD?
What are the symptoms?
When does it usually occur after a transfusion? 
How is it diagnosed?
What is the mortality?
A

Transfusion-associated graft versus host disease.
It occurs when immunocompetent lymphocytes are transfused to an immunocompromised host.

Rash, vomiting, diarrhea, lymphadenopathy, pancytopenia

4-30 days after the transfusion and is diagnosed on skin and bone biopsies
90% mortality

56
Q

When can TA-GVHD occur in an immunocompetent recipient?

A

If the donor is homozygous for HLA haplotype that the recipient is heterozygous for.
The recipient will not make Ab against the donor HLA, but the donor HLA will make Ab against the un-matched recipient HLA haplotype

57
Q

How is TA-GVHD prevented?

A

Irradiation of all blood products intended for transfusion

58
Q

What is considered to be a “massive transfusion”?

What is the most likely complication of a massive transfusion?

A

Volume of blood greater than or equal to one blood volume/24 hours (ex. 10 units of whole blood in 24 hours)

Most common complication is dilutional thrombocytopenia.
Other complications are:
1. platelets in stored blood are not fully functional
2. clotting factors (except 8) are sufficient
3. Microvascular bleeds
4. Hypothermia due to the rapid transfusion of cold blood–arrhythmia/cardiac arrest, increased citrate/K+

59
Q

Why might a patient get hypothermia in a massive transfusion?
How do we account for this?

A

The blood is cold and can cause arrhythmia and cardiac arrest if injected too fast.
Use an IV with heat exchange device to warm blood gently (other heating is contraindicated bc it can damage RBC and cause intravascular hemolysis)

60
Q

Toxicities of ______ and ___ can be amplified in the presence of hypothermia.

A

citrate and K+

61
Q

Patients with liver failure may have an impaired ability to metabolize _______________. This can lead to _____________.

Patients with renal failure may have elevated __________ if transfused with blood that has been ________________________.

A

citrate excess–> hypocalcemia

K+ if the blood has been stored over 1 week

62
Q

What situation could cause hypokalemia after a transfusion?

A

RBCs take up K+ so there is a potential for hypokalemia in any transfusion

63
Q

What 3 situations have the potential to cause elevated levels of potassium?

A
  1. hypothermia
  2. renal failure
  3. mechanical hemolysis
64
Q

What technique usually limits bacterial growth in stored RBCs?
What bacteria does it NOT limit?

A

Refrigeration usually limits bacteria growth except for cryophilic organisms like Yersinia which produce endotoxins in the cold

65
Q

When RBC units are inspected (daily) for bacterial growth, what evidence suggests that it is occurring?

A

Color change in the unit

66
Q

What is type of blood transfusion has the highest risk for transmission of bacteria? Why?
What is the current risk of transmission of bacteria?
How do we combat against this?

A

Platelets have the highest risk because they are stored at room temperature.
1/2500 platelet transfusions transmit bacterial infection
This is why platelets are only kept for 5 days

67
Q

Why might a syphilis test on donor blood not eliminate the risk of transmission of syphilis in fresh blood or platelets?

A

Bc the test does not detect spirochete form

Infected recipients develop a rash

68
Q

What viruses can be transmitted in transfusions?

A
  1. Hepatitis
  2. HIV
  3. HTLV
  4. CMV
  5. Creutzfeldt-Jakob disease
69
Q

What is the risk of transmitting hepatitis B and Hepatitis C in blood transfusions?
What has decreased viral contaminant in blood?

A

B: 1/500,000
C:1/3million

  1. Viral inactivation by heat treatment of serum albumin and plasma proteins
  2. Recombinant factor concentrates
70
Q

What is the risk of transmitting HIV in a transfusion?

What testing reduces the risk of transmission?

A

1/3million
NAT- nucleic acid testing for HIV antigens on donor blood
HIV-1 p24 antigen testing

71
Q

How is CMV transmitted in blood donation?

Who must receive CMV- blood?

A

CMV is transmitted on WBCs in transfused blood but NOT through FFP.
Immunocompetent patients will not develop disease with CMV but immunocompromised patients must receive CMV- or leukoreduced blood

72
Q

What is Creutzfeldt-Jakob disease?

A

Mad cow disease.
People who have received human-derived growth hormone or a dura mater transplant, or who have a family member with CJD cannot donate blood.

73
Q

What parasitic infection is easily transmitted in transfusions?

A

Malaria because a lot of donors don’t know they have it due to the 10-15 year latent phase.
People who have traveled to endemic malaria regions cannot give for 1 year.
People diagnosed with malaria or who are immigrants, refugees or citizens from endemic regions cannot give for 3 years

Fundamentals 3- Heme (19 decks)

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