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Blood Conservation- Exam 1 Flashcards

1
Q

Blood Transfusion Complications (General)

A 
Post-op infections
Ventilator- acquired pneumonia
Central line sepsis
Increased LOS
Increased mortality rates
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2
Q

2 Types of Transfusion Risks

A

Infectious

Non-infectious

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3
Q

Types of Infectious Transfusion Risks

A

Bacterial
HIV
Hepatitis

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4
Q

Types of Non-Infectious Transfusion Risks

A 
Febrile Rxns
Urticarial (Allergic) Rxns
Anaphylactic Rxns
Acute Hemolytic Rxns
Volume Overload
Hypothermia
Citrate Toxicity
Potassium Effects
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5
Q

Febrile Reactions

A

Fever, chills
Antibodies reacting w. white cell antigens or white cell fragments in transfused blood products or due to cytokines which accumulate during storage
Most common with platelet transfusions

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6
Q

What non-infectious reaction is most common with platelet transfusions?

A

Febrile Reactions

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7
Q

Urticarial (Allergic) Reactions

A

1%
urticaria, itching, flushing
caused by foreign proteins

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8
Q

Anaphylactic Reactions

A

Hypotension, tachycardia, cardiac arrythmia, shock, cardiac arrest
caused by patients who have IgA deficiency who have anti-IgA antibodies (require specially washed/tested blood products)

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9
Q

Acute Hemolytic Reactions

A

Caused by transfusions of ABO incompatible blood

Chills, fever, pain, hypotension, dark urine (plasma free hgb) uncontrolled bleeding due to DIC

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10
Q

Volume Overload

A

Not on bypass; big concern in ICU; no where for volume to go

On bypass- can tx a lot of rxns and can prevent volume overload

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11
Q

Citrate Toxicity

A

Metabolized by liver
Rapid transfusion of large quantiity of blood products
Binds calcium and magnesium- depleting stores
Myocardial depression
Coagulopathy

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12
Q

Potassium Effects

A

Stored RBC leak K+
Irradiation increased the rate of leak
Cardiac effects (must give slowly or they could go into cardiac arrest)

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13
Q

TRALI

A

transfusion related acute lung injury

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14
Q

TRALI Symptoms

A

Similar to ARDS

Hypotension, fever, dyspnea, tachycardia

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15
Q

What is TRALI?

A

Non-cardiogenic pulmonary edema with diffuse bilateral pulmonary infiltrates on CXR

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16
Q

How fast can TRALI occur?

A

Occurs within 6 hours of tx

Most cases present within 1-2 hours

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17
Q

What are the culprits for causing TRALI?

A

All blood products

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18
Q

How common is TRALI?

A

1/2000 transfusions

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19
Q

TRALI Pathophysiology

A

Unclear.

Attributed to HLA Antibodies, Granulocyte antibodies and biologically active mediators in the blood

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20
Q

What is the Tx for TRALI?

A

Ventilator support for ~96 hours

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21
Q

What ii TRALI mortality?

A

5-10%

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22
Q

Clinically, transfusions are associated with….

A

Longer hospital stays
Longer time to extubation
Mobidity
Mortality

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23
Q

What are some techniques to minimize our impact on blood usage?

A 
Autologous transfusion
Pre-bypass autologous donation
Intraoperative cell saver use
Shed mediastinal blood recovery
Accept lower HCT
RAP
Hemoconcentration
Plasma/Platelet Pheresis
Mini-circuits
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24
Q

Bloodless Medicine

A

Transfusion-free medicine

Multimodality and Multidisciplinary approach to patient care without the use of allogenic blood.

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25
Blood Conservation
Global concept aimed at reducing patient exposure to allogenic blood products. Does not exclude use.
26
Jehovah's Witness booklet related to bloodless medicine
Blood, Medicine, and the law of God (1961) - Transfusion rxns - Transfusion related syphilis, malaria, hepatitis
27
Which doctor took JW tranfusion requests to heart?
Denton Cooley (1960's)
28
What is Cooley's 1964 publication
Open Heart Surgery in the JW; described techniques for treating these patients 1977- reported experience with 500 JW patients
29
How did the military contribute to blood management?
Did surgery on wounded soldiers before transfusions were even available confronted with blood loss but not way to replace the blood; stopped bleeding promptly and effectively
30
WWI and Blood Management
Blood Anticoagulation Allowed for transport of blood to the wounded Problem: Storage!
31
WWII and Blood Management
Storage problem overcome with the advent of blood banks
32
What blood management development occurred in 1953?
Use of blood alternatives | Switched from plasma to Dextran (volume expander) deue to incidence of hepatitis transmittal
33
Dextran
Sugar substrate, used outside US instead of plasma in 1953
34
What blood management develoment occured in 1985?
Started looking into blood subsitutes; military role | Searched for oxygen carrier
35
Who introduced the first cell saver in a military hospital?
Surgeon Gerald Klebanoff (Vietnam Vet)
36
What is significant about Recombinant Factor VIIa?
Hemopheliacs | Israeli army discovered potential to stop life threatening hemorrhage (used aprotinin before)
37
How many organized bloodless programs are in the US?
More than 100
38
What is the major variable related to percent transfusions?
Institution physicians (not patients!)
39
What should be obtained in a focused patient Hx pre-op?
Age Gender Weight/Height Race/ethnicity/background/religion
40
Why is age important in a focused hx?
Tolerance of anemia is age dependent | As age increased, risk of transfusion increases
41
Why is gender important in focused hx?
Women more likely than men to get transfused | lower hct; prone to blood loss with menses
42
What size patients are at risk for transfusion?
Small patients | Obese patients
43
What patient-related obstacles should be asked about in pre-op?
``` Anemia Hemostatic disturbances Medical conditions increasing perioperative blood loss Obstacles to surgical hemostasis Factors decreasing anemia tolerance ```
44
What lab work should be done pre-op?
Hgb PT/INR/PTT Platelet count and platelet function tests
45
Drugs that have increased bleeding risk
NSAIDs, PCN, NTG, HIgh doses of Vitamin C, St. John's Wort, Ginger, Garlic, etc.
46
What temperatures optimize clotting?
Warm
47
How long before surgery would autologous donation have to be done?
At least 2 weeks prior
48
Auto-Donation requires what HCT?
33%
49
Contraindications for Autologous Donation
``` Recent MI CHF Aortic Stenosis Transient Ischemic Attacks HTN Unstable Angina Bacteremia ```
50
What allows the donation of platelets and plasma?
Plateletpheresis and Plasmapheresis
51
Prebypass Autologous Normovolemic Hemodilution
Used to remove blood from the patient pre-bypass for transfusion later in the case (spares platelets) Removed volume replaced with crystalloid
52
Prebypass Autologous Normovolemic Hemodilution HCT requirement
AT least 35%
53
How much fluid is removed in prebypass autologous normovolemic hemodilution?
500-1000mL (1-3 units) | -Depends on starting HCT, age, BSA, existing conditions
54
When is blood reinfused during PANH?
After protamine is administered
55
Contraindications for PANH?
``` COPD CHF CAD Unstable Angina Renal insufficiency Severe aortic stenosis Coagulopathy ```
56
How much prime do you remove in RAP?
200-600mL of prime
57
Dry Venous Line Technique
Venous line emptied prior to connection to venous cannula Requires VAVD Volume removed to a big and discarded or sequestered
58
How much fluid does the dry venous line technique remove?
400-1000 mL
59
Mini-Circuit Advantages
Decreased foreign surface area (less inflammatory) Decreases prime volume (less hemodilution) Decreases blood-air contact
60
What does a mini circuit lack?
Venous reservoir Cardiotomy Often no heat exchange or art line filter
61
What is mini circuit prime volume?
500 mL; can be decreased with RAP- ing
62
What procedures use mini circuits usually?
Mostly CABGs | Some valves have been done
63
2 types of Mini-circuits
Totally Integrated Devices | Combination of Components
64
Totally Integrated Devices (Mini circuit)
Include air handling and eliminiation systems, centrifugal pump and membrane oxygantor ex. CorX (Cardiovention) and Cobe Synergy
65
Combination of Components
MECC System (jostra) MCPB Deltra Stream ERP(medos) Resting Heart System (Medtronic)
66
What variables affect the outcomes in mini circuits?
``` Steroids Aprotinin Degree of heparinization Type of tubing coating Patient population ```
67
ERC
Electric Remove Clamp
68
APC
Air Purge Control
69
Ultrafiltration/Hemoconcentration
Filtration of water across a semipermeable membrane via hydrostatic pressure gradient Water crosses membrane which creates a solute concentration gradient Solute from blood (high concentration) to water (low concentration)
70
What must you add if you're Z-BUFing?
Add sodium bicarb to the normal saline you're Z BUFing with to avoid acidosis
71
MUF
Modified Ultrafiltration Withdrawing blood from the patient via the arterial line (post bypass); run blood through hemoconcentrator, pump blood back to patient via venous line
72
What does a cell saver remove?
Fat, air, tissue debris, potassium, hormones, bioactivators, etc.
73
Cell Saver Limitations
``` Delay in processing Loss of plasma proteins Loss of coag factors and plts Expense Operator attention and time ```
74
Cardiopat
Shed blood collected and processed Uses dynamic disk to process- processes variable volume of blood Consistently delivers washed RBCs w/ hct of 70-80% Processes up to 2 L/hr or as little as 5mL of RBCs
75
What HCT can you tolerate if you are healthy and have good LV function?
20-25%

CV Perf Tech II (17 decks)

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