Blood Products Flashcards
Packed Red Blood Cells (PRBCs) ~ _____ cc/unit
350 cc/unit
Rarely transfuse if Hgb > __ g/dL; almost always if Hgb < __ g/dL.
Hgb >10 g/dL; <6 g/dL
If Hgb is greater than __ g/dL, most are comfortable with the infusion of a crystalloid or colloid.
7 g/dL
(The ASA recommends transfusion to avoid Hgb below 6 g/dL in healthy patients)
In a typical 70 kg patient one-unit PRBC transfusion is expected to increase Hgb by __ g/dL and hematocrit by __%.
1 g/dL ; 3%
Most PRBC units have an HCT of __ - __%.
50-60%
Massive Transfusion Protocol (When to Initiate)
• Loss of entire blood volume within ___ hrs
• ___% of blood volume in 3 hrs
• Ongoing bleeding at > ___ ml/min
• Rapid bleeding with circulatory failure despite volume
replacement
• Loss of entire blood volume within 24 hrs
• 50% of blood volume in 3 hrs
• Ongoing bleeding at >150 ml/min
• Rapid bleeding with circulatory failure despite volume
replacement
Massive Transfusion Protocol (Procedure)
• Sample for type and screen to blood bank
• Blood products in containers (coolers)
• 1:1:1 ratio of RBC:FFP:Platelets
(____ u RBC, ___ u FFP, __ apheresis unit platelets)
• ___ u Cryoprecipitate in coolers 3, 6, and 9
• Complete use of 1 cooler before next cooler
• Upon issuing a cooler, blood bank prepares next cooler
• 1 cooler every 20-30 min until protocol discontinued
• Sample for type and screen to blood bank
• Blood products in containers (coolers)
• 1:1:1 ratio of RBC:FFP:Platelets
(6 u RBC, 5 u FFP, 1 apheresis unit platelets)
• 10 u Cryoprecipitate in coolers 3, 6, and 9
• Complete use of 1 cooler before next cooler
• Upon issuing a cooler, blood bank prepares next cooler
• 1 cooler every 20-30 min until protocol discontinued
Labs upon initiation of Massive Transfusion Protocol:
- Type and screen
- CBC
- PT/PTT/INR
- ABG
- Comp Metabolic panel
- iCa
- Lactate
What labs are sent every subsequent hour?
Labs to send every one hour
CBC
PT/PTT/INR
Fibrinogen
ABG
iCa
Lactate
What are some metabolic characteristics of PRBCs?
Classes of Acute Hemorrhage
- What’s the blood loss (cc and % EBV) for each class?
- When would you expect to see a decreased blood pressure?
- When would you expect to see a decreased pulse pressure?
- When should you start to replace with blood?
Platelets
Prophylactic transfusion for surgery usually indicated if:
<___/microL; or <___/microL and and high risk of bleeding; not indicated for states of increased destruction, e.g., ITP
Indicated for microvascular bleeding with <___/microL; or <___/microL and risk for increased bleeding
Prophylactic transfusion for surgery usually indicated if <50,000/microL; or <100,000/microL and high risk of bleeding; not indicated for states of increased destruction, e.g., ITP
Indicated for microvascular bleeding with <50,000/microL; or <100,000/microL and risk for increased bleeding
Platelets
Transfuse ___ u/10 kg.
In a 70 kg patient each unit will increase the platelet count by approximately _____/microL
One single donor pheresis unit ≅ ___ random donor units
Transfuse 1 u/10 kg.
In a 70 kg patient each unit will increase the platelet count by approximately 7 - 10,000/microL (7 to 10 × 109/L at 1 hour after transfusion).
One single donor pheresis unit ≅ 6 random donor units
Do NOT administer platelets through ______, or ______ systems, or rapid transfused systems because the platelets will stick to the tubing and this will decrease the number of platelets that reach the patient.
Do not administer through filters, warmed systems, or rapid transfused systems because the platelets will stick to the tubing and this will decrease the number of platelets that reach the patient.
In trauma, transfuse platelets to keep > ____k or > ___k in TBI.
In rapid transfusion, give one six-pack of platelets per __-units of PRBC.
In trauma, transfuse platelets to keep > 50k or >100k in TBI.
In rapid transfusion, give one six-pack of platelets per 6-units of PRBC.
If platelets are stored at room temperature, they can be used up to ____ days after collection with constant and gentle agitation.
Seven-days
T or F:
When possible, ABO-compatible platelets should be used.
TRUE
But
Platelets will continue to be chosen without regard to antigen systems for the majority of patients. ABO-incompatible platelets produce very adequate hemostasis.
Fresh Frozen Plasma (FFP):
Urgent reversal of warfarin therapy ( __ - __ mL/kg )
5–8 mL/kg
Fresh Frozen Plasma (FFP)
Correction of microvascular bleeding with elevated (>____ times normal) INR or aPTT, or when suspected factor depletion as after transfusion of more than one blood volume
Treatment of heparin resistance (e.g., _______ deficiency) in a patient requiring heparin
Correction of microvascular bleeding with elevated (>2 times normal) INR or aPTT, or when suspected factor depletion as after transfusion of more than one blood volume
Treatment of heparin resistance (e.g., antithrombin III deficiency) in a patient requiring heparin
Fresh Frozen Plasma (FFP)
Give enough to achieve at least ___% of normal plasma factor concentration (___ - ___ mL/kg)
Give enough to achieve at least 30% of normal plasma factor concentration (10–15 mL/kg)
Platelets for transfusion also contain plasma: 4–5 u platelets or 1 single-donor unit contains factors equal to about 1 u FFP
FRESH FROZEN PLASMA
It contains all the plasma proteins, particularly
factors __ and __, which gradually decline during
the storage of blood.
Thawed plasma is stored at 1 °C to 6 °C for up to ___ days.
Factors V and VII
Five days
Cryoprecipitate or Fibrinogen Concentrate:
Prophylactic use in peri-operative or peripartum patients with congenital fibrinogen deficiencies or ________ unresponsive to desmopressin (DDAVP, 1-deamino-8-d-arginine vasopressin)
Bleeding in patients with von Willebrand’s disease if specific concentrates are unavailable
Patients with a fibrinogen level < ___ mg/dL (normal _____ mg/dL)
For trauma, the goal is to keep > _________ mg/dl
Correction of microvascular bleeding in massively transfused patients with an unknown fibrinogen
DOSING: cryoprecipitate: give _____ single donor units (about ___ units per 10 kg) cold. Does it need to be filtered?
For fibrinogen concentrate, give ______ grams early in resuscitation.
von Willebrand’s disease
< 80–100 mg/dL (normal 150–450 mg/dL)
Trauma: > 100-150 mg/dl
Cryo Dosing: 15-20 single donor units (about 2-units per 10 kg) cold but filtered
Fibrinogen concentrate: 2-3 grams
Table: Characteristics of Blood Component
___ cc Ca2+ gluconate PIV
or
___ cc CaCl PIV
should be administered every ____ cc blood products given.
10- 20 cc Ca Gluconate
2-5 cc CaCl
500 cc blood products given
Table: Blood Products Uses and Effects
Note for Cryo, the formula for raising fibrinogen by 50 to100 mg/dl is 0.2 x kg wt. = number of units
CRYOPRECIPITATE:
- Cryoprecipitate is prepared when ___ is thawed, and the precipitate is reconstituted.
- T or F: Cryoprecipitate is frequently administered as ABO compatible
- T or F: Cryoprecipitate should be administered through a filter and as rapidly as possible.
FFP
The product contains factor VIII:C (i.e., procoagulant activity), factor VIII:vWF (i.e., von Willebrand factor), fibrinogen, factor XIII, and fibronectin, which is a glycoprotein that may play a role in reticuloendothelial clearance of foreign particles and bacteria fromthe blood. All other plasma proteins are present in only trace amounts in cryoprecipitate.
True, but this probably is not very important because the concentration of antibodies in cryoprecipitate is extremely low.
True, The rate of administration should be at least 200 mL/h
In emergent situations requiring massive transfusion when the patient’s blood has not been cross and matched, group ___ PRBC and ___ plasma products should be issued until the recipient’s blood type is determined.
If ___ or more units of non-crossmatched PRBC and platelets are transfused, residual _________ in these products may result in transfusion reaction, hemolysis, and/ or a positive direct coombs test if additional units of crossmatched blood products are transfused. Prior to converting to the patient’s blood type, blood samples should be tested for significant amounts of anti-A and anti-B titers.
Group O PRBC
Group AB Plasma
Ten (10)
Antibodies
ABO incompatible plasma
In an adult, there is approximately a ____% decrease in the concentration of clotting factors and platelets for every ____ mL of blood loss that is replaced with crystalloid.
Clinically significant dilutional coagulopathy also results after transfusion of ______ units of PRBCs
10%; 500 ml
8 to 10 units
Typically, ______ (and how much) should be given if either prothrombin time (PT) or partial thromboplastin time (PTT) exceeds 1.5 x normal values.
2 to 8 units of FFP
Cryoprecipitate or virus-inactivated fibrinogen concentrate may be used when _____ levels are critically low (< _____ mg/ dL).
Platelet counts below 50 K/ mcL are often seen after ___ blood volumes are transfused.
A full dose of 6 units of whole blood derived platelets, 1 apheresis concentrate, or single donor platelets should increase the platelet count by _______.
Fibrinogen; < 100—200 mg/ dL
1 or 2 blood volumes
30 K/ mcL
Savage et al. 10 demonstrated that a loss of blood necessitating transfusion of ____ units of blood within a 60-minute period of time was associated with a twofold increased risk of mortality.
This time period is defined as the critical administration threshold and has been accepted as an alternative definition of massive transfusion, because it takes into account the rate of blood loss.
Three (3)
Look over the Validated Massive Transusion Protocols.
T or F:
One unit of FFP contains 0.5 g of fibrinogen, twice the amount found in 1 unit of cryoprecipitate.
TRUE
Therefore, transfusion of appropriate ratios of FFP to PRBCs should adequately replace fibrinogen in most cases of massive transfusion.
An adult with a healthy liver can metabolize the citrate present in stored blood products to bicarbonate at a rate of ______ every 5 minutes. The average unit of blood contains ______ g of citrate, so how quickly can you give blood without worrying about this? What’s the problem you may see?
3 grams every 5 minutes.
The average unit of blood contains 3 g of citrate.
An infusion rate of 1 unit of PRBC given over a period shorter than 5 minutes will result in elevated free citrate and decreased plasma free calcium levels.
Review common crystalloid composition table
Why should hydroxyethyl starch solution never be used in massive transfusion?
Because it blocks the fibrinogen receptor (GPIIb-IIIa) and can further affect polymerization
If fibrinogen concentrate is not available to replace fibrinogen deficiency, then what can you give?
(** This is why one unit of ___ is recommended per unit of ____.)
A 10-unit bag of cryoprecipitate contains 2500 mg of fibrinogen.
So a ratio of one unit of cryoprecipitate per unit of PRBC is commonly recommended.
Fibrinogen concentrates should be given to patients whose measured fibrinogen level is < _____ or whose TEG shows a ____ over four-minutes or alpha angle of less than _____.
100 mg/dl
K time
60 degrees
What is DDAVP used for? Dose?
How does DDAVP work?
DDAVP is used for the management of mild hemophilia A, von Willebrand’s disease, uremia.
The typical dose is 0.4 mcg/kg.
It works by releasing endogenous stores of von Willebrand factor from endothelial cells.
The activity of the factorXa/Va prothrombinase complex is reduced byt 50%, 70%, and 80% at pH of 7.2, 7.0, and 6.8. How does this impair hemostasis?
This decreases the levels of thrombina and fibrin.
A patient’s body temperature below ____ is associated with oncreased mortality
34.5 celcius or 94.1 F
During massive transfusion, we ideally want to:
Maintain temperature above ______
pH > ____
Base Excess > ____
Lactate < ____
Platelets > _____
PT.activated PTT < ____
Fibrinogen > _____
Temp > 35 C
pH > 7.2
Base Excess > -6
Lactate < 4 mmol/L
Platelets > 50 x 10-9
< 1.5 normal limits
Fibrinogen > 100-200 mg/dL
In emergent situations requiring massive transfusion when the patient’s blood has not been cross matched, group ____ PRBC and ___ plasma products should be issues until the recipient’s blood type is determined.
If ___ or more units of non-crossmatched PRBC and platelets are transfused, residual ABO incompatible plasma in these products may result in transfusion reaction.
Prior to converting to the patient’s blood type, blood samples should be tested for significant amounts of?
Group O PRBC and AB plasma
10 or more units
Anti-A and anti-B titers
Hypothermia (i.e. temp below 34.5 C increases mortality) reduces the enzymatic activity of coagulation proteins and prevents calcium dependent activation of?
Platelets by von Willebrand factor
In massive transfusion, giving _____ fibrinogen per unit of PRBC is independently associated with improved survival.
T or F Virus inactivated fibrinogen concentrate should be used to correct fibrinogen deficiency.
200 mg
True
If the fibrinogen concentrate is not available, then you can use cryoprecipitate. One 10-unit bad of cryoprecipitate contains how much fibrinogen?
Considering this, what is the ratio of cryoprecipitate to PRBC that should be transfused?
10-unit bag has 2,500 mg of fibrinogen (about 250 mg per unit)
Since the recommendation is to give 200 mg of fibrinogen per PRBC unit, then it should be one unit of cryoprecipitate per unit of PRBC.
One unit of FFP contains how much fibrinogen?
How does this compare to the amount in one unit of cryoprecipitate?
One unit of FFP has 0.5 g of fibrinogen
This is twice the amount in 1 unit of cryoprecipitate
(As a result, the appropriate ratio of FFP to PRBC should adequately replace fibrinogen in most cases of massive transfusion.)
Review catheter flow rates:
14G =
16G =
18G =
20G =
22G =
