Blood Products and Transfusion (Exam II) Flashcards
What is blood comprised of primarily?
Plasma
What percentage of blood volume is made up by plasma?
55%
Which blood product has an ↑ risk of infection and why?
- Pooled packs d/t being from multiple donors
If we had to pick one thing to transfuse what would it be?
- whole blood
What blood type is a universal donor? Universal acceptor?
- Donor = O neg
- Acceptor = AB +
What are 2 Hb related issues we will see often in clinical settings?
- β thalassemia → Hb Barts
- α thalassemia → Hb H
What are the possible blood antigen types? What are possible Rh factors?
- Antigen → A B AB O
- Rh → Rh+ and Rh-
Is the general population primarily Rh+ or Rh- ?
Rh+ (85%) and Rh- (15%)
What 4 things can cause a right shift of the OxyHb curve?
- ↓ pH
- ↑ CO2
- ↑ temp
- ↑ 23-DPG
T or F: If our O₂ saturation is good so is our PO₂?
- False → O₂sat has nothing to do with PO₂ (could have 1 Hb fully saturated; ex. anemia)
For blood type O which Antigen is present on erythrocyte and which Antibody is in the serum?
- Antigen: n/a
- Antibody: Anti-A and Anti-B
For blood type AB which Antigen is present on erythrocyte and which Antibody is in the serum?
- Antigen: A and B
- Antibody: none
For blood type B, which Antigen is present on erythrocyte and which Antibody is in the serum?
- Antigen: B
- Antibody: Anti-A
For blood type A which Antigen is present on erythrocyte and which Antibody is in the serum?
- Antigen: A
- Antibody: Anti-B
AB donor blood will react with which other blood types?
- A, B, and O
B donor blood will react with which blood types?
- A
- O
A donor blood will react with which blood types?
- B
- O
O donor blood will react with which blood types?
- none
When whole blood is centrifuged what separation products result?
- Platelet rich plasma (PRP)
- WBC
- RBC
What happens if we centrifuge platelet rich plasma (PRP) again?
- Centrifuge PRP again → Separates plasma from platelets
Where is PRP used in surgery?
- Surgeon injects locally → ortho, dental, plastics cases commonly
from WWI–>Vietnam war what was preferred blood product?
whole blood for bleeding intra-op, major trauma, and primary resuscitation fluid in military settings
From 1970-1990 what blood products were preferred and why?
component therapy- preferred b/c it reduced waste, increased storage time, and targeted specific deficiencies
In iraq and Afghanistan what is the cornerstone of resuscitation?
fresh whole blood
Is whole blood still used today?
Level I trauma centers have WB strategies
What are the 5 different blood components we can use for treatments?
- RBC
- FFP
- Cryo
- PLT
- LTOWB - Low titer Group O Whole Blood
Is plasma present in PRBC’s?
No plasma!!
What is the lifespan of WB?
~ 3 wks
What chemicals are added to blood that allows it to be stored?
- CPDA-1 → Citrate phosphate dextrose adenine; chelates Ca++ to prevent clotting
- Phosphate → used as buffer
- Dextrose → fuel source
- Adenine → to support ATP synthesis (extends storage from 21 to 35 days)
Due to the chemicals used to allow blood to be stored what labs do we need to check when transfusing lots of blood?
- Ca++ (it will ↓)
- BG (it will ↑)
Which electrolyte will stored blood always have ↑ levels of? Why?
- K+ d/t cells lysing as they degrade in the bag
What happens to 2,3-DPG in stored blood?
What does this do to the OxyHb association curve?
- ↓ 2,3-DPG
- Left shift → impairs O2 delivery
PRBCs contain ______ unless they have been specifically ________?
- Leukocytes (WBCs)
- Leukoreduced
How are PRBC’s prepared?
remove 200-250mL of plasma from WB
PRBC’s will be left with 200-350mL
does not contain functional platelets or granulocytes
has same O2 carrying capacity as WB
intended to increase O2 carrying capacity (good for anemic patients who do not need increased volume, just increased o2 carrying capacity)
How much does 1 unit of PRBCs ↑ H&H level?
- Hb: ↑ 1 g/dL
- Hct: ↑ 3%
How is FFP prepared?
remove plasma from WB within 8 hours of collection–>leaves us with 200-250mL blood
Which blood transfusion product is a source of antithrombin III?
FFP
What is the dose of FFP?
- 10-15 mL/kg
At what temperature is FFP stored?
-18C or below
Re-thawing takes times
some centers have liquid plasma available, freeze dried plasma is on the horizon
How much will 1 unit of FFP ↑ level of each clotting factor?
- ↑ 2 to 3% for each factor
What are two specific uses of FFP Dr. C mentioned in class?
- Heparin resistance d/t antithrombin deficiency
- Treat hereditary angioedema (also use TXA along with FFP)
What is the INR of FFP?
- 1.5 to 1.8
How is cryo prepared?
protein fraction taken off the top of the FFP when being thawed (then refrozen up to 1yr) (still stored at -18C)
What clotting factors does cryoprecipitate have?
- Factor VIII: C
- Factor VIII: vWF
- Factor XIII
- Fibrinogen
What target of fibrinogen are we trying to maintain when using cryo?
100 mg/dL
How much will two units of cryo raise fibrinogen levels?
- 2 bags of cryo/10 kg body weight = 100 mg/dL ↑ in fibrinogen
Which patient population is cryo really important for?
- Pregnant women who are bleeding
How are platelets prepared?
cytapheresis/separating PRP from a unit of WB within 8hrs of collection and re-centrifuged to remove plasma
How much will one unit of PLT increase PLT count by?
- 5000 to 10000
Is there any clinical data that says warming platelets is bad?
No its a common practice → no data to support not warming platelets
What is the AABB recommendation for warming platelets?
Do not warm platelets
When platelets are low at what level will we start to spontaneously bleed?
PLT < 30000
What is the deadly triad when transfusing a patient?
- Hypothermic
- Coagulopathic
- Acidotic
When is WB indicated for transfusion?
- To maintain volume and O2 carrying capacity in acute massive hemorrhage (> 20% blood volume loss )
What is the storage temperature for whole blood?
1-6C
What are S/Sx of Hemolytic transfusion reaction?
- fever
- chill
- hemoglobinemia
- hemoglobinuria
- hypotension
- dyspnea.
What are mediators of Hemolytic transfusion reactions?
IgM antibodies
What are the S/S of nonhemolytic febrile transfusion reactions?
Fever and chills
What are the mediators of non-hemolytic febrile transfusion reactions?
HLA Class 1 Ag antibodies
How do we treat Non-hemolytic febrile transfusion reactions?
- Antipyretics
- Use leukocyte reduced products
What are some S/S of an allergic transfusion reaction?
- urticaria
- erythema
- itching
- anaphylaxis.
What are the mediators of allergic transfusion reactions?
- plasma proteins
- IgA antibodies
How do we treat allergic transfusion reactions?
- antihistamines
- treat symptoms, transfuse IgA-deficient components
What are S/S of Non-cardiogenic pulmonary transfusion reactions?
- ARDS
- Fever
- Chill
- Hypotension
- Cyanosis
***NONCARDIOGENIC PULMONARY EDEMA
What are the mediators for a non-cardiogenic pulmonary transfusion reaction?
Recipient WBC antibodies
How do we treat Non-cardiogenic pulmonary transfusion reactions?
- Lots of PEEP
- Steroids
How do we know if we have a TRUE transfusion reaction?
Noncardiogenic pulmonary transfusion reaction after blood product administration
What is TRALI?
Transfusion Related Acute Lung Injury - temporarily r/t to blood transfusion within 1st 6 hrs of a transfusion
What is the mortality rate associated with TRALI?
5%-25%, most recover within 72hrs
What types of blood products is TRALI most associated with this?
- FFP
- PLTs
What are the 3 acute nonimmunologic effects of transfusion reaction?
- Bacterial contamination
- Circulatory overload (TACO)
- Hemolysis d/t physical /chemical means
mediators, s/s, treatment of bacterial contamination
mediators: endotoxins produced by GI bacteria
S/S: fever, sepsis, hemoglobinuria
Tx: IV ABX, treat hypotension and DIC
mediators, S/S, Tx of TACO (circulatory overload)
mediator: fluid volume
S/S: coughing, cyanosis, orthopnea, severe headache, peripheral edema, diff breathing.
Treatment and Prevention: administer subsequent Tx slowly & in a small volume.
Mediators, S/S, Tx d/t physical/chemical means
M: exogenous destruction of RBC
S/S: hemoglobinuria
Tx: document and rule out hemolysis d/t other causes, treat DIC
What are the three delayed immunologic effects of transfusion reaction?
- Hemolytic transfusion reactions
- Transfusion associated Graft-versus-host disease
- Post-transfusion purpura
Mediators, S/S and Tx of delayed hemolytic transfusion reactions
Mediators : IgG A/b.
S/S: shortened RBC survival, decreased Hb, fever, jaundice, hemoglobinuria.
Treatment and Prevention: Ig-negative blood for further transfusions.
Mediators, S/s. treatment of transfusion associated graft v host disease
Mediators : viable donor lymphocytes.
S/S: fever, skin rash, desquamation, anorexia, nausea, vomiting, diarrhea, hepatitis, pancytopenia
Treatment and Prevention: gamma irradiation of cellular components.
Mediators, S/S, treatment of post-transfusion purpura
MOA: platelet specific A/b.
S/S: thrombocytopenia, clinical bleeding.
Treatment and Prevention: IV Ig, plasma exchange, corticosteroids.
Criteria for TRALI
acute onset hypoxemia
ratio of PaO2/FiO2<300 or SpO2 <90% on RA
occur during or within 6hrs of transfusion
bilateral diffuse pulmonary infiltrates
no evidence of LA HTN (circulatory overload)
immediate management of TRALI
STOP transfusion!
support pt
if intubated, obtain undulated edema fluid ASAP and simultaneous plasma for determination of total protein
obtain CBC and CXR
notify blood bank and request a different until and quarantine other unit from same donor
What are some quick ways to differentiate between TRALI and TACO?
- TRALI → Fever and ↓BP, no response to diuretic
- TACO → HTN, ↑JVP, ↓ EF, significant response to diuretic, S3 Heart sound
both: acute dyspnea, auscultation: rales, diffuse bilateral infiltrates
mediators, S/S, and treatment of Transfusion induced hemosiderosis
MOA : Iron overload.
S/S: subclinical to death.
Treatment and Prevention: decrease frequency of transfusion, neocytes, iron chelation therapy.
What classes of hemorrhage are there and what is associated blood loss for each?
- Class 1 = up to 750 mL (< 15%)
- Class 2 = 750 to 1500 mL (15-30%)
- Class 3 = 1500 to 2000 mL (30-40%)
- Class 4 = > 2000 mL (>40%)
What are 3 definitions of MTP in Adults?
- Total blood volume is replaced within 24 hours
- 50% of total blood volume is replaced in 3 hours ←Most common
- Rapid bleeding rate = 4 units RBCS transfused within 4 hours or 150 mL/min blood loss
What is considered MTP for Kids?
- > 40mL/kg transfusion
What is balanced resuscitation?
- 1:1:1 ratio (PLT:Plasma:RBC)
What are the fibrinogen levels of Cryo, FFP, and LTOWB?
- Cryo = 2500 mg
- LTOWB = 1000 mg
- FFP = 400 mg
What is the difference between stored whole blood (SWB) and LTOWB?
- SWB anticoagulants < LTOWB
What type of blood is preferred for men? women of child-bearing age?
men: Rh + blood
Women: Rh - blood
What are the recommendations for whole blood transfusion in kids?
- If they are <15 yr old or <40 kg then limit WB to 30 mL/kg
side effects of hypocalcemia
Long QTc, decreased CO, coagulopathy, SZ
Which clotting factors required Ca++ to work?
2 7 9 10, protein C and S.
Ca plays a role in stabilizing fibrinogen and platelets in developing thrombus
Which drug has more elemental calcium; Ca gluconate or CaCl?
- CaCL (270 mg/10mL vs 90 mg/10ml for gluconate)
How much will 1, 2, and 5 units of blood decrease iCa?
- 1 unit drops iCal to 1.13 mmol/L
- 2 unit drops iCal to < 1mmol/L
- 5 units drops iCal to < 0.8 mmol/L
In a study as Western Australia University, what was the most critical variable in determining mortality associated with blood transfusions?
hypocalcemia!!!
more specific than fibrinogen or acidosis levels!
TEG flow chart- when to give which component of blood!
What is the value for TEG-ACT?
- 80-140 sec
this is our normal activated clotting time (ACT)
measures clotting factors (extrinsic/intrinsic)
What is the normal value for R time?
- 5.0 - 10.0 min
reaction time to initial fibrin formation
clotting factors (intrinsic pathway)
What is the normal value for K time?
- 1-3 minutes
“kinetic time” for fibrin cross linkage to reach 20mm clot strength
measures fibrinogen, platelet #
What is the normal value for α angle?
- 53 - 72°
What is the normal value for MA?
- 50-70mm
What is the normal value for G value?
- 5.3-12.4 dynes/cm2
What is the normal value for LY 30?
- 0-3%
Clot “Lysis” at 30 minutes following MA
If TEG-ACT is > 140 what do we transfuse?
- FFP
If R time is > 10 what do we transfuse?
- FFP
If K time is > 3 what do we transfuse?
- Cryo
If α angle < 53° what do we transfuse?
- Cryo and platelets
If MA < 50 what do we transfuse?
- PLT
If LY30 > 3% what do we transfuse?
TXA (Tranexamic Acid)
Examples of TEGS
