Blood Products and Transfusion (Exam III) Stephen's Cards 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 recipient?
- Donor = O neg
- Recipient = AB +
Which patient is the potential exception to accepting blood from an O- donor?
If we have to how can we compensate for this?
- Pregant women d/t fetus possibly being O+
- Rhogam
What are 2 Hgb related issues we will see often in clinical settings?
- β thalassemia → Hgb Barts
- α thalassemia → Hgb H
How does Rh Factor affect blood compatibility?
Antigens & Antibodies of Blood Products
- Antigens are on the surface of the RBC (A, B, AB)
- Antibodies are in the plasma
- Antibodies in the plasma can attack the antigens on the surface of the RBC which is why they need to be compatible
- Rh + blood can receive Rh -
- Rh - CANNOT receive 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)
O (-) & (+) Blood:
Antigens present?
Antibodies present?
Can donate to? Receive from?
O-
* Antigen: None
* Antibody: Anti-A, Anti-B, Anti-Rh
* Can be received by almost everyone, can only receive O (-)
O+
* Antigen: None
* Antibodies: Anti-A, Anti-B
* Can receive blood from O- and O+
* can donate to O+, A+, B+, AB+
AB (+) & (-) Blood:
Antigens Present?
Antibodies Present?
Can donate to? Receive from?
AB +
* Antigens: A, B, and Rh+
* Antibodies: None
* Can receive all blood types because this blood type has NO antibodies created against RBC antigens
* but can only donate to AB + because of the antigens present
AB -
* Antigens: A, B
* Antibodies: Anti-Rh
* Can receive all (-) blood types
B (+) & B (-) Blood:
Antigens Present?
Antibodies Present?
Can donate to? Receive from?
B+
* Antigen: B, Rh
* Antibody: Anti-A
* Can donate to: B+, AB +
* Can receive from: B+, B-, O-, O+
B-
* Antigen: B
* Antibody: Anti-A, Anti-Rh
* Can donate to: B-, B+, AB-, AB+
* Can receive: B-, O-
A (+) & A (-)
Antigens Present?
Antibodies Present?
Can donate to? Receive from?
A+
* Antigen: A, Rh
* Antibody: Anti-B
* Donate to: AB+, A+
* Can receive: A-, A+, O-, O+
A-
* Antigen: A
* Antibody: Anti-B, Anti-Rh
* Donate to: A+, A-, AB-, AB+
* Can receive: A-, O-
Which blood types cannot receive AB Antigen blood?
- A, B, O
Which blood type cannot receive B Antigen Blood?
- A
- O
Which blood type cannot receive A antigen blood?
- B
- O
O - can receive what blood?
O (-) donor blood will react with which blood types?
- O (-) does not react with any blood types
- O (-) can only receive O (-)
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
What are the 5 different blood components we can use for treatments?
- RBC
- FFP
- Cryo
- PLT
- LTOWB - Low titer Group O Whole Blood
What is the lifespan of WB?
~ 3 wks
What chemicals are added to blood that allows it to be stored?
**CPDA-1 ** is added. It contains:
- → 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 much does 1 unit of PRBCs ↑ H&H level?
- Hb: ↑ 1 g/dL
- Hct: ↑ 3%
Which blood transfusion product is a source of antithrombin III?
FFP
What is the dose of FFP?
- 10-15 mL/kg
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 angioedema (also use TXA along with FFP)
What is the INR of FFP?
- 1.5 to 1.8
What clotting factors does cryoprecipitate have?
- Factor VIII: C (coagulation activity)
- Factor VIII: vWF (inactive form, bound to 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 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
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 are S/Sx of Hemolytic transfusion reaction?
- fever (late sign)
- chill
- hemoglobinemia
- hemoglobinuria
- hypotension
- dyspnea.
What are mediators ofhemolytic transfusion reactions?
IgM antibodies immediately bind to the transfused ABO-incompatible RBCs.
What are the S/S of nonhemolytic febrile transfusion reactions?
Fever and chills
What are the mediators of non-hemolytic febrile transfusion reactions?
- Caused by recipient antibodies against donor leukocyte (WBC) HLA Class I antigens
- Refers to antibodies (A/b) targeting Human Leukocyte Antigen (HLA) Class I antigens on donor white blood cells (WBCs) or platelets, rather than red blood cells
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?
- IgE antibodies against donor plasma proteins
- especially in IgA-deficient patients with anti-IgA antibodies.
How do we treat allergic transfusion reactions?
- antihistamines
- treat symptoms
Not all noncardiogenic pulmonary edema reactions are what?
What are S/S of Noncardiogenic pulmonary edema transfusion reactions?
- ARDS
- Fever
- Chill
- Hypotension
- Cyanosis
Not all noncardiogenic pulmonary edema tranfusion reactions are TRALI
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
Four criteria for trali?
What is TRALI?
Transfusion Related Acute Lung Injury - temporarily r/t to blood transfusion within 1st 6 hrs of a transfusion
* Acute onset hypoxemia
* PaO2/FiO2 ratio <300 or SpO2 <90% on RA
* B/L diffuse pulmonary infiltrates
* No volume overload
What types of blood products is TRALI most associated with this?
- FFP
- PLTs
What happens when too much product is given?
What are the 3 acute nonimmunologic (= not anaphylactic) effects of transfusion reaction?
- Bacterial contamination
- Circulatory overload (TACO)
- Hemolysis
What are the three delayed immunologic effects of transfusion reaction?
- Hemolytic transfusion reactions
- Transfusion associated Graft-versus-host disease
- Post-transfusion purpura
Fever? HoTN or HTN? EF? Responds to diuretics?
Differentiate between TACO and TRALI
* TACO is fluid overload- all s/s associated with that.
* NO fever
* HTN
* Decreased EF
* Responds well to diuretics
* TRALI:
* Fever
* HoTN
* Normal EF
* No response to diuretics
Can give crystalloids up until which point?
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%)
Can give crystalloids until Class III
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 has smaller amounts of anticoagulants
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
Which clotting factors require Ca++ to work?
- 2
- 7
- 9
- 10
Which drug has more elemental calcium; Ca gluconate or CaCl?
- CaCL (270 mg/10mL vs 90 mg/10ml for gluconate)
- Need ~ 3x the amount of CaGluconate
How much will 1, 2, and 5 units of blood decrease iCa?
- 1 unit = 1.13 mmol/L
- 2 unit = < 1mmol/L
- 5 units = < 0.8 mmol/L
What is it?
What is the value for TEG-ACT?
- 80-140 sec
- Activated clotting time to initial fibrin formation
What is R-Time? What does it measure? Short/prolonged values?
What is the normal value for R time?
- 5.0 - 10.0 min
- Reaction time, initial clot formation (time for first fibrin strand to appear)
- Measures coagulation factor activity, specifically intrinsic pathway clotting factors
- Prolonged R-time: Hypocoagulable
- Short R-time: Hypercoagulable
What is K time? What does it measure? Short/long values mean?
What is the normal value for K time?
- 1-3 minutes
- “Kinetic” time; the speed at which the clot reaches a 20mm amplitude on the TEG tracing
- Measures the speed at which fibrin builds and cross-links–> directly reflects fibrinogen function
- Short K time –> hypercoagulable state (high fibrinogen, pregnancy). Corresponds w/ a large a-angle
- Long K time –> prolonged clot formation (anticoags, low fibrinogen). Corresponds w/ a short a-angle
What is it/what does it measure? Small or large A-angle?
What is the normal value for α angle?
Inversely related to what?
- 53 - 72°
- The α-angle represents the rate of clot formation and reflects fibrin cross-linking and fibrinogen function
- Determined from the slope between R (reaction time) and K (kinetics time) on the TEG tracing.
- Small a-angle values indicate hypofibrinogenemia or the affects of anticoags
- Large a-angle values indicate hypercoagulable state
Inversely related to K-time
What is it? What does it measure? High or low values mean what?
What is the normal value for MA?
- 50-70mm
- Maximum amplitude of teg tracing; peak of clot firmness
- Measures platelet number and function
- High MA suggests increased clot strength
- Low MA indicates low fibrinogen or abnormal platelet function
What is it? What does it measure? High or low values?
What is the normal value for G value?
- 5.3-12.4 dynes/cm2
- Measures overall clot strength and function of the entire coagulation cascade
- Directly reflects platelet function and fibrin crosslinking
- High value indicates very strong clot, possible hypercoagulapathy. Increased risk of thrombosis
- Low value indicates weak clot, hypocoagulable states. Increased risk of bleeding
What is it? What does it measure? High or low values?
What is the normal value for LY 30?
- 0-3%
- Represents the proportion of the clot lost due to fibrinolysis at 30 minutes
- High LY30 indicates excessive fibrinolysis. The body is lysing the clots too quickly-> bleeding risk
- Low LY30 indicates hypercoagulopathic state. Body is failing to break clots down-> thrombosis risk
If TEG-ACT is > 140 what do we transfuse?
- FFP
If R time is > 10 what do we transfuse?
- FFP or prothrombin complex concentrate
If K time is > 3 what do we transfuse?
- Cryo because K time directly measures fibrinogen
If α angle < 53° what do we transfuse
- Cryo and platelets
If MA < 50 what do we transfuse?
Check fibrinogen and platelet mapping
FF low—> give cryo
Platelet mapping abnormal —> give platelets
If LY30 is >3% what do we transfuse?
TXA (Tranexamic Acid)
- R-Time
- K-time
- A-angle
- Maximum amplitude
- LY-30
- Shows time in minutes
- This side of the graph indicates coagulation
- This side indicates fibrinolysis
Hypocalcemia is the most critical variable in determining what during MTP?
Mortality
Conditions we see traumatic hypocalcemia in?
What is traumatic hypocalcemia?
- Citrate is metabolized in the liver- but in shock or liver dysfunction/injury, citrate accumulates, exacerbating calcium depletion.
- Hemorrhage leads to hypothermia –> further decreasing citrate metabolism
- Traumatic hypocalcemia is common in massive transfusion, hemorrhage, and shock
Delayed NONimmunologic effect from transfusions?
-Transfusion induced hemosiderosis
Can Rh (+) blood receive Rh (-)?
Can Rh (-) blood receive Rh (+)?
- Rh (+) can receive Rh (-)
- Rh (-) cannot receive Rh (+)
What are the 2 main components of blood?
- Plasma at 55%
- Formed elements at 45%
What is the largest component of whole blood?
Plasma
What are the components of plasma in blood?
- water at 92%
- Proteins at 7%
- Other solutes such as ions, nutrients, waste products, and gases at 1%
What are the components of formed elements in blood?
- Erythrocytes
- Platelets
- Leukocytes (lymphocytes, neutrophils, basophils, eosinophils, etc)
What surgeries are at increased risk for needing a blood transfusion?
What lab work needs to be done pre-op?
- Liver transplant
- Cardiac bypass surgery
- Any vascular cases
- Abdominal surgery
- Type and screen needs to be done pre-op on these patients.
If you have a patient that starts bleeding and you don’t have a type and screen done, what blood products can be given?
- Uncrossmatched blood
- Type specific blood if all you know is the type. EX: AB blood for AB type.
- The further you get from doing a type and screen, the higher the risk for a transfusion reaction.
True/False
You can change a patients blood type after administering large amounts of blood.
True
What is the blood transfusion history from WWI to the vietnam war?
- Whole blood was preferred for bleeding in surgery or major trauma.
- This was the primary resuscitation fluid method in the military.
- They tried to stick with type specific but adverse reactions did happen.
What is the blood transfusion history from the 1970s - 1990s?
- We transitiond from whole blood to component blood therapy.
- This allowed for reduced waste, increased storage times/shelf life, and targeted specific deficiencies.
What was the initial indication for using normal saline?
- To IV rehydrate in Cholera patients.
- NS is not a good resuscitation product because it just diffuses out into the interstitium after 30 minutes. It also diltes all the colloids and whole blood components you need in your vasculature to keep your blood pressure up.
Why can you not give LR with blood products?
It causes clotting in your line because there is calcium in LR.
What is the blood transfusion history from the 1900s - early 2000s during Iraq and Afghanistan wars?
- Fresh whole blood was the cornerstone of resuscitation.
- Walking blood bank
What is the blood transfusion history today?
- Multiple level 1 trauma centers are adopting fresh whole blood transfusion strategies
- Walking blood bank from a pre-identified group of blood donors.
When are leukoreduced or irradiated PRBCs used?
In patients that have cancer or are immunosuppressed.
How are packed red blood cells derived?
By taking whole blood and removing 200-250mL of plasma from it.
What are the contents of packed red blood cells?
- Red blood cells
- some plasma
How many mLs are in 1 unit of PRBCs?
200-500mL
What is not contained in a unit of PRBCs?
- Functional platelets
- Granulocytes
What is the intended use for a PRBC infusion?
To increase the O2 carrying capacity in anemic patients who require an increase in their red cell mass w/out increase in their blood volume.
True/False
PRBCs have the same O2 carrying capacity as whole blood
True
How is FFP derived?
By removing plasma from whole blood within 8 hours of collection.
How many mLs are in 1 bag of FFP?
200-250mL
What is the shelf life of FFP?
- Expires 12 months after donation when kept frozen.
- If thawed for use, the shelf life is only 72 hours.
At what temperature is FFP stored?
- -18C or below
What are the 3 different variations of plasma?
- FFP which requires thawing and takes time
- Liquid plasma which is only available on some hospitals
- Freeze dried plasma which lengthens shelf life. This is new
What is the standard test used to evaluate blood clotting?
INR
What is the INR of FFP?
- 1.5 to 1.8
- If you are using FFP to treat an INR, you cant get lower than 1.5
How is cryoprecipitate derived?
It is the protein fraction taken off the top of the FFP when being thawed
What is the shelf life of cryoprecipitate?
12 months if kept frozen
How much will two units of cryo raise fibrinogen levels?
- 2 bags of cryo/10 kg body weight = 100 mg/dL ↑ in fibrinogen
- except in cases of DIC or continued bleeding with massive transfusion.
What are the components of a unit of platelets?
Platelets/ thrombocytes only
What is the indication for a platelet infusion?
- Thrombocytopenia
- Prophylaxis for invasive procedures such as lumbar punctures and epidurals.
- DIC
- Bleeding/hemorrhage
How many mLs are in a bag of platelets?
- Random value and can differ from facility to facility.
- Often times you will see a bag of platelets pulled together from multiple donors to form a 6 unit or 10 unit bag of platelets.
Is there any clinical data that says warming platelets is bad?
- No its a common practice → no data to support not warming platelets
- It doesn’t functionally matter, but it does matter academically. It will decrease your platelet count if you give it warmed from 255,000 to 253,000, which in the grand sceme of things doesn’t really make much of a difference.
- When you warm platelets they aggregate.
How many mLs are in a unit of whole blood?
400-500mL
This is a higher volume than any of the component blood therapies.
What is the storage temperature for whole blood?
1-6C
Not kept frozen just kept cool.
What is the shelf life of whole blood?
3-5 weeks
Less additives
What anesthesia considerations are there for blood product administration?
- Blood must be given through an FDA approved warming device such as a belmont or level 1.
- The preferred IV to prime your blood tubing with or to give along with blood transfusions is normosol or plasmalyte because it is pH balanced.
- NS would be your next choice however it can cause acidosis.
- Don’t prime with LR
- If you prime with plasma, your blood will flow faster and better.
- Current recommendation is to not give platelets through the warmer, however this may go away in a few years.
