Blood Products and Transfusion (Exam III)- Corndog Flashcards
1
Q
What are the 2 main components of blood?
A
- Plasma at 55%
- Formed elements at 45%
2
Q
What is the largest component of whole blood?
A
Plasma
3
Q
What are the components of plasma in blood?
A
- water at 92%
- Proteins at 7%
- Other solutes such as ions, nutrients, waste products, and gases at 1%
4
Q
What are the components of formed elements in blood?
A
- Erythrocytes
- Platelets
- Leukocytes (lymphocytes, neutrophils, basophils, eosinophils, etc)
5
Q
What are 2 Hgb related issues we will see often in clinical settings?
A
- β thalassemia → Hgb Barts
- α thalassemia → Hgb H
6
Q
What is the universal blood donor?
A
O negative
7
Q
What is the universal blood acceptor/recepient?
A
AB positive
8
Q
What percent of the population is Rh factor positive +?
A
85%
9
Q
What percent of the population is Rh factor negative -?
A
15%
10
Q
Can Rh (+) blood receive Rh (-)?
Can Rh (-) blood receive Rh (+)?
A
- Rh (+) can receive Rh (-)
- Rh (-) cannot receive Rh (+)
11
Q
How does Rh Factor affect blood compatibility?
Antigens & Antibodies of Blood Products
A
- 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
12
Q
What surgeries are at increased risk for needing a blood transfusion?
What lab work needs to be done pre-op?
A
- Liver transplant
- Cardiac bypass surgery
- Any vascular cases
- Abdominal surgery
- Type and screen needs to be done pre-op on these patients.
13
Q
If you have a patient that starts bleeding and you don’t have a type and screen done, what blood products can be given?
A
- 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.
14
Q
True/False
You can change a patients blood type after administering large amounts of blood.
A
True
15
Q
Which patient is the potential exception to accepting blood from an O+ donor?
If we have to how can we compensate for this?
A
- Pregant women d/t fetus possibly being O+
- Rhogam
16
Q
What types of O blood can males recieve as donar blood?
A
O+ and O-
17
Q
O (+) Blood:
Antigens present?
Antibodies present?
Can donate to? Receive from?
A
- Antigen: None
- Antibodies: Anti-A, Anti-B
- can donate to O+, A+, B+, AB+
- Can receive blood from O+ and O-
18
Q
O (-) Blood:
Antigens present?
Antibodies present?
Can donate to? Receive from?
A
- Antigen: None
- Antibody: Anti-A, Anti-B, Anti-Rh
- Can be donate to by almost everyone
- can only receive from O (-)
19
Q
AB (+) Blood:
Antigens Present?
Antibodies Present?
Can donate to? Receive from?
A
- Antigens: A, B, and Rh+
- Antibodies: None
- Can only donate to AB + because of the antigens present
- Can receive all blood types because this blood type has NO antibodies created against RBC antigens
20
Q
AB (-) Blood:
Antigens Present?
Antibodies Present?
Can donate to? Receive from?
A
- Antigens: A, B
- Antibodies: Anti-Rh
- Can only donate to AB-
- Can receive all (-) blood types
21
Q
B (+) Blood:
Antigens Present?
Antibodies Present?
Can donate to? Receive from?
A
- Antigen: B, Rh
- Antibody: Anti-A
- Can donate to: B+, AB +
- Can receive from: B+, B-, O+, O-
22
Q
B(-) Blood:
Antigens Present?
Antibodies Present?
Can donate to? Receive from?
A
- Antigen: B
- Antibody: Anti-A, Anti-Rh
- Can donate to: B+, B-, AB+, AB-
- Can receive: B-, O-
23
Q
A (+) blood:
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-
24
Q
A (-) blood:
Antigens Present?
Antibodies Present?
Can donate to? Receive from?
A
- Antigen: A
- Antibody: Anti-B, Anti-Rh
- Donate to: A+, A-, AB-, AB+
- Can receive: A-, O-
25
# 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 (-)
26
Which blood types cannot receive AB Antigen blood?
* A, B, O
27
Which blood type cannot receive B Antigen Blood?
* A
* O
28
Which blood type cannot receive A antigen blood?
* B
* O
29
What 4 things can cause a right shift of the OxyHb curve?
* ↓ pH (because you have an increase in acid)
* ↑ CO2
* ↑ temp
* ↑ 23-DPG
30
When whole blood is centrifuged what separation products result?
* RBC
* WBC
* Platelet rich plasma (PRP)
31
What happens if we further centrifuge platelet rich plasma (PRP)?
* The plasma and platelets seperate, with platelets settling at the bottom of the bag because they are heavier.
32
Where is PRP used in surgery?
* Surgeon injects locally → ortho, dental, plastics cases commonly
33
What are the 5 different blood components we can use for treatments?
* RBC
* FFP
* Cryo
* PLT
* LTOWB - Low titer Group O Whole Blood
34
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.
35
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.
36
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.
37
Why can you not give LR with blood products?
It causes clotting in your line because there is calcium in LR.
38
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
39
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.
40
What chemicals are added to blood that allows it to be stored?
**CPDA-1 ** is added. It contains: Citrate phosphate dextrose adenine;
* Citrate >> chelates Ca++ to prevent clotting
* Phosphate → used as buffer
* Dextrose → fuel source
* Adenine → to support ATP synthesis (extends storage from 21 to 35 days)
41
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 ↑)
42
Which electrolyte will stored blood always have ↑ levels of? Why?
* K+ d/t cells lysing as they degrade in the bag
43
What happens to 2,3-DPG in stored blood?
What does this do to the OxyHb association curve?
* ↓ 2,3-DPG, the longer the blood is stored
* Left shift → impairs O2 delivery
* The longer the whole blood sits, the less functional it becomes
44
PRBCs contain ____ unless they have been specifically ________?
* Leukocytes (WBCs)
* Leukoreduced
45
When are leukoreduced or irradiated PRBCs used?
In patients that have cancer or are immunosuppressed.
46
How are packed red blood cells derived?
By taking whole blood and removing 200-250mL of plasma from it.
47
What are the contents of packed red blood cells?
* Red blood cells
* some plasma
48
How many mLs are in 1 unit of PRBCs?
200-500mL
49
What is not contained in a unit of PRBCs?
* Functional platelets
* Granulocytes
50
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.
51
True/False
PRBCs have the same O2 carrying capacity as whole blood
True
52
How much does 1 unit of PRBCs ↑ H&H level?
* Hb: ↑ 1 g/dL (10g/L)
* Hct: ↑ 3%
53
How is FFP derived?
By removing plasma from whole blood within 8 hours of collection.
54
Which blood transfusion product is a source of antithrombin III?
FFP
55
How many mLs are in 1 bag of FFP?
200-250mL
56
What are the contents of FFP?
* Water
* Carbohydrates
* fats
* minerals
* Proteins
* All labile and stabile clotting factors
57
What is the intended use for an FFP infusion?
* Heparin resistance d/t antithrombin III deficiency
* Treat angioedema (also use TXA along with FFP)
* to replace volume in burn patients
* BLEEDING
* In hypovolemic patients secondary to low oncotic pressure
* Reversal of vitamin K anagonists such as warfarin.
* Liver dysfunction with signs of active bleeding
* DIC
58
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.
59
What is the dose of FFP?
* 10-15 mL/kg
60
At what temperature is FFP stored?
* -18C or below
61
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
62
How much will 1 unit of FFP ↑ level of each clotting factor?
* ↑ 2 to 3% for each factor in adults.
63
What is the standard test used to evaluate blood clotting?
INR
64
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
65
How is cryoprecipitate derived?
It is the protein fraction taken off the top of the FFP when being thawed
66
What are the contents/clotting factors of cryoprecipitate?
* Factor VII: C (coagulation activity)
* Factor VIII: vWF
* Factor VIII
* Fibrinogen
67
What are the indications for a cryoprecipitate tranfusion?
* Patients getting massive transfusion
* massive hemorrhage
* Systemic depletion of clotting factors
* Congenital bleeding disorders such as hemophilia and vWB deciciency.
68
What is the shelf life of cryoprecipitate?
12 months if kept frozen
69
What temperature is cryoprecipitate stored at?
* -18C and below
70
What target of fibrinogen are we trying to maintain when using cryo?
100 mg/dL
71
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.
72
Which patient population is cryo really important for?
* Pregnant women who are bleeding
73
How are platelets derived?
By cytapheresis by seperating PRP from a unit of whole blood within 8 hours of collection and recenturfuged to remove the plasma from the PRP
74
What are the components of a unit of platelets?
Platelets/ thrombocytes only
75
What is the indication for a platelet infusion?
* Thrombocytopenia
* Prophylaxis for invasive procedures such as lumbar punctures and epidurals.
* DIC
* Bleeding/hemorrhage
76
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.
77
Which blood product has an ↑ risk of infection and why?
* Pooled packs such as platelets d/t being from multiple donors
78
How much will one unit of PLT increase PLT count by?
* 5000 to 10000
79
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.
80
When platelets are low at what level will we start to spontaneously bleed?
PLT < 30000
81
What is whole blood?
A source of product for all blood components combined
82
What is the indication for a whole blood transfusion?
* Blood loss due to hemorrhage
* To maintain volume and O2 carrying capacity in acute massive hemorrhage (> 20% blood volume loss )
83
What are the components of whole blood?
* All cells
* Platelets
* Clotting factors
* Plasma
84
How many mLs are in a unit of whole blood?
400-500mL
This is a higher volume than any of the component blood therapies.
85
What is the storage temperature for whole blood?
1-6C
Not kept frozen just kept cool.
86
What is the shelf life of whole blood?
3-5 weeks
Less additives
87
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.
88
What is the lethal triad when transfusing a patient?
* Hypothermic
* Coagulopathic
* Acidotic
89
What is the deadly diamond when transfusing a patient?
* Hypothermic
* Coagulopathic
* Acidotic
* Hypocalcemia
90
What are mediators of hemolytic transfusion reactions?
IgM antibodies immediately bind to the transfused ABO-incompatible RBCs.
91
What are S/Sx of Hemolytic transfusion reaction?
* fever (late sign)
* chill
* hemoglobinemia
* hemoglobinuria
* hypotension
* dyspnea.
92
How do we treat hemolytic transfusion reactions?
* Decrease opportunities for error
* Treat ARF and DIC
93
What are the anesthesia considerations for hemolytic transfusion reactions?
* Hypotension could be hard to pinpoint what is causing it since we also give drugs that cause hypotension.
* Get a foley so you can monitor urine output and check for signs of hemoglobinuria.
* Fever is a late finding in these patients
* Morbidity and mortality is very high in these patients.
94
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
95
What are the S/S of nonhemolytic febrile transfusion reactions?
Fever and chills
96
How do we treat Non-hemolytic febrile transfusion reactions?
* Antipyretics
* Use leukocyte reduced products
97
What are the mediators of allergic transfusion reactions?
* IgE antibodies against **donor plasma proteins**
* especially in IgA-deficient patients with anti-IgA antibodies.
98
What are some S/S of an allergic transfusion reaction?
* urticaria
* erythema
* itching
* anaphylaxis.
99
How do we treat allergic transfusion reactions?
* antihistamines
* treat symptoms
* Transfuse IgA-deficient components.
100
What are the mediators for a non-cardiogenic pulmonary transfusion reaction?
Recipient WBC antibodies
101
What are S/S of Noncardiogenic pulmonary edema transfusion reactions?
* ARDS
* Fever
* Chill
* Hypotension
* Cyanosis
* Noncardiogenic pulmonary edema
102
How can we detect noncardiogenic pulmonary transfusion reactions under anesthesia?
* Looking for cyanosis around the lips.
* The most common signs we can detect at the head of the bed will be pulmonary.
* Decreased airway pressures
* Pink frothy secretions in your circuit tubing.
103
How do we treat Non-cardiogenic pulmonary transfusion reactions?
* Lots of PEEP
* Vigorous respiratory support
* Keep them intubated
* Steroids
* Lasix
104
What is the most common transfusion reaction?
* Allergic transfusion reactions.
* The most common symptom of this reaction is itching at the IV site and up through that arm.
* Rarely does this type of reaction lead to anaphylaxis.
105
# Four criteria for trali?
What is TRALI?
* Transfusion Related Acute Lung Injury that is temporarily related to a blood transfusion within 1st 6 hrs of a transfusion.
* It is typically associated with plasma components such as platelets and FFP, although cases have been reported with PRBCs since there is some residual plasma in the bag.
* You give someone a tranfusion and they end up with a lung injury.
106
What is the true incidence of TRALI?
It is unknown because of the difficulty in making the diagnosis and because of underreporting.
107
What is the incidence in patients getting TRALI in patients recieving plasma containing products?
1:1300 to 1:5000
108
What is the mortality rate for TRALI?
5-25%, however, most patients recover within 72 hours.
109
What is the criteria for TRALI?
* Acute onset hypoxemia
* Ratio of PaO2/FiO2 <300 or SpO2 <90% on room air.
* Occurs during or within 6 hours of transfusion.
* Bilateral diffuse pulmonary infiltrates.
* No evidence of left atrial hypertension or volume overload.
* Chest x-ray shows evidence of bilateral pulmonary edema unassociated with heart failure (non-cardiogenic pulmonary edema), with bilateral patchy infiltrates, which may rapidly progress to complete "white out” indistinguishable from Acute Respiratory Distress Syndrome (ARDS).
*
110
What S/S will you see with TRALI?
* Fever - very common
* acute onset hypoxemia
* Clinical exam reveals respiratory distress and pulmonary crackles may be present with no signs of congestive heart failure or volume overload.
* Cyanosis - very common
* Dyspnea
* Hypotension - majority
* Respiratory distress requiring O2 support or mechanical ventilation.
* No JVD
111
What types of blood products is TRALI most associated with this?
* FFP
* PLTs
112
What is the immediate management of TRALI?
* Stop the transfusion immediately
* Support the patient
* If the patient is intubated, obtain undiluted edema fluid as soon as possible(within 15 min) and simultaneous plasma for determination of total protein.
* Obtain CBC
* Get a chest X-ray
* Notify the blood bank of possible TRALI request a different unit and quarantine other unit from the same donor.
113
What are the 3 acute nonimmunologic effects of transfusion reaction?
* Bacterial contamination
* Circulatory overload (TACO)
* Hemolysis
114
What are the mediators for bacterial infection nonimmunologic effects of tranfusion reaction?
How does this occur?
* Endotoxins produced by GN tract.
* Not scrubbing the hub before IV administration of blood, dirty tubing, contaminated units.
115
What are the S/S for bacterial infection nonimmunologic effects of tranfusion reaction?
* Fever
* Shock
* Hemoglobinuria
116
What are the treatments for bacterial infection nonimmunologic effects of tranfusion reaction?
* IV antibiotics
* Treat hypotension and DIC
117
What is TACO?
* Transfusion associated circulatory overload.
* Essentially the same thing as TRALI, exept now we have the volume overload component.
* It is an acute nonimmunologic effect
118
What are the mediators of TACO nonimmunologic effects of tranfusion reaction?
fluid volme
119
What are the S/S of TACO nonimmunologic effects of tranfusion reaction?
* Coughing
* Cyanosis
* Orthopnea
* Severe headache
* Peripheral edema
* JVD
* difficulty breathing
* Third spacingWhat non immuno
120
What is the treatment of TACO nonimmunologic effects of tranfusion reaction?
* Administer subsequent blood slowly and in small volumes
121
What are the mediators of hemolysis nonimmunologic effects of tranfusion reaction?
Exogenous destruction of RBCs by physical or chemical means.
122
What are the S/S of hemolysis nonimmunologic effects of tranfusion reaction?
Hemoglobinurea
123
What is the treatment of hemolysis nonimmunologic effects of tranfusion reaction?
* document & rule out hemolysis d/t other causes;
* treat DIC.
124
What are the three delayed immunologic effects of transfusion reaction?
* 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.)
* Transfusion associated Graft-versus-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.)
* Post-transfusion purpura (MOA: platelet specific A/b.
S/S: thrombocytopenia, clinical bleeding.
Treatment and Prevention: IV Ig, plasma exchange, corticosteroids)
125
What complications are seen most often in the OR outside of TACO and TRALI?
The delayed immunologic complications are seen most often in the OR outside of TACO and TRALI
126
What is post transfusion purpura almost always confused with in the OR?
* Allergic reactions
* Get a CBC because a lot of times these patients may experience thrombocytopenia and they may need steroids , IVIg, or plasmapheresis.
127
What is another (4th) delayed nonimmunoligic effect that can happen with transfusion reactions?
* Transfusion induced hemosiderosis.
* The patient has an overload of iron from the transfusion.
* Typically it is not a big deal and it is a gradual progression.
* Very rarely will this be an acute event.
* Treatment = decrease frequency of transfusion and use iron chelation therapy.
* This is not a common problem we encounter.
128
Differentiate between TACO and TRALI
*** TACO** is fluid overload- all s/s associated with that.
* NO fever
* Hypertension
* Decreased EF
* Responds well to diuretics
*** TRALI:**
* Fever
* Hypotension
* Normal EF
* No response to diuretics
129
Type 1 Hemorrhage
* Blood loss in mL
* Blood loss in % volume
* Pulse
* Blood pressure
* Pulse pressure
* Respiratory rate
* Urine output
* Mental Status
* Fluid replacement (3:1) rule
* Blood loss in mL - up to 750mL
* Blood loss in % volume - up to 15%
* Pulse - <100bpm
* Blood pressure - normal
* Pulse pressure - normal or increased
* Respiratory rate - 14-20
* Urine output - >30mL/hr
* Mental Status - slightly anxious
* Fluid replacement (3:1) rule - Crystalloid
130
Type 2 Hemorrhage
* Blood loss in mL
* Blood loss in % volume
* Pulse
* Blood pressure
* Pulse pressure
* Respiratory rate
* Urine output
* Mental Status
* Fluid replacement (3:1) rule
* Blood loss in mL - 750-1500mL
* Blood loss in % volume - 15-50%
* Pulse - >100bpm
* Blood pressure - normal
* Pulse pressure - decreased
* Respiratory rate - 20-30
* Urine output - 20-30mL/hr
* Mental Status - mildly anxious
* Fluid replacement (3:1) rule - crystalloid
131
Type 3 Hemorrhage
* Blood loss in mL
* Blood loss in % volume
* Pulse
* Blood pressure
* Pulse pressure
* Respiratory rate
* Urine output
* Mental Status
* Fluid replacement (3:1) rule
* Blood loss in mL - 1500-2000mL
* Blood loss in % volume - 30-40%
* Pulse - >120bpm
* Blood pressure - decreased
* Pulse pressure - decreased
* Respiratory rate - 30-40
* Urine output - 5-15mL/hr
* Mental Status - anxious and confused
* Fluid replacement (3:1) rule - crystalloid and blood
132
Type 4 Hemorrhage
* Blood loss in mL
* Blood loss in % volume
* Pulse
* Blood pressure
* Pulse pressure
* Respiratory rate
* Urine output
* Mental Status
* Fluid replacement (3:1) rule
* Blood loss in mL - >2000mL
* Blood loss in % volume - >40%
* Pulse - >140bpm
* Blood pressure - decreased
* Pulse pressure - decreased
* Respiratory rate - >35
* Urine output - negligible
* Mental Status - confused and lethargic
* Fluid replacement (3:1) rule - crystalloid and blood
133
How much blood can we lose and still be ok?
We can lose about 1liter/ 20% of our blood without having any sort of signs and symptoms.
134
In what hemorrhage class should you move past the crystalloids and start administering blood?
Why?
* Class III
* Because they have had more than 20% blood loss and are more symptomatic
135
What is the best indication for determing blood loss amount in the OR?
What is the caution to this?
* Looking at the volume of blood in the suction cannister.
* Caution: That cannister may also include other fluid and products besides just blood such as sponges, laps, irrigation fluid.
136
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
137
What is considered MTP for Kids?
* > 40mL/kg transfusion
138
What is balanced resuscitation?
* 1:1:1 ratio (PLT:Plasma:RBC)
* This is the current standard of care in Level I trauma centers.
* The goal of balanced resuscitation is to reapproximate whole blood.
139
What issues do we run into with blood component therapy?
* Significant losses of coagulation factor + platelet function in reconstituted products (More anemic + thrombocytopenic + coagulopathic)
* Requires multiple products (Multiple donors = higher risk of infection)
* Dilute blood mixture
(Anticoagulants + multiple additive solutions)
140
Compare whole blood to component blood therapy.
Whole blood
* 570mL
* Hgb - 12-13
* Hct - 35-3Platelet - 138-165,000
* fibrinogen normal at baseline
* Factor VIII >50% d7
* TEG - nearly normal d21
* Platelet aggregation - greater than 50% baseline d7-10
* Practical aspects (4L) - 8bags, 1 storage mode, 8units = 4000mL
Component blood therapy (1:1:1)
* 660mL
* * Hgb - 9
* Hct - 28
* Platelet - 90-120,000
* fibrinogen all 62% dilution at baseline
* Factor VIII - loss of Favtor VIII
* TEG - reduced compared to whole blood
* Platelet aggregation - nearly complete loss d5 in RT-PLT
* Practical aspects (4L) - 13 bags, 3 storage modes, 6:6:1 = 4150mL
141
Is whole blood or component blood more superior for hemostatic potential?
* Whole blood
* 1 unit of whole blood = less dilution from anticoagulants andless additives than component blood therapy.
* Whole blood has a higher platelet count
* Whole blood uses less volume
* Whole blood has greater coagulation factor levels
142
What are the fibrinogen levels of Cryo, FFP, and LTOWB?
* Cryo = 2500 mg. This is the first choice you want to use)
* LTOWB = 1000 mg
* FFP = 400 mg
143
Describe stored whole blood
Stored whole blood
* contains all components of blood products
* Has smaller amounts of anticoagulants
* Is a single product and has only 1 storage modality
* Is FDA approved when appropriately collected, stored, and tested
* Stored at 2-6C
* Can be stored for 21-35 days
* Hemostatic capability is 14-21 days
* Stored whole blood is just like LTOWB, it has just been stored for a little bit longer.
* Testing is the same as blood components
* Is the preferred resuscitation product
144
Describe the implementation of whole blood programs
* There are a limited number of centers in the US that provide whole blood transfusions for massive hemorrhages.
* It is a highly regulated process through the FDA and american association of blood banks.
* Rh negative blood is used for females of child bearing age
* Rh positive blood is the product of choice for males
* A lot of whole blood programs started in Texas due to the military connection in san antonio.
* A lot of the whole blood research for pediatrics comes from pittsburg
145
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
* Few studies have been done in pediatric pateints due to no established clinical criteria.
* There is not a whole lot of research on using whole blood on pediatric traumas, however pediatric CV patients do use whole blood and there is more research in that area.
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What is the number 1 reason people activate the MTP?
To give blood quickly even if it is not always necessary. This can end up wasting a lot of blood products
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What causes hypocalcemia in MTP patients?
What is used to treated hypocalcemia in MTP patients?
* Cause = the additive citrate in blood products
* Calcium chloride
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What lab value indicates hypocalcemia?
What percentage of trauma MTP patients become hypocalcemic?
* iCal <1.12mmol/L
* 97.4%
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What lab value indicates severe hypocalcemia?
What percentage of trauma MTP patients become severely hypocalcemic?
* iCal<0.8-0.9mmol/L
* 50-70%
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Which clotting factors require Ca++ to work?
* 2
* 7
* 9
* 10
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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
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What happens to patients when they are severly hypocalcemic?
* Low blood pressure
* End up having to give even more blood products
* doubles the mortality rate
* Don't clot appropriately
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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
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What is citrate?
* An anticoagulant used in blood products for storage.
* It prevents clotting in the bag by binding to calcium, but can also cause hypocalcemia once the blood is administered.
* It is metabolized by the liver.
* Hemorrhage leads to hypothermia and also decreases ical.
* Hypothermia + a liver injury eill cause decreased citrate metabolism
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# What is it?
What is the value for TEG-ACT?
* 80-140 sec
* Activated clotting time to initial fibrin formation
* Measures clotting factors from the intrinsic and extrinsic pathway
* A TEG can give us a more tailored approach to determining what blood products we actually need. Therefore, we have less transfusion reactions
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# 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
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# 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
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# 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
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# 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
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# 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
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# 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
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If TEG-ACT is > 140 what do we transfuse?
* FFP
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If R time is > 10 what do we transfuse?
* FFP
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If K time is > 3 what do we transfuse?
* Cryo
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If α angle < 53° what do we transfuse?
* Cryo and platelets
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If MA < 50 what do we transfuse?
* PLT
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If LY30 is >3% what do we transfuse?
TXA (Tranexamic Acid)
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1. R-Time
2. K-time
3. A-angle
4. Maximum amplitude
5. LY-30
6. Shows time in minutes
7. This side of the graph indicates coagulation
8. This side indicates fibrinolysis
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T or F: If our O₂ saturation is good so is our PO₂?
* False → O₂ sat has nothing to do with PO₂ (could have 1 Hb fully saturated; ex. anemia)
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Hypocalcemia is the most critical variable in determining what during MTP?
Mortality
