Blood Products/Transfusion Flashcards
Blood composition picture
Different types of hemoglobin picture
Hemoglobin molecule picture
The universal donor is:
O (-)
Universal acceptor/receipient
AB (+)
Blood types is separated into what two categories?
What is included in these?
Antigens:
- A
- B
- AB
- O
Rh factor:
- Rh+ = ~85%
- Rh- = ~15%
Oxyhemoglobin dissociation curve
(this card is only here to put the graphs in the deck)
What are RBCs used for?
Oxygen transport
Blood typing chart
Compatibility among ABO blood groups chart
What does the + or - mean?
(-) = no reaction
+ = reaction
Types of transfusions chart
What specific gravity are RBCs prepared on?
1.08-1.09
What specific gravity are platelets prepared on?
1.03-1.04
Blood component preparation is done by what 2 things?
- Based on different specific gravities
- By using differential centrifugated blood components separated into layers
From a unit of whole blood, the centrifuged product settle out into what 3 things?
RBC,WBC & platelet-rich plasma (PRP).
_____ is heavier than _____ & will settled at the bottom of the bag.
Platelet
Plasma
Blood component therapy includes:
RBC
FFP
Cryo
PLT
LTOWB
During what historical event was whole blood preferred for bleeding in surgery/major trauma?
World War I
Vietnam War
When did the transition of whole blood to component therapy happen?
1970s-1990s
What are the benefits of component therapy?
- reduced waste
- increased storage times
- target specific deficiencies
What was the “Cornerstone of resuscitation”?
Iraq + Afghanistan - fresh WB
How is storage of blood achieved?
Explain each component
By adding Citrate phosphate dextrose adenine (CPDA-1)
- Citrate for chelation of calcium to prevent clotting
- Phosphate as a buffer
- Dextrose as a fuel source
- Adenine as a substrate for the synthesis of ATP extending storage time from 21 to 35 days
The longer blood is stored, the lower are the levels of _____, shifting the oxyhemoglobin dissociation curve to the ____, which impairs _____ ______.
2,3-DPG
left
oxygen delivery
________ are derived from whole blood from which the plasma has been removed
These contain _____ unless they have been specifically leukoreduced
PRBCs
leukocytes
What are the two broad categories that make of the composition of blood?
Elements (wbc, rbc, plts)
Plasma
What is the largest component of whole blood?
Plasma
What are examples of procedures with increased risk of transfusion?
Liver transplant
Vascular
Major abdominal surgery
Bypass
Why do we avoid giving O+ blood to child-bearing aged women?
Increased risk of fetal incompatibility
What is cryo?
Rich clotting factors
- protein fraction taken off the top of the FFP when being thawed
What is LTOWB?
Low titer O whole blood
- pre-identified donors that were screened for antibodies → low risk for transfusion reactions
How are RBC prepared?
What is the normal volume of one bag of RBC?
By removing 200-250ml of plasma from a unit of W.B.
200-350 ml
T/F
PRBCs do not contain functional platelets or granulocytes
True
T/F
PBRCs have the same O2 carrying capacity as whole blood
True
What are RBCs intended for?
To increase the O2 carrying capacity in anemic pt who require an increase in their red cell mass w/out increase in their blood volume
How much does 1 PRBC increase hgb and hct?
Hgb: 1 g/dL
Hct: 3%
How are FFPs prepared?
What is the normal volume in one bag?
By removing plasma from W.B w/in 8H of collection
200-250 ml
What is the source for antithrombin III?
FFP
How long until FFPs expire?
12 months after donation
What is the dose for FFP?
10-15 ml/kg
What are FFPs stored at?
-18 C or below
How much does 1 unit of FFP increase clotting factors?
2%-3%
What does one unit of FFP contain?
Water, carbohydrates, fats, minerals, proteins (all labile and stable clotting fx)
Indication for use of FFP chart
How do we evaluate clotting?
INR
How long until cryo expires?
Frozen up to 1 year
What does cryo contain?
Factor VII (C)
Factor VIII (vWF)
Factor XIII
Fibrinogen
What is cryo stored at?
-18C or below
How much would you expect the fibrinogen to increase with 2 units of cryo/10 kg of body weight?
What’s the exception?
100 mg/dL
- in cases of DIC or continued bleeding with massive transfusion
Indication for cryo chart
How are platelets prepared?
What’s the normal volume for one bag?
Prepared by cytapheresis/by separating PRP from a unit of W.B w/in 8H of collection & recentrifuged to remove plasma.
Random value
What does one unit of platelets contain?
Trick question
Only platelets
How much does your plt count increase with 1 unit of plts?
5,000-10,000
What type of IVF can you not give with blood products?
Why?
LR
LR causes clotting d/t the calcium in it
What is currently under study right now regarding platelets?
If you can warm them or not
Indication for platelets chart
What does the AABB guidelines currently say to use for priming blood administration tubing?
Electrolyte-R pH 7.4 (Normosol/plasmalyte)
NS 0.9%
What is the normal volume of 1 bag of whole blood?
What is the storage temp?
400-500 ml
1-6 C
What is the indication for whole blood?
to maintain blood volume & O2 carrying capacity in acute, massive blood loss.
- Actively bleeding pt>20% of body blood volume.
Complications of blood transfusion chart for acute
Complications of blood transfusion chart for delayed
Mediators of hemolytic transfusion reaction
IgM A/b (usually ABO), complement
S/S of hemolytic transfusion reaction
fever, chill, hemoglobinemia, hemoglobinuria, hypotension, dyspnea
Treatment/prevention of hemolytic transfusion reaction
ecrease opportunities for error, treat ARF & DIC.
What can you assess for hemolytic transfusion reaction if pt is under anesthesia?
Physical signs
hypotension
Hemoglobinuria
Mediators of non hemolytic febrile transfusion reaction
A/b to HLA Class I Ag.
S/S of Nonhemolytic febrile transfusion reactions
Fever, chills
Treatment/prevention of Nonhemolytic febrile transfusion reactions
antipyretics, leukocyte reduced
Mediators of allergic transfusion reaction
plasma proteins(mild reactions), A/b to IgA(anaphylactic reactions)
S/S of allergic transfusion reaction
urticaria, erythema, itching, anaphylaxis
Treatment/prevention of allergic transfusion reaction
antihistamines; treat sx, transfuse IgA-deficient components
Mediators of Noncardiogenic pulmonary transfusion reactions
donor/recipient WBC A/b.
Treatment/prevention of noncardiogenic pulmonary transfusion reactions
vigorous respiratory support (PEEP), steroids, diuretics
S/S of noncardiogenic pulmonary transfusion reactions
ARDS, fever, chill, cyanosis, hypotension, noncardiogenic pulmonary edema
What is TRALI?
Transfusion Related Acute Lung Injury
- defined as an acute lung injury that is temporally related to a blood transfusion; specifically, it occurs within the first six hours following a transfusion.
Why is the true incidence of TRALI unknown?
because of the difficulty in making the diagnosis and because of underreporting
What is the estimated number of incidence of TRALI?
1:1300 to 1:1500
Mortality rate of TRALI
It ranges from 5% to 25% with most patients recovering within 72 hours.
What type of blood product is TRALI most associated with?
Plasma components (FFP, plts)
What happens in TRALI?
Leukoagglutination and pooling of granulocytes in the recipient’s lungs may occur, with release of the contents of leukocyte granules, and resulting injury to cellular membranes, endothelial surfaces, and potentially to lung parenchyma. In most cases leukoagglutination results in mild dyspnea and pulmonary infiltrates within about 6 hours of transfusion, and spontaneously resolves.
What is the criteria for TRALI?
- Acute onset hypoxemia.
- Ratio of Pao2/FiO2 <300 or SpO2 <90% on room air.
- Occur during or within 6 hours of transfusion.
- B/L diffuse pulmonary infiltrates
- No evidence of left atrial hypertension(i.e. circulatory overload).
S/S of TRALI
Dyspnea/ respiratory distress requiring o2 support-virtually all.
Requiring mechanical ventilation-70%
Documented hypoxemia- virtually all
Cyanosis-very common.
Hypotension- majority.
Fever-very common
Clinical exam reveals respiratory distress and pulmonary crackles may be present with no signs of congestive heart failure or volume overload.
T/F
TRALI is due to the volume overload, and has symptoms such as JVD or enlarged atrium
False
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 and chest radiography
- Notify the blood bank of possible TRALI request a different unit and quarantine other unit from the same donor.
What are the 3 acute nonimmunologic effects associated with transfusion?
- Bacterial component
- Circulatory overload (TACO)
- Hemolysis d/t physical/chemical means
Mediators of bacterial contamination
endotoxins produced by GN bact.
S/S of bacterial contamination
fever, shock, hemoglobinuria.
Treatment/prevention of bacterial contamination
IV ABX; treat hypotension & DIC.
Mediators of TACO
fluid volume.
S/S of TACO
coughing, cyanosis, orthopnea, severe headache, peripheral edema, diff breathing.
Treatment/prevention of TACO
administer subsequent Tx slowly & in a small volume
Mediators of Hemolysis d/t physical/chemical means
exogenous destruction of RBC.
S/S of Hemolysis d/t physical/chemical means
hemoglobinuria.
Treatment/prevention of Hemolysis d/t physical/chemical means
document & rule out hemolysis d/t other causes; treat DIC.
What are the 3 delayed immunologic effects associated with transfusion?
- Hemolytic transfusion reactions
- Transfusion associated Graft-versus-host disease
- Post-transfusion purpura
Mediators of Hemolytic transfusion reactions
IgG A/b
S/S of Hemolytic transfusion reactions
shortened RBC survival, decreased Hb, fever, jaundice, hemoglobinuria
Treatment/prevention of Hemolytic transfusion reactions
Ig-negative blood for further transfusions.
Are delayed or acute effects of transfusion more common?
What’s the exception?
Delayed
TACO or TRALI
Mediators of Transfusion associated Graft-versus-host disease
viable donor lymphocytes
S/s of Transfusion associated Graft-versus-host disease
fever, skin rash, desquamation, anorexia, nausea, vomiting, diarrhea, hepatitis, pancytopenia
Treatment/prevention of Transfusion associated Graft-versus-host disease
gamma irradiation of cellular components.
Mediator of Post-transfusion purpura
platelet specific A/b
S/S of Post-transfusion purpura
thrombocytopenia, clinical bleeding
Treatment/prevention of Post-transfusion purpura
IV Ig, plasma exchange, corticosteroids
TRALI vs TACO
What is an example of delayed. nonimmunologic effects?
Mediated by what?
Transfusion-Induced Hemosiderosis.
- Iron overload
S/S of Transfusion-Induced Hemosiderosis.
Subclinical to death
Treatment/prevention of Transfusion-Induced Hemosiderosis.
decrease frequency of transfusion, neocytes, iron chelation therapy.
Hemorrhage table
We will see this table per Cornelius
Criteria for MTP
1) Total blood volume is replaced within 24 hours
2) 50% of total blood volume is replaced in 3 hours
3) Rapid bleeding rate = 4 units RBCS transfused within 4 hours or 150 mL/min blood loss
MTP in children
> 40 mL/kg transfusion
What is the current product transfusion ratio for MTP?
1:1:1
plts:plasma:RBC
Considerations of 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
Whole blood vs component therapy chart
Fibrinogen levels
LTOWB-1000mg
FFP-400mg
Cryo-2500mg
Considerations/info of stored whole blood
Contains all components of blood products
- Smaller amounts of anticoagulants
Single product
- One storage modality
FDA approved when appropriately collected, stored and tested
- Cold - 2-6 degrees C
- Storage - 21-35 days
- Hemostatic capability - 14-21 days
- Testing - same as blood components
Considerations/info of LTOWB
Stored whole blood = preferred resuscitation product
- Universal donor = low-titer type O whole blood (LTOWB)
Trauma patients with unknown blood types
- Pre-transfusion blood sample determine blood type
- Additional transfusions require LTOWB or group O RBCs for 1 month after initial transfusion
WB programs are a highly regulated process by what 2 organizations?
FDA and AABB
WB program coordination with a blood supplier includes:
UT Health Protocol - Daily inventory = 20 units
- Group O (male-only donors) + anti-A/B titers <1:200
- 21-day expiration + no leukoreduction
RH- blood is typically for:
RH- females of child-bearing age
RH+ blood is usually for:
Males (product of choice)
Oschner LSU LTOWB info:
- Currently have an average of 1.5 mtp’s weekly
- Will receive 6 units of whole blood every week
- Units will remain available as ltowb for 21 days
- Will primarily be utilized for the mtp but may be offered for other needs dependent on product availability
WB special considerations
Few studies in pediatric patients
- No established clinical criteria
Recommendations:
- Age <15 or weight <40 kg
- limit WB to 30 mL/kg
Calcium plays a significant role in:
coagulation
platelet adhesion
contractility of myocardial and smooth muscle cells
What things require calcium?
- clotting factors II, VII, IX and X
- proteins C and S for activation at the damaged endothelium
____% of trauma MTP pts are hypocalcemic at what level?
97.4
<1.12 mmol/L
Low calcium can cause:
long QTc, decreased cardiac output, coagulopathy, seizures
____% of trauma MTP pts have severe hypocalcemia at what level?
50-70%
<0.8-0.9 mmol/L
Once you are severely hypocalcemic (<0.8-0.9 mmol/L) what is the mortality?
49%
vs normal 24%
What is traumatic hypocalcemia?
- Citrate is metabolized in the liver
- Citrate in blood bags insignificant in a healthy liver
- Hemorrhage leads to hypothermia and decreased iC++
Hypothermia+Liver Injury=Decreased Citrate Metabolism
What is the lethal triad in trauma?
Hypothermia, acidosis, coagulopathy
Is calcium chloride or gluconate preferred?
What’s the exception?
Gluconate preferred IV
Chloride may be preferable to calcium gluconate in the presence of abnormal liver function
TEG component picture
What are the different components?
- R time → reaction time
How long from time clot is exposed to until it starts forming - K time→ how long it takes clot to get firm
- Angle → how long it takes to get to firmness
- MA– how strong clot gets
- LY30→ how long does it take to lyse clot
TEG interpretation picture
- If reaction time is prolonged, you can give FFP or PCC
- If clot is too weak (MA weak), maybe can do platelet mapping or give platelets
- If Ly30 is too high, clot is getting lysed too fast, they need TXA
What is the benefit of doing a TEG?
Less transfusion reactions
THROMBOELASTOGRAM GUIDE
THROMBOELASTOGRAM GUIDED TREATMENT
TEG example chart
- Heparin /warfarin → prolonged reaction time
- Hyperfibrinolysis – they form nice clot but it breaks down too quickly
- Hypercoagulable state → they start clotting at a normal period of time, but then it goes off the rials and you get a big clot
- Bottom right – end stage of DIC b/c of depletion of clotting factors
