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Basic Principles N928 > Blood Therapy > Flashcards

Blood Therapy Flashcards

1
Q

Purpose of Parenteral Fluid Therapy

A

maintenance fluids
replacement of fluids lost as a result of surgery and anesthesia
correction of electrolyte disturbances

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2
Q

Lactated Ringers avg ph

A

6.5

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3
Q

Lactated Ringers osmolarity

A

273mOsm/L

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4
Q

Lactated Ringers Electrolyte composition

A 
130 mM Na
109  mM CL
29 mM lactate
4mM K
2.7 mM Ca2+
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5
Q

Normal Saline pH

A

5

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6
Q

Normal saline osmolarity

A

308mOsm/L

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7
Q

Normal saline composition

A

154mM Na and Cl

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8
Q

Advantages of Crystalloids

A 
inexpensive
promotes urinary flow
restores third space loss
used for ECF replacement
used for initial resusitation
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9
Q

Disadvantages of Cystalloids

A 
dilutes plasma proteins
reduce capillary osmotic pressure
peripheral edema
transient
potential for pulmonary edema
osmotic diuresis
impaired immune response
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10
Q

Advantages of Colloid

A

sustained increase in plasma volume
requires smaller volume for resusitation
less peripheral edema
more rapid resuscitation

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11
Q

Disadvantages of Colloid

A

can cause coagulopathy (dextan >hetastartch >hextend)
anaphylatic reaction (dextan)
decreases Ca2+ (albumin)
can cause renal failure (dextran)

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12
Q

Main categories of IV fluids

A

crystalloids and colloids

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13
Q

Crystalloids

A

normal saline

lactated ringers

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14
Q

Colloids

A

albumin
plasmanate
dextran
hetastarch

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15
Q

Normal saline

A

hyperchloremic

metabolic acidosis

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16
Q

Lactated ringers

A

metabolic alkalosis

potassium accumulation in patients with renal failure

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17
Q

Colloids

A

solutions containing osmotically active substance of high molecular weight that do not easily cross the capillary membrane and space and expand circulating volume

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18
Q

Albumin

A

manufactured from pooled donor plasma

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19
Q

indications for albumin

A

treatment of shock d/t loss of plasma, acute burns, fluid resusicatation, hypo-albumineamia, following paracentesis, liver transplantation

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20
Q

Adverse reactions for albumin

A

pruritus, fever, rash, N&V, tachycardia

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21
Q

Albumin is supplied

A

5% and 25% solutions

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22
Q

Duration of Albumin

A

16-24 hours

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23
Q

Plasmanate

A

protein containing colloid

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24
Q

Indications of plasmanate

A 
hypovolemic shock (esp burn shock)
hypoproteinia (low protein states)
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25
Q

Adverse reactions of plasmanate

A

reactions, chills, fever, urticaria, N&V

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26
Q

Duration of Plasmanate

A

24-36 hours

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27
Q

Supplied of Plasmanate

A

5% solution in 250ml and 500ml

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28
Q

Dextran

A

artifical colloid: polysaccharides molecules

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29
Q

Indications of Dextran

A

improve micro-circulatory flow in microsurgeries, extracorporeal circulation during cardiopulmonary bypass

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30
Q

Adverse Reactions of Dextran

A

anaphylaxis, coagulation abnormalites, interference with cross match blood, precipitation of acute renal failure

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31
Q

Dextran Supplied

A

dextran 70

6% solution with average Mw 70,000;

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32
Q

Dextran 40

A

10% solution with avg Mw 40,000

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33
Q

Hetastarch

A

synthetic

made from plant starch

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34
Q

Indications of Hetastarch

A

hypovolemia

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35
Q

Max dose of hetastarch

A

20ml/kg

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36
Q

Adverse Reactions of Hetastarch

A

hypersensitivity, coagulopathy, hemodilution, circulatory overload, metabolic acidosis

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37
Q

Hetastarch is Supplied

A

Hespan 6% solution in NS

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38
Q

Duration of Hetastarch

A

24-36hour

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39
Q

Hextend

A

6% hetastarch in a buffered solution
lactate buffer
balanced electrolytes
physiologic glucose

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40
Q

Hextend Study

A

found that hextend could be given in volumes exceeding 20ml/kg without coagulopathy

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41
Q

Voluven

A

smaller molecule than other HES solution
less plasma accumulation
safer in patients with renal impairment
comparable effects on volume expansion & hemodynamics as other HES solutions
associated with fewer effects on coagulation
acceptable alternative to albumin

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42
Q

Blood component therapy

A

may be neccessary to increase oxygen carrying capacity increase intravascular volume, and restore hemostasis

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43
Q

Transfusion triggers

A 
perioperative blood loss
clinical condition of the patient
patient specific blood volume
calculation of allowable blood loss
access to patient blood type
patient preferences
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44
Q

Benefits of Blood Component Therapy

A

increased oxygen carrying capacity

improved coagulation

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45
Q

Risks of Blood Component Therapy

A

infection

incompatibility

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46
Q

Estimating Blood Loss (subjective)

A

measuring net suction volume and counting or weighing sponges
usually underestimated

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47
Q

Estimating Blood Loss (objective)

A

sodium fluorescein dye

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48
Q

Estimating Blood Loss

A

POC testing of Hgb or Hct

does not measure amount of blood loss

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49
Q

Clinical Symptoms of Patient

A

tachycardia
decreased mixed venous oxygen saturation
measurement of systemic oxygen delivery (DO2)

50
Q

Measuring DO2

A

DO2= CO xCaO2

51
Q

CO=

A

HR xSV

52
Q

HR x SV

A

preload
inotropy
afterload

53
Q

CaO2

A

1.34 x Hgb x SpO2 + 0.003 xPaO2

54
Q

Blood volume of full term infant

A

80-90ml/kg

55
Q

blood volume of infant

A

80ml/kg

56
Q

Blood Volume of Adults

A

65-70ml/kg

57
Q

BV of Obese Adult

A

50ml/kg

58
Q

Maximum allowable blood loss

A

EBV x (starting hematocrit - target hematocrit)/ starting hematocrit

59
Q

Establishing Blood Compatibility

A

Type and Screen
Antibody testing
Type and Cross

60
Q

Type and Screen

A 
ABO test
Rh Test (aka type D)
61
Q

Rh Positive test

A

Rh D Antigen

62
Q

Rh negative test

A

no Rh D antigen

63
Q

Type and Cross

A

ultimate test of blood compatibility

64
Q

Type A Blood Group Compatibility

A

A O
A antigen
Anti-B antibodies

65
Q

Type B Blood Group Compatibility

A

B O
B antigen
Anti-A antibodies

66
Q

Type AB Blood Group Compatibility

A

AB A B O

67
Q

Type O Blood group Compatibility

A

O
Anti- A antibodies
Anti-B antibodies

68
Q

RH +

A

RH+ and RH -

69
Q

RH -

A

RH-

anti-D if sensitized

70
Q

Universal Recipient

A

AB+

71
Q

Universal Donor

A

O-

72
Q

RBC

A

hemorrhage & improve oxygen delivery to tissues

73
Q

Indications for RBC

A

symptomatic in high risk patients
acute blood loss of > 30% BV
hemodynamically unstable patients

74
Q

FFP

A

reversal of anticoagulant effects

75
Q

Platelets

A

prevent hemorrhage in patients with thrombocytopenia or platelet function defects

76
Q

Cryoprecipate

A

hypofribinogenemia (setting of massive hemorrhage or consumptive coagulopathy)

77
Q

Changes in Banked Blood

A

depletion of 2,3 diphosphoglycerate (DPG)
Depletion of ATP
oxidative damage
increased adhesion to human vascular endothelium
acidosis
altered morphology of red blood cells (change shape, decreased flexibility)
accumulation of microaggregates
Hyperkalemia
absence of viable platelets
absence of factors V and V111
hemolysis
accumulation of pro-inflammatory metabolic and breakdown of products

78
Q

Transfusion Trigger

A

no single transfusion threshold should be based on the specific clinical situation
Hgb < 5g/dl significant mortality

79
Q

Hgb >10g/dl

A

usually unneccessary

80
Q

Hgb 6-10g/dl

A

based on clinical factors

81
Q

Hgb <6g/dl

A

usually neccessary

82
Q

Most common Surgical Procedures Requiring Transfusion

A 
orthopedic (especially hip and knee replacement)
colorectal 
cardiac
major vascular
liver transplant
trauma
83
Q

Patient blood management

A

strategy to reduce unneccessary transfusions and maximize patient outcomes

  1. optimize patient’s own red blood cell mass
  2. minimize blood loss
  3. optimize patient’s physiologic tolerance of anemia
84
Q

Preoperative Strategies

A

screen for and treat anemia
treat ion deficiency and administer erythropoiesis- stimulating agents as indicated
identify and manage any bleeding risks such as medications or chronic diseas
assess patient reserve adn optimize patient’s specific tolerable blood loss
formulate management plan with evidence- based transfusion strategy
pre-operative autologous blood donation in select situation
may require preop visit up to 30 days to elective surgery to accomodate therapy

85
Q

Intra-operative Strategies

A

perform elective surgery when hematologically optimized
use meticulous blood-sparing surgical techniques
continually measure and assess hemoglobin and hematocrit
plan and optimize fluid management of non-blood products
optimize cardiac output, oxygen delivery, and ventilation
use blood salvage and autologous transfusion when possible

86
Q

Postoperative strategies

A

treat anemia with erythropoiesis-stimulating agents and iron deficiency as indicated
vigilant monitoring and management of postoperative bleeding
avoid and/or treat infections promptly
carefully manage anticoagulant medications

87
Q

Class 1 hemorrhage

A

<15% reduction in BV
<750ml of BL
>10 Hgb
transfusion not necessary if no pre-existing anemia

88
Q

Class 2 Hemorrhage

A

15-30% reduction of volume
750-1500ml
8-10 Hgb
not necessary unless pre-existing anemia or cardiopulmonary disease

89
Q

Class 3 hemorrhage

A

30-40% BV
1500-2000ml BL
6-8Hgb
probably neccessary

90
Q

Class 4 hemorrhage

A

> 40% BV
2000ml
<6 hgb
neccessary

91
Q

Massive RBC Transfusion

A

replacement of estimated blood volume within 24 hours
>10 units of RBCs over 24 hours
50% of BV within 3 hours or less

92
Q

Massive Transfusion Concerns

A

dilutional coagulopathy or diluational thrombocytopenia
banked blood anticoagulated with sodium citrate, which binds calcium and inhibits coagulation
rapid infusion can decrease ionized calcium (aka calcium intoxication)

93
Q

Fresh Frozen Plasma

A

contains all coagulation factors

94
Q

Indications for FFP

A

deficiency of coagulation factors with abnormal coagulation test in the presence of active bleeding
planned surgery or invasive procedure in the presence of abnormal coagulation tests
reversal of warfarin in the presence of active bleeding
warfarin-related intracranial hemorrhage
planned procedure when vitamin K is inadequate to reverse the warfarin factor deficiency with no alternative therapy
trauma patients requiring massive transfusion

95
Q

Indications for Platelet

A

prevent bleeding or stop ongoing bleeding in patients with low platelet or functional platelet disorders

96
Q

Normal platelet count

A

150,000-450,000 cells/ul

97
Q

Tranfuse platelets for

A

less then 50,000 cells/ul but not more than 100,000 cell/ul

50-100k microvascular bleeding or at risk for continued bleeding

98
Q

Platelet transfusion threshold in bleeding patients

A

< 50,000 in severe bleeding including disseminated intravascular coagulation
< 30,000 when bleeding not life threatening or considered not severe
<100,000 for bleeding in multiple trauma patients or patients with intracranial bleed

99
Q

Prophylactic Transfusion Threshold

A

before neurosurgery or ocular surgery <100
before major surgery <50,000
in dic <50,000
before central line placement <20,000
before epidural anesthesia <80,000
vaginal delivery platelet transfusion is considered at <30 and when traumatic delivery then <50,000

100
Q

Cryoprecipitate

A

contains factor VIII (von willebrand factor) & fibrinogen

101
Q

Indications of Cryoprecipitate

A

patients with von willebrand disease or patients with probable or documentated deficit in fibrinogen (<80-100)
administer as rapidly as possible (rate atlease 200 an hour)

102
Q

Blood Transfusion Complications

A

most common and serious- incompatibility
results in an immune reaction with risk of an acute hemolytic reaction
1/2 of all deaths are caused by procedural or administrative error
clinical picture complicated by GA, which can obscure the symptoms associated with hemolytic reaction

103
Q

transfusion-associated graft vs host disease

A

results when donor lymphocytes incorporate themselves into the tissues of the recipient, leading the recipient immune system to attack the embedded recipient tissues
rash, leukopenia, thrombocytopenia
sepsis, death and usually occur as a result

104
Q

Transfusion related acute lung injury

A

acute lung injury occuring within 6 hours of transfusion in individuals previously free of ALI
believed to occur as frequently as 1:432 units of platelets or as infrequently as 1:7900 units of FFP
likely underreported because may be confused wiht other forms of ALI

105
Q

Transfusion Related immunodulation

A

presence of leukocytes in allogenic blood
homologous transfusions which invariably contain some leukocytes have been implicated in immunosuppression of recipients leading to unexpectedly early recurrence of cancer adn higher then expected rates of postoperative infection

106
Q

Nonhemolytic transfusion reactions

A

occurence 1-5% of all transfusions
fever
chills
urticaria

107
Q

Leukoreduction

A

use of filters to reduce the level of WBC
proven to be effective in reducing the incidence of nonhemolytic transfusion reactions and is likely to be effective in the reduction of TRIM
leukocytes exert a variety of immunodulatory effects on the recipient in a magnitude that is proportional to the length of time the donor unit is stored

108
Q

Alternatives to Blood Transfusion

A

donor directed blood transfusion

autologous blood transfusion

109
Q

Donor directed blood transfusion

A

homologous blood transfusion from a donor selected by the recipient and believed by some to decrease the risk of transmission of disease

110
Q

Cell Salvage

A

aspiration of blood shed into the surgical field, which is washed to removed debris and then reinfused

111
Q

Cell salvage is used in

A 
cardiac
orthopedic
radical prostatectomy
nephrectomy
AAA
aneurysm
112
Q

Contraindications of Cell salvage

A

surgery involving wounds contaminated by bacteria, sepsis, bowel contents, amnotic fluid or malignant cells

113
Q

Preoperative Blood Donation

A

collection and storage of recipient’s own blood for re-infusion at a later date
half of autologously donated blood is discarded contributing to waste

114
Q

Pre-Op blood donation risks:

A

preop anemia (resultant myocardial ischemia)
bacterial contamination
clerical erro

115
Q

Acute Normovolemic Hemodilution

A

transfusion alternative involving the removal of whole blood from a patient immediately before or after the initation of anesthesia and surgery and replacing volume with crystalloid or colloid solution
blood lost during surgery will have a low hematocrit
reinfusion of the whole blood (with a normal hematocrit as well as clotting factors) is initated when intraoperative loss of blood has stopped, or earlier if the patient’s condition warrants it

116
Q

1 Unit of PRBCs will increase

A

1 hgb g/dl and Hct 2-3% in adults

117
Q

10ml/kg transfusion of PRBCs will

A

increase Hgb by 3g/dl and hct by 10%

118
Q

Platelets are 1 unit

A

200-400cc

119
Q

One unit of platelets increases

A

platelet count by 7l-10k 1 hour post transfusion

120
Q

Do platelets need to be ABO compatible?

A

no

121
Q

How much does one unit of FFP increase clotting level factors by?

A

2-3%

122
Q

When is FFP contraindicated?

A

augmentation of plasma volume or albumin concentration

Basic Principles N928 (10 decks)

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