Exam 3 - Blood Transfusions Flashcards
What percentage of blood volume is made up by plasma?
What does plasma mostly consist of?
- 55%
- 92% water
What blood type is a universal donor? Universal acceptor?
- Donor = O neg
- Acceptor = AB +
What are 3 Hgb alterations we will see most often in clinical settings?
- β thalassemia → Hgb Barts
- α thalassemia → Hgb H
- Sickle Cell → Hgb S
What is the distrubution of Rh factor in the population?
Rh+ (85%) and Rh- (15%)
What 4 things can cause a right shift of the OxyHb curve?
- ↑ H+ (acidosis)
- ↑ CO2
- ↑ temp
- ↑ 2,3-DPG
O2 leaves hgb more readily - decreased affinity
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
What is contained within FFP?
Plasma, fluids, clotting factors, and proteins
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?
- 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 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)
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
2 major indications for FFP?
- Heparin resistance d/t antithrombin deficiency
- Treat angioedema (also use TXA along with FFP)
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
Dosing for fibrinogen replacement?
How much will this raise fibrinogen concentrations?
- 2 units of cryo/10 kg body weight
- ~ 100 mg/dL
Indications for cryo transfusions?
- Bleeding with evidence of low fibrinogen
- Prophylaxis in pt’s with hemophilia A and vWD
How much will one unit of PLT increase PLT count by?
- 5,000 to 10,000
Why should you not give LR with blood products?
LR has Ca++ and can cause the products to clot
Is there any clinical data that says warming platelets is bad?
No its a common practice → no data to support not warming platelets
BUT still recommended to not warm
Indications for platelet transfusion?
- Stable w/o bleeding and PLT < 10,000
- PLT < 50,000 and invasive procedure, evidence of bleeding, DIC
- Eye or CNS procedures and PLT < 100,000
What is the trauma triad of death?
- Hypothermic
- Coagulopathic
- Acidotic
What are the IV fluid recommendations for blood product transfusion?
- Electrolyte R (normosol/plasmalyte)
- NS
- Only use for prming tubing and flushing before and after
When is WB indicated for transfusion?
- To maintain blood volume and O2 carrying capacity in acute massive hemorrhage (> 20% blood volume loss)
What are S/Sx of hemolytic transfusion reaction?
- fever
- chill
- hemoglobinemia
- hemoglobinuria (seen under GETA)
- hypotension (seen under GETA)
- dyspnea.
What are mediators of an acutehemolytic transfusion reactions?
IgM antibodies (ABO usually)
What are the S/S of nonhemolytic febrile transfusion reactions?
Treatment?
- Fever and chills
- Antipyretics and leukocyte reduced blood
What are the mediators of non-hemolytic febrile transfusion reactions?
HLA Class Ag antibodies
What are some S/S of an allergic transfusion reaction?
- urticaria
- erythema
- itching
- anaphylaxis.
What are the mediators of allergic transfusion reactions?
- plasma proteins (allergic)
- IgA antibodies (anaphylactic)
How do we treat allergic transfusion reactions?
- antihistamines
- treat symptoms
- IgA component transfusion
What are S/S of Non-cardiogenic pulmonary transfusion reactions?
- ARDS (↑ airway pressures and secretions)
- Fever
- Chill
- Hypotension
- Cyanosis
What are the mediators for a non-cardiogenic pulmonary transfusion reaction?
Recipient WBC antibodies
How do we treat Non-cardiogenic pulmonary transfusion reactions?
- Vigorous respiratory support (↑ PEEP)
- Steroids
Criteria for TRALI diagnosis?
- Blood transfusion within the last 6 hours
- Acute hypoexemia (P/F < 300 or SpO2 < 90% on RA)
- B/l diffuse infiltrates
- No evidence of circulatory overload
Incidence of TRALI?
Mortality rate?
- 1:1,300 - 5,000
- 5-25%, most patients recover within 72 hours
What types of blood products is TRALI most associated with?
- Can occur in any product with plasma
- FFP
- PLTs
Patho behind TRALI?
Leukoagglutination and pooling of granulocytes leads to damage to cellular membranes and endothelial surfaces resulting in dyspnea and pulonary infiltrates
TRALI treatment?
- Stop the transfusion
- Vent support
- CBC and CXR
- Notify blood bank
- Pt may need ECMO
What are the 3 acute nonimmunologic transfusion reactions?
- Bacterial contamination
- TACO
- Hemolysis d/t exogenous physical/chemical means
What are the three delayed immunologic effects of transfusion reaction?
MOA of each?
- Hemolytic transfusion reactions (IgG)
- Transfusion associated Graft-versus-host disease (donor lymphocytes)
- Post-transfusion purpura (platelet specific antibodies)
Symptoms and treatment for hemolytic transfusion reactions?
Symptoms
* Decreased Hb
* Fever
* Jaundice
* Hemoglobinuria
Treament
- Ig negative blood for future transfusions
GVHD symtoms and treatment?
Symptoms
- Fever
- Skin rash
- Desquamation (skin shedding)
- N/V/D
- Hepatitis
- Pancytopenia
Treatments
- Gamma irradiation of cellular components
Post-transfusion purapura symptoms and treatment?
Symptoms
- Thrombocytopenia
- Clinical bleeding
Treatments
- IV Ig
- Plasma exchange
- Steroids
What are some quick ways to differentiate between TRALI and TACO?
- TRALI → Fever, ↓BP, EF normal, minimal response to diuretics
- TACO → No fever, HTN, ↑JVP, ↓ EF, significant improvement with diuresis
What is transfusion induced hemosiderosis?
Transfusion related iron overload
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
- 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)
Why does whole blood have superior hemostatic potential over individualr blood components?
- Less dilution from anticoagulants and additives
- Higher platelet counts and coagulation factor levels
What are the fibrinogen levels of Cryo, FFP, and LTOWB?
- Cryo = 2500 mg
- LTOWB = 1000 mg
- FFP = 400 mg
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
Not many studies available
Which clotting factors required Ca++ to work?
2 ,7, 9, 10, protein C and S
Which drug has more elemental calcium; Ca gluconate or CaCl?
- CaCl (270 mg/10mL vs 90 mg/10ml for gluconate)
What causes drops in calcium from blood transfusion?
Hypothermia + Liver injury = decreased citrate metabolism = increased chelation of serum calcium
What will 1,2, and 5 units of blood decrease iCa levels to?
- 1 unit = 1.12 mmol/L
- 2 unit = < 1mmol/L
- 5 units = < 0.8 mmol/L
What is the normal value for TEG-ACT (rapid)?
What is it measuring?
- 80-140 sec
- Time to initial fibrin formation
What is the normal value for R time?
What is it measuring?
- 5.0 - 10.0 min
- “Reaction Time” to initial fibrin formation - intrinsic pathway
What is the normal value for K time?
What is it measuring?
- 1-3 minutes
- “Kinetic Time” for fibrin cross linkage to reach 20 mm clot strength (fibrinogen and plt number)
What is the normal value for α angle?
What is it measuring?
- 53 - 72°
- Slope from baseline representing clot formation (fibrinogen and plt number)
What is the normal value for MA?
What is it measuring?
- 50-70mm
- Maximum Amplitude of tracing (plt number and function)
What is the normal value for G value?
What is it measuring?
- 5.3-12.4 dynes/cm2
- Calculated value of clot strength (entire coag cascade)
What is the normal value for LY 30?
What is it measuring?
- 0-3%
- Clot lysis at 30 mins after maximum aplitude (fibrinolysis)
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/or platelets
If MA < 50 what do we transfuse?
- PLT
If LY30 > 3% what do we transfuse?
TXA (Tranexamic Acid)
