Exam C Study Guide Flashcards
Goals of Transfusion Therapy?
to increase tissue oxygenation and/or restore hemostasis.
Four Major Categories of Blood Products?
-Cellular components
-Plasma components
-Hematopoietic progenitor cell (HPC)
-Plasma fractionation products
What are the different cellular components?
-whole blood
-red cells
-granulocytes
What are the different plasma components?
platelet products, cryoprecipitate, fresh frozen plasma, other transfusable plasma components
What are the Hematopoietic progenitor cell (HPC) products?
bone marrow, peripheral blood stem cell and cord blood cell preparations
What are the plasma fractionation products?
albumin, various immune globulins, coagulation factor concentrates
Acid-citrate-dextrose:
-good for ____ days
-pH?
-21
-lowest pH of any blood preservatives
What are the different Red Blood Cell preservatives?
-ACD
-CPD
-CPDA-1
-CP2D-AS
Citrate-phosphate-dextrose (CPD):
-good for ____ days
-pH?
-21 days
-Decreases red blood cell pH; however, not as much as ACD
Citrate-phosphate-dextrose-adenine (c. CPDA-1):
-good for _____days
35
What does Citrate-phosphate-dextrose-adenine (CPDA-1) do?
-Adenine increases ADP levels therefore causing ATP formation
-Decreased 2,3 DPG by day 35
Citrate-phosphate-dextrose (CP2D-AS):
-good for _____ days
42
What is the advantage of Citrate-phosphate-dextrose (CP2D-AS)?
2,3 DPG and ATP values are improved over CPDA-1; however, by the 42nd day the 2,3 DPG and ATP levels are significantly decreased
What are the additive solutions used for RBC preservation?
AS-1, AS-3, AS-5
What dos AS-1, AS-3,
and AS-5 all have?
All have saline, adenine and glucose
Additive solutions:
___ and ____ have mannitol to protect against storage lesions.
AS-1, AS-5
Additive solutions:
____ has citrate and phosphate to protect from storage lesions.
AS-3
AS-____ is approved in Europe, but not in the US
7
The infusion of all blood components should occur in less than ____ hours.
4
-The infusion rate may be adjusted to allow for individual patient circumstances but should fall within the 4-hour limit.
What should be documented as part of the order to transfuse?
infusion rate
The 4-hour limit does not necessarily apply to infusion of __________ products
fractionation
The basic infusion set incorporates flexible plastic tubing and a standard inline blood filter with a pore size of ______ microns.
170–260
_____________ filters may be used for red blood cell transfusions.
Microaggregate
Leukocyte reduction filters are used to reduce the number of white blood cells in red blood cell or platelet components to less than _____ white blood cells per unit.
5 × 10^6
Are filters used for red blood cell components interchangeable with the filters designed for platelet components?
No
-Using a needle with too small a bore diameter may cause hemolysis when transfusing red blood cells. As with other transfusion parameters, needle size may vary with patient conditions
Why should the infusion rate be slowed when using smaller needles when transfusing RBCs?
to prevent hemolysis
-Needles with a large-bore diameter should be used when rapidly transfusing red blood cells.
-Rapid infusers resemble pressure cuffs that surround the entire bag of blood.
-Rapid infusers should not be inflated to _____mm Hg or above because this level of pressure may cause the bag to rupture.
300
Massive rapid infusion or infusion into a central venous catheter carries a higher risk of __________.
hypothermia
Blood warmers can be used to prevent hypothermia but should be maintained and monitored so the blood never reaches a temperature that could cause hemolysis.
__________ pumps can be used to regulate the blood flow into the patient.
-These are often used in neonates where small shifts in volume may drastically affect the infant
Mechanical
When would mechanical pumps be used in adults?
when rate control is indicated.
True or false:
Normal saline, 0.9% sodium chloride (USP), may be added to most blood components.
True
Generally, medications and other intravenous solutions should not be added to blood components as they may cause…
clotting or hemolysis.
Some examples of substances that have regulatory approval to safely add to red blood cell units include…
ABO-compatible plasma, 5% albumin, and Plasma-Lyte®.
Ringer’s lactate solution should not be added to blood components because the high _______ content inactivates the anticoagulant, causing clots to form.
calcium
What are the uses of whole blood?
-Exchange transfusions
-Acute massive blood loss
True or false:
Fresh whole blood may be used in specific circumstances but for the most part it has been replaced by specific component therapy
True
If whole blood is used, it should be ____ identical and should be crossmatched.
ABO
Each unit of whole blood should increase the patient’s hematocrit by ___% and hemoglobin by ___%
3, 1
Storage time for Whole blood:
-CPD up to ___ days
-CPDA-1 up to ___ days
-CPD-AS up to ____ days
21
35
42-45
What are some of the uses of Packed Red Blood Cells?
-Anemia
-Most blood replacements during surgery
-Pre-operative transfusions
-In severe, acute blood loss it, along with other components and fluids can correct the situation
What is the storage time for PRBCs compared to whole blood
the same
Patients with a hemoglobin concentrate above ___/dL (100 g/L) rarely need a blood transfusion.
10
Patients with a hemoglobin below ___ g/dL (70 g/L)… many patients experience symptoms of poor oxygenation and benefit from red blood cell transfusions.
7
Between ____ and ___ g/dL (70 and 100 g/L), the patient’s clinical presentation and the particular problem being treated exert more influence on the decision to transfuse.
7, 10
Stored whole blood may be used in preoperative autologous donation (PAD) programs, when a patient donates one or more units of blood _____ weeks before a scheduled surgery.
1-3
In PAD, collected units are often held as whole blood to eliminate the costs involved in component preparation and storage.
Directed Donation:
If the donation is from a first-degree family member, this unit must be _______ prior to infusion in order to prevent transfusion-associated graft versus host disease (TA-GVHD).
irradiated
-Units are screened for infectious diseases in the same manner as community donors.
Directed Donations:
What is done with plasma portions of the units?
Directed units are processed into packed red blood cell units. Plasma portions of these units are usually placed in the main donor supply and not designated for the recipient of the directed donation.
Ture or false:
If the red blood cell unit is not transfused to the intended recipient it may cross over into the main donor supply.
True
Granulocyte Transfusion is used primarily to treat?
neutropenic patients who have bacterial and/or fungal sepsis that has been shown to be resistant to antimicrobial interim therapy. Thus, granulocyte therapy is not generally a first-line therapy for these patients.
Granulocyte Transfusion is given as interim therapy for what patients?
for patients who are expected to recover neutrophil production, as well as those with congenital abnormalities in neutrophil function
Granulocytes are prepared from either apheresis technique or from fresh whole blood. They are stored at room temperature and expire _________ after preparation
24 hours
Granulocyte units should be transfused as soon as possible, and must be transfused within ___ hours of collection, to obtain the most viable cell dose.
24
Granulocyte units should always be irradiated to prevent ______ but should not be infused with microaggregate or leukoreduction filters.
TA-GVHD
The donor and recipient should be both ___ and ______________ (HLA) compatible.
Rh and human leukocyte antigen
A crossmatch should be performed if more than ___ mL of red blood cells are present in the granulocyte unit.
2
Leukocyte reduction filters are available that can be used with…
whole blood, red blood cell or platelet units.
Purpose of leukoreduction?
Helps to prevent the formation of antibodies to HLA antigens because white blood cells carry HLA antigens.
Leukoreduction can be done by…
centrifugation, filtering upon unit preparation, washing the product or filtering at bedside.
Who should receive leukoreduced cellular blood products?
Patients who would be most adversely affected by alloimmunization to HLA antigens (duh)
-Other patients that benefit from leukoreduction are patients with febrile, nonhemolytic transfusion reactions.
Leukoreduction decreases the viral load in the product and therefore can reduce the incidence of transfusion-related transmission of viruses known to reside on white blood cells (such as…
human T-cell lymphotropic virus [HTLV-1] and Epstein-Barr virus [EBV])
Leukoreduction can also prevent ________ to platelet transfusions
rectroriness
-Please note that single-donor platelets can be collected by an apheresis machine in a manner that renders the product leukodepleted during the collection process
What is irradiation used for?
To prevent TA-GVHD (transfusion-associated graft-versus-host disease).
TA-GVHD occurs when viable transfused lymphocytes…
replicate in the recipient, recognize them as foreign, and mount a destructive immune response against the recipient’s body.
What is the risk of TA-GVHD (transfusion-associated graft-versus-host disease)?
a pancytopenia within days of the transfusion and is almost uniformly fatal.
This disrupts the DNA in the white blood cell nuclei, which destroys the white blood cell’s ability to replicate.
Gamma irradiation
To prevent TA-GVHD the blood component should receive a radiation dose of _____ Gy (2500 cGY) delivered to the midplane and ___ Gy (1500 cGy) to all parts of the bag.
25, 15
Since immunocompromised patients are most susceptible to TA-GVHD, they commonly receive _________ red blood cell and platelet units.
irradiated
Products that are from a first-degree relative of the recipient must be __________, as the recipient would be at a high risk for TA-GVHD
irradiated
CMV infection is often asymptomatic in a person with a robust immune system.
In immune suppressed individuals, CMV infection can cause…
debilitating effects and even death.
Patient populations where transfusion-transmitted CMV infection can cause significant morbidity and mortality include:
-Low birth weight infants (<1500g)
-CMV seronegative HPC transplant recipients or potential recipients
-CMV seronegative antepartum women
-Fetuses receiving intrauterine transfusion
-HIV-infected patients and children born to HIV-positive mothers
What are the two methods to decrease the risk of transfusion-associated CMV transmission?
-Leukoreduction
-Testing blood donors for antibodies to CMV
How does leukoreduction prevent CMV?
CMV infects white blood cells; therefore, leukoreduction can reduce the viral load in blood components
In order to reduce CMV transmission and HLA alloimmunization, some countries have converted their blood supply to __________.
prestorage
What is the incidence of CMV infection in the general population?
varies and can be quite high.
Will leukoreduction or CMV seronegativity confer complete protection from CMV?
-neither confer complete protection from transition.
-The combo of both offers the most protection
Washing of red blood cell and platelet units is indicated in only a few clinical situations.
The procedure uses centrifugation most often in an _____ system.
open
Washed red blood cell units expire in _____ hours from the time of washing, platelets in ___ hours.
24, 4
***Washing of red blood cell units eliminates approximately ____% of the white blood cells, about ____% of red blood cell mass, and virtually ____% of the plasma.
85, 15, 99
True or false:
Washed red blood cell and platelet components can be transfused to IgA-deficient patients who have antibodies to IgA.
True
_________ may be indicated in patients who have severe allergic reactions to blood products.
Washing
Washing should not be used as a means to reduce __________.
white blood cells
Blood from donors with rare red blood cell phenotypes may be stored frozen for up to ____ years and used for autologous or allogeneic transfusion.
10
Freezing:
Each unit is phenotyped extensively prior to freezing using a cryoprotective agent, such as 20 or 40% glycerol. When the unit is to be transfused the cryoprotective agent must be washed; this process is called _____________.
deglycerolization
The deglycing procedure is as follows:
a. ____% sodium chloride solution
b. _____% sodium chloride solution with 0.2 gm% glucose solution
12%, 0.9%
The expiration date of the deglycerolized red blood cell components is ______hours for open systems or ____weeks for closed systems
24, 2
True or false:
Cryopreservation of platelets is widely available.
False. Not widely available.
_______ is the most common cryopreservative used for frozen platelet storage.
DMSO
Frozen platelet products can be stored for ___ years.
2
What are three types of plasma-derived products commonly used?
Fresh frozen plasma (FFP), platelet products, and cryoprecipitate
FFP normally comes from whole blood donations.
-It must be removed and frozen within ____ hours.
8
Fresh Frozen Plasma is primarily used to…
to replace dysfunctional or deficient coagulation proteins. Coagulation factor deficiencies are usually caused by congenital diseases.
Fresh Frozen Plasma uses:
Multiple coagulation deficiencies are often present in patients with _______ damage or failure.
liver
-Vitamin K antagonists or deficiencies affect multiple coagulation factors
What is the storage for FFP when frozen?
-18oC or colder for 1 year
What is the storage for FFP when thawed?
1-6oC for 4 hours or 5 days, but 5 day storage loses some of the important coagulation factors.
1 unit of FFP should increase the coagulation factors by about _____%.
25-30
FFP should not be used to dilute red blood cell units for faster infusion. ____________ can be used and will not expose the patient to another donor.
Crystalloids
Specific coagulation factor concentrates have largely replaced FFP as the treatment of choice for people with congenital factor abnormalities. FFP is usually only used if…
no factor concentrate is available.The decision to treat patients with FFP should not be based solely on laboratory values but should take into consideration the patient’s underlying disease and clinical status.
Platelet components are prepared from a single donor or random donor. The single donor is typically an apheresis procedure in which one bag is equivelant to ____ random donor platelets. The random donor platelet is obtained from a whole blood donation.
6-8
Platelets are viable for up to ___ days, but must be stored at room temp and continuously shaken and if the system is opened, they will expire in ___ hours upon opening.
5, 4
Platelet uses?
-Indicated in a variety of clinical situations where decreased platelet production, increased platelet destruction, or platelet dysfunction may lead to bleeding.
-Certain thrombocytopenic patients may benefit from prophylactic platelet transfusion to reduce bleeding risk.
A platelet count of less than _______________ is often used as a trigger to initiate prophylactic platelet transfusions to prevent intracranial hemorrhage.
10 × 10^3/µL (10 × 109/L)
Common patient groups with low platelet counts that are treated prophlactically include:
-Premature neonates
-Cancer patients receiving chemotherapy and transplant patients
-Transplant patients of both solid organ and HPC.
1 unit of platelets should increase the platelet count by…
5,000-10,000
Many donor centers primarily collect apheresis platelet products, which are also called single-donor platelets. For adults, the usual dose per transfusion is ___ apheresis platelet or ____ whole blood–derived platelets. Typical dosage of whole blood–derived platelets can vary among facilities from 4 to 10 units per dose. Apheresis platelets where the donor and recipient are matched for certain antigens may be transfused when a recipient becomes refractory to platelet transfusions.
1, 6
Cryoprecipitate is manufactured from what blood component?
FFP
The major use of cryoprecipitate is as a source of ___________.
fibrinogen
-but can also be used to treat congenital deficiencies or dysfunctions of fibrinogen.
What does Cryoprecipitate contain?
contains factor VIII, fibrinogen, von Willebrand factor (vWF), Factor XIII, and fibronectin.
What is storage for cryoprecipitate?
-18oC for one year from draw date
- room temperature for 4 hours after thawing
Cryoprecipitate:
One bag should increase Factor VIII by ____ units and Factor 1 by ____mg/dL
80
5
What may eventually replace the use of cryoprecipitate as fibrinogen replacement?
Human fibrinogen (RiastapTM) was approved by the U.S. Food and Drug Administration (FDA) in 2009 to treat patients with a congenital fibrinogen deficiency. A recombinant human fibrinogen product is available in Europe and may eventually replace the use of cryoprecipitate
Plasma Fractionation Products: The FDA and the __________ Association provide oversight and accreditation of plasma fractionation facilities in the United States.
Plasma Protein Therapeutics
Who distributes plasma fractionation products?
by the transfusion service or by the pharmacy
What are Coagulation Factor Concentrates used for?
to prevent or to treat bleeding episodes in patients with coagulation deficiencies
-targeted therapy with the appropriate factor concentrate.
What are the benefits of Factor concentrates over broad-spectrum treatment with FFP transfusion?
are easier to transfuse and safer for the patient
Factor concentrates have a smaller volume and have less risk of disease transmission because of what step?
viral inactivation steps used in the manufacturing process.
Several factor concentrates are now made in a recombinant form and contain no human plasma-derived products, reducing the risk of infectious disease transmission theoretically to _____.
zero
What are the most commonly used factor concentrates?
-Factor VIII
-Factor IX
-Factor VIIa
Other plasma-derived protein concentrates include…
antithrombin, protein C, and C1-esterase inhibitor.
Factor VIII is for the treatment of…
Hemophilia A, von Willebrand’s disease
Factor IX is for the treatment of…
Hemophilia B
Factor VIIa is for the treatment of…
either hereditary or acquired Factor VII deficiency.
The protein that is present in the largest amount in human plasma.
Albumin
-Contributes to fluid balance both within the blood vessels and throughout the body.
-Most commonly used as a volume replacement in trauma, shock, burns, and therapeutic plasma exchange.
Albumin
Common indications for the administration of RhIg include:
-Rh(D)-negative mothers in the 28th week of pregnancy
-Following delivery of an Rh(D)-positive infant.
-Pregnant Rh(D)-negative women who are at increased risk for a feto–maternal hemorrhage in the perinatal period
-Rh(D)-positive platelets to an Rh(D)-negative woman of childbearing age
Administered to prevent immunization to the D antigen.
Rh Immune Globulin (RhIg)
RhIg is often administered intramuscularly when given in what period?
in the perinatal or postnatal period.
The route chosen for post-transfusion RhIg administration is often dependent on…
on the dose of RhIg that will be given.
______ may be used in some cases as an alternative to intravenous immunoglobulin (IVIG) for the treatment of immune thrombocytopenia (ITP).
RhIg
Intravenous Immune Globulin (IVIG)
-Used to treat a variety of disorders, including:
a. Primary immune deficiencies
b. Acquired immune deficiencies
c. Autoimmune disorders
d. Infectious diseases
Defined as replacement of a patient’s total blood volume with donor components within 24 hours
Massive Transfusion
Most facilities generally define massive transfusion as more than ___ red blood cell units transfused in 24 hours or less.
10
Adverse Transfusion Reactions:
Usually not used to describe transfusion-transmitted bacterial, viral, prion, or parasitic infections.
Ture or false?
True
-All other unintended adverse events are normally described under the umbrella term of transfusion reactions.
Reactions are commonly classed as acute if they occur within ___ hours of transfusion.
24
May present anywhere from one day to two or more weeks after transfusion.
Delayed Transfusion Reactions
Transfusion-Reaction Surveillance:
What are the two oldest and most well-established surveillance networks?
- Serious Hazards of Transfusion (SHOT) – a voluntary reporting scheme in the United Kingdom.
- Haemovigilance Network of the Agence française de sécurité des produits de santé (AFSSAPS) – a mandatory reporting scheme in France.
A biovigilance system was first proposed in the United States in 2006, a collaborative effort involving both public and private organizations. The national ___________ program, which is one of the four components that make up the complete system, was launched in 2010.
hemovigilance
- In the United States, the FDA has a guidance document that outlines steps for notifying the agency of any fatalities related to blood collection or transfusion
Do adverse transfusion reactions have to be rported?
No. , but any transfusion-associated fatalities area required to be reported to the Centre for Biologics Evaluation and Research (CBER) as soon as possible, with a full written report required within 7 days.
- One of the best known and most completely characterized adverse events in transfusion medicine.
- Most commonly associated with patient antibodies that are directed against antigens present on the transfused red blood cells.
Immune-Mediated Hemolytic Transfusion Reaction
- Pretransfusion testing and patient identification procedures have been designed primarily to prevent this reaction.
Immune-Mediated Hemolytic Transfusion Reaction can be divided into what two groups?
Acute hemolytic reactions
Delayed hemolytic reactions
The most serious acute hemolytic reactions occur as a result of patients receiving ____-incompatible red blood cells, either through misidentification of the patient, the specimen, or the blood component, or through errors in pretransfusion testing
ABO
Delayed hemolytic reactions are most often due to the presence of patient antibodies to…
non-ABO red blood cell antigens.
Symptoms of acute hemolytic reactions
Infusion site pain, hypotension, wheezing, chest pain, flushing, and gastrointestinal symptoms.
Acute hemolytic reactions are Characterized by blank abnormalities.
is also characterized by associated coagulation abnormalities.
What type of damage is associated with acute hemolytic reactions
Renal damage is a significant risk for patients experiencing an acute hemolytic reaction.
Laboratory diagnosis of acute hemolytic anemia
The laboratory investigation is key to
The DAT will be what
what should be ruled out
-The laboratory investigation is key to correctly diagnosing an acute hemolytic transfusion reaction, particularly a clerical check to identify any errors in patient or blood component identification.
-In most cases, the post-transfusion direct antiglobulin test (DAT) will be positive; however, a negative DAT should not rule out the diagnosis of having this type of reaction.
Acute hemolytic anemia transfusion reactions
The most important first step when an adverse reaction is suspected is to
stop the transfusion
Acute Hemolytic Transfusion Reaction
Treatment depends on what
what is used to increase urine output and improve blood flow
- Treatment depends on the amount of incompatible blood transfused and the severity of the patient’s symptoms.
- Lasix may be used to increase urine output and improve blood flow to the kidneys.
Acute Hemolytic Transfusion Reaction
What may be administered?
The most common cause of Acute hemolytic anemias
i. Platelets, plasma, and/or cryoprecipitate may be administered.
xii. The most common cause is a patient receiving the incorrect blood component.
The most important tool in preventing an acute hemolytic reaction is
i. The most important tool in preventing an acute hemolytic reaction is strict adherence to policies and procedures.
Acute hemolytic transfusion reactions
patients present with or without what
what is present in the urine
- Fever with or without chills
- Hemoglobinuria
patients with Acute hemolytic anemia will often present with
what condition correlates with acute hemolytic anemia
Dyspnea(SOB) or hypotension that can progress to shock
DIC or disseminated intravascular shock
Delayed hemolytic transfusion reactions
Events are often what
known to occur with much greater what
i. Events are often unrecognized and frequently go unreported.
ii. Known to occur with much greater frequency than acute hemolytic reactions.
Delayed Hemolytic Transfusion Reaction
Begin the same way as acute hemolytic reactions, but blank is not initiated, and reactions tend to be blank.
iii. Begin much the same way as acute hemolytic reactions; however, complement activation is not initiated or is incomplete.
iv. Reaction tends to be less severe than acute hemolytic reactions.
Delayed Hemoloytic Transfusion Reaction
Symptoms
reactions can progress to
i. Symptoms include fever and anemia days to weeks after transfusion along with signs of extravascular hemolysis, including jaundice, leukocytosis, and hemoglobinuria.
ii. Reaction in some patients can progress to hyperhemolysis.
b. Delayed Hemolytic Transfusion Reaction
Lab follow-up is key to
Treatment generally consists of
vi. Laboratory follow-up is key to diagnosing.
vii. Treatment generally consists of observation and supportive care.
b. Delayed Hemoloytic Transfusion Reaction
b. Delayed Hemolytic Transfusion Reaction
If the resulting anemia necessitates additional transfusions, then
viii. If the resulting anemia necessitates additional transfusions, red blood cells negative for the antigen(s) against which the patient’s antibody(ies) is directed must be selected in order to prevent further hemolysis.
b. Delayed Hemolytic Transfusion Reaction
For patients who remain unresponsive blank can be done
Errors that cause the reaction can be mitigated by what
x. For patients who remain unresponsive, a splenectomy may be indicated.
xi. Errors that cause this reaction can be mitigated by strict adherence to all policies and procedures around pretransfusion testing and blood component administration. Use of technology and automation can also reduce the risk of human error.
b. Delayed Hemolytic Transfusion Reaction
Complete patient history can help what
xii. A complete patient history can often help identify patients that are at an increased risk for delayed hemolytic transfusion reactions.
b. Delayed Hemolytic Transfusion Reaction
Testing for recently transfused or pregnant patients must be performed with samples drawn no more then.
xiii. Testing for recently transfused or pregnant patients must be performed with samples drawn no more than 3 days before planned transfusion.
Febrile Nonhemolytic Transfusion Reaction (FNHTR)
The most commonly reported what
defined as a reaction that involves a increase in what
- The most commonly reported complications associated with transfusion.
- Defined as typical that the reaction involves an increase in body temperature of at least 33.8° F (1° C) either during or shortly after the transfusion.
Febrile Nonhemolytic Transfusion Reaction (FNHTR)
What is also considered FNHTR
- The occurrence of chills or rigor, even in the absence of fever, also is considered a FNHTR.
Febrile Nonhemolytic Transfusion Reaction (FNHTR)
Reactions occurs most frequently among
- Reaction occurs most frequently among people who have been multiply transfused or previously pregnant.
Febrile Nonhemolytic Transfusion Reaction (FNHTR)
Recurrences are common after
the reaction is generally what
Recurrences are common after an initial reaction is reported. The reaction, however, is generally mild and not considered to be life-threatening.
