FLUIDS-transfusion Flashcards
What is on the cell membrane of erythrocytes that determines blood group
Antigenic glycoprotein
What does the plasma contain that opposes erythrocyte blood goup
Opposing Antibodies to the erythrocyte cell membrane antigenic glycoprotein
What Plasma antibodies does each blood type contain O A B AB
O = Anit-A, Anti-B A = Anti-B B = Anti-A AB = none
Universal donor
Universal recipient
donor = O negative (no ABO or Rh antigens) recipient = AB positive (contains anti-A, anti-B, and Rh antigens)
Can Rh-negative blood type receive Rh-positive
No
How does a mother become sensitized to the Rh antigen if she is Rh-negative and fetus is Rh-positive
During delivery, the Rh-positive antigen crosses the placenta
The mother will then develop antibodies to the Rh antigen
How does maternal Rh-sensitization put subsequent pregnancies at risk
The mother is sensitized following the first pregnancy
Subsequent pregnancies with an Rh-positive fetus can lead to erythroblastosis fetalis
What is erythroblastosis fetalis
A hemolytic disease of a newborn that is Rh-positive of an Rh-negative mother that has been sensitized, developing antibodies against the Rh antigen
How is erythroblastosis fetalis prevented
Mother is given Rhogam (Rh immune globulin) starting at 28 weeks gestation to prevent sensitization
What is the plasma universal donor and acceptor
Donor = AB positive (contains no anti-A, anti-B, or Rh antigens) Acceptor = O negative (contains anti-A, anti-B, and Rh antigens)
What does the type, screen, and crossmatch test
Type = determines ABP and Rh-D antigens type Screen = Most clinically significant antibodies Crossmatch = compatibility between recipient plasma and blood to be transfused
Consequences of large RBC transfusion
Coagulopathy
Which blood component has the highest risk of bacterial contamination and why
Platelets
They are stored at room temp for 5 days
Infusion recommendations for platelets
No filter or fluid warmer
How much is fibrinogen increased with a 5 bag pool
50 mg/dL
At what lab values are the following transfusions indicated PRBC FFP Platelets Cryo
PRBC = hgb<6 g/dL FFP = PT or PTT >1.5 control Platelets = Thrombocytopenia of 50,000-100,000 Cryo = fibrinogen <80-100 mg/dL
How much does a unit of FFP increase factor concentration
20-30%
What components are in FFP
All coagulation factors
Fibrinogen
Plasma proteins
What components are in cryoprecipitate
Concentrated fibrinogen
Factor 8
Factor 13
vWF
What components are in whole blood
RBCs WBCs Plasma Plt debris Firbinogen
6 indications for FFP transfusion
- Coagulopathy
- Warfarin reversal
- AT deficiency
- Massive transfusion
- DIC
- C1 esterase deficiency (angioedema)
2 Indications for platelet transfusion
- Thrombocytopenia
2. Qualitative platelet defect
3 indications for cryoprecipitate transfusion
- Fibrinogen deficiency
- Von Willebrand disease
- Hemophilia
At what point should patients with CAD receive a blood transfusion
when hct falls below 28-30%
What is the estimated blood volume for the following populations Neonate (premature)= Neonate (full term)= Infant= School-age child= Adult=
Neonate (premature)= 90-100 mL/kg Neonate (full term)= 80-90 mL/kg Infant= 80 mL/kg School-age child= 70 mL/Kg Adult= 70 mL/kg
What is the equation for max allowable blood loss
MABL = EBV x ([start hgb - target hgb]/start hgb)
What is MABL for a 70 kg male with a hgb 12 g/dL and transfusion threshold of 6 g/dL
2,450 mL
4,900 mL x ([12-6]/12)
What is the average hct of a unit of PRBC
70%
How much does 1 unit of PRBC increase hgb/hct
hgb = 1 g/dL Hct = 2-3%
How do erythrocytes utilize energy
They don’t contain mitochondria so they rely on glycolysis and lactic acid to convert glucose to ATP
Why is blood stored at 1-6*C
To extend the lifespan by slowing the rate of glycolysis
What are 4 additives to PRBCs that increase shelf life
Citrate
Phosphate
Dextrose
Adenine
What is the function of each additive in the the storage of PRBCs Citrate Phosphate Dextrose Adenine
Citrate= anticoagulant (inhibits fx 4 Ca++) Phosphate = Buffer against acidosis Dextrose = Substrate for glycolysis Adenine = substrates for ATP
What are 7 changes to PRBCs that can occur during storage
- Decreased 2,3-DPG (left shift)
- Decreased ATP
- Decreased pH
- Increased K+
- Impaired ability to change shape
- Hemolysis
- Increased production of proinflammatory mediators
What is leukoreduction
Removes WBCs from RBC and platelets
What is the purpose of leukoreduction
To decrease the chances of HLA alloimmunization, febrile nonhemolytic transfusion rxn, and CMV transmission
What is HLA alloimmunization
When the body develops antibodies against human leukocyte antigens
How does HLA alloimmunization affect platelet transfusions
It can make the pt “refractory” to plt transfusion b/c the body attacks the HLA proteins present of the plt surface
What is the process of washing in transfusion preparation
Using saline to wash the blood product and removing any remaining plasma and antigens in the donor unit
RBC antigens are not removed
What is the purpose of washing when processing blood units
To prevent anaphylaxis in IgA deficient patients
What is the purpose of irradiation when preparing a transfusion
It exposes the unit to gamma radiation and disrupts WBC DNA in the donor cells, destroying donor leukocytes
What does irradiation of donor blood prevent
graft v. host disease in immunocompromised pts
What is graft-vs-host disease
Donor leukocytes attack recipient bone marrow, leading to pancytopenia, fever, hepatitis, and diarrhea
Which populations benefit from irradiated blood products
Leukemia
Lymphoma
Hematopoietic stem cell transplant
DiGeorge syndrome
Which blood product processing technique reduces the risk of HLA alloimmunization
Leukoreduction
Which blood product processing technique reduces the risk of anaphylaxis in IgA deficient patients
Washing
Which blood product processing technique reduces the risk of graft-vs-host disease in immunocompromised pts
Irradiation
Rank the following viral complications from blood transfusions from greatest to least
CMV, HIV, Hep C, Hep B, Human T-Cell lymphotropic virus
CMV > Hep B > Hep C > HIV > HTLV
What type of infection is most common with blood transfusion
CMV
What is the cause of acute hemolytic reaction to blood transfusion
ABO incompatibility
Complement is activated in recipient’s blood, and plasma antibodies attach the antigens on donor cell membranes
What pathological processes can result from acute hemolytic reaction
Renal failure
DIC
HoTN
What 3 signs of acute hemolytic reaction are present during anesthesia
- Hemoglobinuria
- HoTN
- Bleeding
What 6 signs of acute hemolytic reaction are masked by anesthesia
- Fever
- Chills
- Chest pain
- Dyspnea
- Nausea
- Flushing
What is the cause of hemoglobinuria with acute hemolytic reactions
Free hgb in the form of acid hematin precipitates inside the renal tubules
This causes mechanical obstruction and ATN
What is the cause of DIC with an acute hemolytic reaction
Erythrocyin is released from the RBC and activates the intrinsic clotting cascade.
This leads to uncontrolled fibrin formation and consumes plts and factors 1, 2, 5, and 7
How does acute hemolytic reaction cause hypotension
Free hgb activates the kallikrein system. The final product of the pathway is bradykinin, a potent vasodilator
What is the treatment for acute hemolytic reaction
- Stop transfusion
- Maintain UO >75-100 mL/hr with IV fluids, mannitol, and lasix
- Alkalinize urine w/ NaHCO3
- Send urine and blood to blood bank
- Check labs: plt, PT, fibrinogen
- Send unused blood to BB
- Support hemodynamics with IVF and vasopressors
What are the 2 categories of nonhemolytic transfusion reactions
Febrile
Allergic
What is febrile transfusion reaction
Pyrogenic cytokines and intracellular components are released from leukocytes in the donor blood products
What blood processing technique decreases febrile transfusion reaction
Leukoreduction
What is the most common adverse reaction to blood transfusion
febrile reaction
What are 5 common s/sx of febrile transfusion reaction
- Fever
- Chills
- HA
- Nausea
- Malaise
What is the treatment for febrile transfusion reaction
- Supportive
2. Acetaminophen
What is the cause of allergic transfusion reaction
Foreign protein in the donor blood product
What are the 2 types of allergic transfusion reactions
- Anaphylactic (IgE mediated)
2. Anaphylactoid (NOT IgE mediated)
Usual presentation of allergic transfusion reactions
- Urticaria
2. Facial swelling
Treatment for allergic transfusion reactions
- Supportive
2. Antihistamines
Should transfusions be continued when an allergic transfusion reaction is identified
For minor reactions = yes continue transfusion
For major reactions = stop transfusion and treat anaphylaxis (dyspnea, laryngeal edema etc)
What is TRALI (transfusion-related acute lung injury)
A form of non-cardiogenic pulmonary edema following transfusion
What is the cause of TRALI
Human leukocyte antigens (HLA) and neutrophil antibodies present in the donor plasma
Neutrophils are activated in the lungs causing endothelial injury and capillary leak. Pulmonary edema results, impairing gas exchange
What is the most common cause of transfusion related mortality
TRALI
Which blood components are at greatest risk of causing TRALI and why
FFP and platelets
These components have the highest concentration of TRALI causing antibodies
Which populations are at higher risk of suffering TRALI
- Critically ill
- Sepsis
- Burns
- Post-CPB
Which donor groups impart the highest risk of TRALI
- Multiparous women
- History of blood transfusion
- history of organ transplant
What are 4 diagnostic criteria for TRALI
- Onset <6 hrs post transfusion
- Bilat infiltrates on CXR
- PaO2/FiO2 <300 mmHg or SpO2 <90% RA
- Normal PAOP (no LA HTN)
What is the recommended management of TRALI
Supportive lung-protective strategies
- PEEP
- Low Vt
- Avoid overhydration
What is TACO (transfusion associated circulatory overload)
A state of volume overload caused by expanding plasma volume beyond pts compensatory ability
What are 6 s/sx of TACO
- Pulmonary edema
- Hypervolemia
- LV dysfunction
- Mitral regurg 2/2 volume overload
- Increased PAOP
- Increased BNP
What are 5 pathophysiologic consequences of massive transfusion
- Alkalosis
- Hypothermia
- Hyperglycemia
- Hypocalcemia
- Hyperkalemia
Why are the following possible with massive transfusion Alkalosis Hypothermia Hyperglycemia Hypocalcemia Hyperkalemia
Alkalosis= citrate metabolizes to HCO3 in the liver Hypothermia= cold blood Hyperglycemia= dextrose additive in stored blood Hypocalcemia= binding of Ca++ by citrate Hyperkalemia= Older blood causes leak of K+ from cell membrane
What is the lethal triad of trauma
- Acidosis
- Hypothermia
- Coagulopathy
What factors impact coagulation in a trauma pt
- Temperature = hypothermia impairs enzymatic processes of the clotting cascade
- Acidosis = from hypoperfusion impact enzymatic structures of clotting cascade
- Massive volume resuscitation= dilutional coagulopathy
What 5 surgical procedures may utilize intraoperative blood salvage techniques
- Cardiac
- Major vascular
- Trauma
- Liver transplant
- Orthopedic
What threshold of expected blood loss is intraop blood salvage recommended
EBL 1,000 mL or 20% of EBV
What 2 populations may benefit from blood salvage techniques
- Pre-existing anemia
2. Refusal of allogenic blood i.e. JW
What is the process of intraop blood salvage
- Blood is collected from field with dedicated suction device
- Mixed w/ anticoag
- Filtered and centrifuged for RBC concentration
- Washed
- Diluted w/ saline to HcT 60-70%
What components of blood are removed during blood salvage
Platelets
Coag factors
What are 4 benefits of salvaged blood over banked blood
- better O2-carrying capacity
- Higher 2,3-DPG concentration
- Greater ATP
- Better shape
What are the risks of intraop blood salvage transfusion
- Contamination (malignant cells, amniotic fluid, urine etc)
- Fever
- Non-immunogenic hemolysis
What should be given in addition to a large transfusion of salvaged blood and why
Coagulation factors (FFP) and Plt B/c of dilutional coagulopathy
What are 5 contraindications for blood salvage use
- Sickle cell disease
- Thalassemia
- Topical drugs in the field (betadine, CHG, topical abx)
- Infected surgical site
- Oncologic procedures
A patient with which blood type is least likely to experience a hemolytic transfusion reaction
AB positive
