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Haematology Flashcards

1
Q

What is the mechanism of action of Dabigatran?

A

Direct thrombin inhibitor

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2
Q

What is the reversal agent for Dabigatran?

A

Idarucizumab

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3
Q

What is the mechanism of action of apixaban and rivaroxaban?

A

Direct factor Xa inhibitor

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4
Q

What is the reversal agent for apixaban and rivaroxaban?

A

Andexanet alfa (recombinant form of factor Xa)

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5
Q

What is the mechanism of action of fondaparinux?

A

Activates antithrombin III

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6
Q

What is an example of a direct thrombin inhibitor other than dabigatran?

A

Bivalirudin usually IV

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7
Q

What does unfractionated heparin inhibit?

A

Thrombin, factors Xa, IXa, XIa, XIIa

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8
Q

What is the mechanism of action of LMWH?

A

Activates the action of antithrombin III on factor Xa

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9
Q

What are the benefits of LMWH vs standard heparin?

A

Less risk of heparin induced thrombocytopenia and osteoporosis

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10
Q

How do you monitor standard heparin?

A

Activated partial thromboplastin time

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11
Q

How do you monitor LMWH?

A

Anti-factor Xa

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12
Q

How do you reverse heparin overdose?

A

Protamine sulphate (only partially reverses LMWH)

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13
Q

What is the mechanism of action of warfarin?

A

Inhibits epoxide reductase preventing the reduction of vitamin K to its active form
This usually works on clotting factors II, VII, IX, X and protein C

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14
Q

What is target INR for mitral valve?

A

3.5

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15
Q

What things potentiate warfarin?

A

Liver disease
P450 enzyme inhibitors e.g. amiodarone, ciprofloxacin
Cranberry juice
Drugs which displace warfarin from plasma albumin e.g. NSAIDs
Drugs that inhibit platelet function e.g. NSAIDs

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16
Q

What are inducers of the P450 system?

A

Antiepileptics e.g. phenytoin, carbamazepine
Barbiturates e.g. phenobarbitone
Rifampicin
St John’s Wort
Chronic alcohol intake
Griseofulvin
Smoking

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17
Q

What are inhibitors of the P450 system?

A

Antibiotics e.g. cirpofloxacin, clarithromycin
Isoniazid
Cimetidine, omeprazole
Amiodarone
Allopurinol
Imidazoles e.g. ketoconazole, fluconazole
SSRIs e.g. fluoxetine, sertraline
Ritonavir
Sodium valproate
Acute alcohol intake
Quinupristin

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18
Q

Do inhibitors or inducers of the P450 system increase INR?

A

Inhibitors

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19
Q

How do you reverse warfarin in major bleeding?

A

Give IV Vitamin K 5mg
Prothrombin complex concentrate (FFP if not available)

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20
Q

How do you manage INR > 8?

A

Minor bleeding: Stop warfarin, IV Vitamin K 1-3mg, repeat if necessary, restart warfarin when INR <5
No bleeding: Stop warfarin, give oral Vitamin K 1-5mg using IV preparation, repeat if necessary, restart warfarin when INR <5

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21
Q

How do you manage INR 5-8?

A

Minor bleeding: Stop warfarin, give IV Vitamin K 1-3mg, restart when INR <5
No bleeding: withhold 1 or 2 doses of warfarin and reduce subsequent maintenance dose

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22
Q

What antiplatelets are first line for ACS?

A

Aspirin and ticagrelor (12 months)

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23
Q

What antiplatelet is second line in ACS if aspirin CI?

A

Clopidogrel

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24
Q

What antiplatelets are first line for PCI?

A

Aspirin and prasugrel or ticagrelor (12 months)

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25
Which antiplatelet is first line for TIA, stroke, PAD?
Clopidogrel lifelong
26
Which antiplatelets are second line for TIA and stroke if clopidogrel CI?
Aspirin (lifelong) and dipyridamole (lifelong)
27
Which antiplatelet is second line for PAD if clopidogrel CI?
Aspirin lifelong
28
Which blood product is used for chronic anaemia?
Packed red cells
29
What does fresh frozen plasma contain?
Clotting factors, albumin and immunoglobulin
30
What does cryoprecipitate contain?
Factor VIII and fibrinogen
31
What is the transfusion threshold?
Patient without ACS: 70g/L Patient with ACS: 80g/L
32
What is the target for after transfusions?
Patient without ACS: 70-90g/L Patient with ACS: 80-100g/L
33
What causes acute haemolytic transfusion reaction?
Mismatch of blood group ABO e.g. secondary to human error
34
Which transfusion reaction is due to a mismatch of blood group ABO e.g. secondary to human error?
Acute haemolytic transfusion reaction
35
How quickly does acute haemolytic transfusion reaction happen?
Minutes after Fever Abdominal and chest pain Agitation Hypotension
36
How is acute haemolytic transfusion reaction manages?
Stop transfusion Generous fluid resuscitation with saline solution Check patient identity Send blood for direct Coombs test Repeat typing and cross matching
37
What causes non-haemolytic febrile reaction?
HLA antibodies reacting with WCC fragments in the blood profit and cytokines that have leaked from the blood cell during storage Often the result of sensitisation by previous pregnancies or transfusions
38
How is a non-haemolytic febrile reaction managed?
Slow or stop transfusion Paracetamol Monitor
39
What are the symptoms of a non-haemolytic febrile reaction?
Fever Chills
40
How is a minor allergic reaction to blood transfusion managed?
Temporarily stop Give antihistamine May restart when symptoms have resolved
41
How is anaphylaxis to blood transfusion managed?
Stop transfusion Give IM adrenaline ABC support Antihistamine Corticosteroid Bronchodilator
42
What causes anaphylaxis to blood transfusion?
Patients with IgA deficiency who have anti-IgA antibodies (hypersensitivity reaction)
43
What is a transfusion related acute lung injury (TRALI)?
Non-cardiogenic pulmonary oedema thought to be secondary to increased vascular permeability caused by host neutrophils that become activated by substances in donated blood
44
How quickly does transfusion related acute lung injury (TRALI) present?
ARDS within 6 hours
45
What are the symptoms of transfusion related acute lung injury (TRALI)?
Fever Hypotension Infiltrates on CXR
46
How is transfusion related acute lung injury (TRALI) managed?
Stop the transfusion Oxygen Supportive care
47
What causes transfusion associated circulatory overload?
Excessive rate of transfusion or pre-existing HF
48
What are the signs of transfusion associated circulatory overload?
Pulmonary oedema Hypertension
49
How is transfusion associated circulatory overload managed?
Slow or stop the transfusion Consider IV loop diuretic Oxygen
50
How do you differentiate between TRALI and TACO?
TRALI = hypotension TACO = hypertension
51
What infection can be passed in blood transfusions?
variant Creutzfeldt-Jakob disease
52
What is the role of the spleen?
Remove immature or abnormal RBC from the circulation
53
What is seen on histology of hyposplenism?
Howell-Jolly bodies (cytoplasmic inclusions) Siderocytes
54
What should patients with hyposplenism be vaccinated for?
Hib, meningitis A&C Annual influenza Pneumococcal vaccine every 5 years
55
What antibiotic prophylaxis is given for at least 2 years in hyposplenism?
Penicillin V or amoxicillin
56
What causes hyposplenism?
Splenectomy Sickle-cell (atrophied spleen due to repeated infection) Coeliac Graves SLE Amyloid
57
What are indications for splenectomy?
Trauma Spontaneous rupture (EBV) Hypersplenism: hereditary spherocytosis or elliptocytosis Malignancy: lymphoma or leukaemia Splenic cysts, heated cysts, abscess
58
How is neutropenic sepsis defined?
Neutrophil count <0.5 in a patient having active anticancer treatment and: Temperature >38 OR Other signs consistent with sepsis
59
What is a common pathogen in neutropenic sepsis?
Staph epidermis due to indwelling lines
60
What is prophylaxis for neutropenic sepsis?
Fluoroquinolone
61
How does DIC present on blood test?
Low platelets Low fibrinogen Increased PT and APTT Increased fibrinogen degradation products Schistocytes due to microangiopathic haemolytic anaemia
62
What is the role of thrombin?
Converts fibrinogen to fibrin
63
What is the role of plasmin?
Breaks down fibrin
64
What is a key mediator of DIC?
Release of a transmembrane glycoprotein (tissue factor)
65
What is DIC?
Widespread clotting with resultant bleeding due to dysregulated coagulation and fibrinolysis
66
What is Budd-Chiari syndrome?
Obstruction to the outflow from the liver caused by thrombosis in the hepatic veins or IVC
67
What is the classic triad of Budd-Chiari syndrome?
Abdominal pain Hepatomegaly Ascites
68
How is a diagnosis of Budd-Chiari syndrome made?
Doppler US
69
What is the management of Budd-Chiari syndrome?
Anticoagulation e.g. LMWH, warfarin Endovascular procedures e.g. thrombolysis or angioplasty Transjugular intrahepatic protosystemic shunt (TIPS) Liver transplant
70

Finals (11 decks)

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