HAEMATOLOGY Flashcards
Definition of anaemia
Low haemoglobin
Interpreting FBC
Hb, White cell, platelets
MCV - clue of cause of anaemia
How do you classify anaemia
Size of red cells
Microcytic - iron deficiency (95% of microcytic caused by this)
How do you classify anaemia
Size of red cells
Microcytic - iron deficiency (95% of microcytic caused by this)
Macrocytic - B12/ folate deficiency
Normocytic - blood loss
Macrocytosis without anaemia causes
Liver disease
Hyperthryroid
Excess alcohol use
Sickle cell anaemia
Autosomal recessive
Single point mutation
Key feature of sickle cell
Painful vaso occlusive crises
Triggers for sickle cell crises
Infection
Cold weather
Hypoxia
What would you see on a smear for sickle cell
Target cells
erythroblasts - dont usually see these in normal population represent high turnover in marrow
what is myelodysplasia
disease of elderly
pre-malignant condition
bone marrow not working properly
what is lymphoma
malignancy of lymphocytes in lymph nodes
symptoms of hodgkins lymphoma
B symptoms
painless lymphadenopathy
types of non -hodgkins lymphoma
high (acute/ progress rapidly, but curable) or low grade (slow progression but incurable)
symptoms of hodgkins lymphoma
B symptoms
painless lymphadenopathy
4 sub types
what is myeloma
proliferation of plasma cells
causes of thrombocytosis
bleeding, malignancy, inflammation, infection
warfarin
slow on and off
test for haemophillia
factor 8 and 9
APTT
treatment of pernicious anaemia with hb very low
still dont transfuse as will have acquired deficiency slowly over time, if transfuse quickly can tip into heart failure (if elderly and features of hf)
neurological manifestations of folate
none
blood components from one donation
red cells
platelets
fresh frozen plasma
cryprecipitate (used to replace fibringogen)
complications of blood transfusions
fluid overload viral infection bacterial infection incompatibility reaction iron overload
risk factors for vte
surgery obesity immobility cancer cocp pregnancy
treatment for pe
rivaroxiban for 3 months
15 mg for 3 weeks then 20 mg for remainder
different dose after 3 weeks
treatment for pe
rivaroxiban for 3 months 15 mg for 3 weeks then 20 mg for remainder different dose after 3 weeks provoked 3 months unprovoked 6 months
what is the action of tranexamic acid
Anti-fibrinolytic
Stops (prevents) the breakdown of clots
what is a direct and indirect coombs test
What is an indirect coombs test used for
Direct tests for antibody on RBC surface
Indirect tests for antibodies in blood, this one is used to diagnose reactions to blood transfusion.
What is the response to protamine sulphate by
1) heparin
2) LMWH
3) Fondaparinux
1) Complete response
2) Partial response
3) No response
Why are LMWH and fondaparinux preferred to unfractioned heparin
Better pharmacokinetics (stable half lives regardless of dose so dont need daily monitoring) Less adverse reactions - lower risk of HIIT because dont have mechanism of action on thrombin (which is mechanism of action that caused thrombocytopaenia)
Management of major haemorrhage
Activate major haemorrhage protocol
Administer high flow oxygen
Insert 2 wide bore peripheral cannulae and provide fluid resuscitation.
Contact key personnel, including experts to treat bleeding cause.
Arrest bleeding and treat underlying cause as soon as possible.
Request laboratory investigations and perform Point of Care Tests where available, including blood gas analysis and viscoelastic tests (ROTEM/ TEG).
Transfuse red cells to maintain a haemoglobin level of 70-90 g/L
Administer tranexamic acid within 3 hours of onset of haemorrhage unless complicated by disseminated intravascular coagulation
Transfuse FFP empirically if estimated blood loss greater than 20% blood volume or if microvascular bleeding
Anticipate the need for additional blood components (including red cells, FFP, platelets and cryoprecipitate)
Use cell salvage where available and appropriate
When bleeding is under control additional doses of FFP should be based on results
what are the complications of major haemorrhage
thrombocytopaenia hypothermia hypocalcaemia hyperkalaemia ARDS coagulopathy
what bloods should you take during major haemorrhage
FBC - Hb, infection, platelets
Clotting - PT, APTT, including Fibrinogen (DIC)
Group and save - group blood
Cross match - cross matched blood
Calcium - needed for coagulation factors to work
ABG - ongoing Hb and electrolytes
How should blood be given in major haemorrhage
2 units RBC (O negative emergency)
1 unit of FFP to every 2 units of RBC
Platelets if fall below <75
Cryo only if fibrinogen is not correcting by FFP and is <1.5
what is fibrinogen concentrate indicated for
Fibrinogen supplementation in patients with congenital hypofibrinogenaemia; as prophylaxis before surgical procedures, or to treat bleeding
Correction of low fibrinogen levels due to acquired bleedingdisorders in Europe and in the Republic of Ireland, although not yet licensed for this indication in the UK.
Alert!! Fibrinogen concentrate can cause widespread thrombi, if administered inappropriately or in excessive dose. A critically low fibrinogen level should be confirmed beforehand.
What are the common acute transfusion reactions
Febrile, allergic, hypotensive reactions Acute haemolytic transfusion reaction TACO - circulatory overload TA Lung injury Transfusion related dyspnea Septic shock - from bacterial contaminant
what are the common delayed transfusion relactions
Haemolytic reactions from pregnancy or previous transfusion
Graft vs host disease
Iron overload
Post transfusion purpura
Outline the management of a suspected acute red cell transfusion reaction
STOP THE TRANSFUSION
Rapidly assess patient
A-E (observations and interventions as necessary)
Any concerns - call for help
Check component and patient are correct/ correct blood has been given
Commence medical treatment as necessary eg salbutamol for bronchospasm
Send giving set to blood bank for coombs test
Document event
Report on local incident management
Report to SHOT
How should you manage a transfusion reaction
STOP the transfusion
Maintain IV access
Undertake rapid clinical assessment including ABC (Airway, Breathing, Circulation)
If appropriate, call for help
Check identification details between the patient, their identity band and the compatibility label of the blood component
Visually assess the unit looking for evidence of unusual clumps or discolouration and check the expiry date
Check standard observations.
management of severe transfusion reaction
Call for help/medical staff immediately
Disconnect the component and giving set from the patient and retain for further investigation
Maintain IV access with physiological saline and use blood pressure, pulse and urine output to guide fluid administration
Ensure the airway is patent, and if the patient is severely dyspnoeic give high flow oxygen through a mask with a reservoir.
Shock/severe hypotension associated with wheeze/stridor i.e. anaphylaxis
Shock/severe hypotension without clinical signs of anaphylaxis or fluid overload i.e. ABO incompatibility or bacterial contamination
Severe dyspnoea without shock i.e. TRALI or TACO (Transfusion Related Acute Lung Injury or Transfusion Associated Circulatory Overload).
Treatment of moderate transfusion reactions
Moderate febrile symptoms
Differential diagnosis is similar to severe ATR
In most cases the transfusion will be discontinued.
If the transfusion is resumed then the patient should be monitored closely.
Moderate allergic symptoms
Symptoms may include angioedema and dyspnoea but not sufficiently severe to be life-threatening.
Antihistamines should be given.
Consider oxygen therapy and inhaled salbutamol.
Treatment of mild transfusion reaction
In mild ATR, medical staff should be informed, but the transfusion may be continued with appropriate treatment and close observation. Treat mild febrile reactions with oral paracetamol (500-1000mg in adults). Treat mild allergic reactions with antihistamines and slow the transfusion rate.
BEST PRACTICE POINT
A mild reaction may be the early stages of a severe reaction - DON’T IGNORE IT. Observe the patient closely
investigations for moderate-severe transfusion reactions
Full Blood Count (FBC)
Urea and Electrolytes (U&Es), Liver Function Test (LFTs)
Urine analysis (for haemoglobinuria, to exclude haemolysis)
what is the threshold and considerations for transfusing platelets
Well patient / no RFs - if fall below 10
(as long as plts are >5 there shouldnt be any increased risk of bleeding in the absence of any other RFs)
If RFs - transfuse at <20
If having surgery <50
If having anything to do with brain eyes - <100
Epidural - <80
Severe bleeding <50
Multiple trauma incl intracerebral bleed <100
what are the indications for cryo
< fibrinogen
von willebrands disease
factor 8 and 13 deficiency
DIC
why is cryo preferred in fibrinogen replacement to FFP
15 mls of cryo
Can keep replacing without overload
Higher concentration of fibrinogen in cryo (250mg in 10 mls) than FFP (400 mg in 200 mls)
