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CCRN Study Deck > Hematologic and Immunologic Systems 4% > Flashcards

Hematologic and Immunologic Systems 4% Flashcards

1
Q

Immunosuppressive effects Malnutrition Noise Anesthetic Agents

A

Cause physiologic or psychological stress which may result in suppression of the immune system

  • Malnutrition: humoral immunity
  • Anesthetic agents: affect natural defense mechanisms and the actions of the immune system
  • Music: noise causes stress, which has a detrimental effect on the immune system
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2
Q

Management of Patient with Disseminated Intravascular Coagulation (DIC)

A
  • Avoidance of injections
  • Replacement of fluids, blood, and clotting factors
  • Turning frequently and gently
  • Manual blood pressure reading (avoid NIBP cuff readings because increased pressure can cause bruising/trauma)
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3
Q

Indication for Administration of Blood

A
  • Symptoms of hypoperfusion such as chest pain or dyspnea.
  • Blood is necessary to carry oxygen
  • Absolute hemoglobin or heamtocrit are no longer indications because of the risk of blood-transmitted diseass.
  • Inability to control bleeding is an indication for surgery
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4
Q

Which Labs Should Be Monitored With Multiple Blood Transfusions

A

Potassium - Hyperkalemia

  • Stored blood has a high potassium content resulting from aging and hemolysis of RBCs

Calcium -Hypocalcemia

  • Citrate used as an anticoagulant in banked blood
  • Citrate binds with calcium that reduces the ionized calcium level and causes tetany
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5
Q

Which Labs Most Specifically Indicate DIC is Cause for Bleeding

A

Fibrin Degradation Products (FDPs)

  • Elevated FDPs speficially indicative of a fibrinolytic process rather than simply a clotting abnormality

D-dimer

  • Form of FDP most specific to DIC
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6
Q

Heparin-Induced Thrombocytopenia (HIT)

A
  • Immune-mediated adverse effect of heparin
  • Causes thrombosis and thrombocytopenia
  • Patient receiving heparin therapy by continuous infusion
  • Petechiae
  • Not dose-related
  • Platelets clump (white clots) which causes ischemia and platelet depletion
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7
Q

What is the first sign of platelet dysfunction (quantity or quality)?

A

Petechiae

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8
Q

Most common cause of a fatal transfusion reaction?

A

Mismatched blood transfusion

  • Causes hemolytic reaction
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9
Q

Disseminated Intravascular Coagulation (DIC)

A
  • Consumptive coagulopathy (consumption of clotting factors)
  • Stimulation of the clotting cascade and formation of microclots cause the consumption of clotting factors and platelets
  • Stimulation of the fibrinolytic process causes formation of fibrin degradation products (FDPs) from clots
  • FDPs also have an anticoagulant effect
  • Always secondary and never hereditary or primary
  • Results in deposition of thrombi in microvasculature (microembolism) and consumption of clotting factors (hemorrhage)
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10
Q

Disseminated Intravascular Coagulation (DIC) Phases

A
  1. Excessive clotting: uses up clotting factors
  2. Bleeding
  3. Stimulation of the fibrinolytic system
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11
Q

Desired platelet count for surgical procedures

A

Platelet count 50,000/mm³

Platelet counts <20,000/mm³ are associated with spontaneous bleeding

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12
Q

Why do patients receiving multiple units of packed RBCs also need to receive platelets?

A
  • RBC’s do not contain platelets
  • Clotting abnormalities in these patients result from hypocalcemia, thrombocytopenia, and depletion of clotting factors
  • Fresh frozen plasma also is indicated to replace the clotting factors
  • Patients receiving multiple units of banked blood develop ineffective clotting
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13
Q

Suspected Transfusion Reaction

A
  1. Stop the transfusion -The more blood that is administered = the more severe the reaction
  2. Infuse normal saline at a keep-vein-open rate -Keep the IV catheter open in case emergency drugs must be given
  3. Check patient’s vital signs
  4. Notify the physician and blood bank
  5. Order new type and crossmatch
  6. Send appropriate specimens to the laboratory
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14
Q

Patients with platelet count 10,000/mm3 are at great risk for what?

A

Spontaneous intracerebral hemorrhage

  • Assess level of consciousness
  • Manifested by changes:
    • LOC
    • headache
    • pupillary changes
    • focal signs
    • hemiparesis
    • hemiplegia
    • aphasia
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15
Q

Lab value changes seen with one unit of packed red blood cells

A
  • Increased hemoglobin by 1 g/dl
  • Increased hematocrit by 3%
  • Changes within approximately 4 to 6 hours
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16
Q

DIagnostic panels suggestive of disseminated intravascular coagulation (DIC)

  • platelets
  • fibrinogen
  • prothrombin time (PT)
  • activated partial thromboplastin time (aPTT)
  • thrombin time
  • fibrin degradation products (FDPs)
A
  • decreased platelets
  • decreased fibrinogen
  • prolonged prothrombin time (PT)
  • prolonged activated partial thromboplastin time (aPTT)
  • prolonged thrombin time
  • increased fibrin degradation products (FDPs)
17
Q

Electocardiogram Signs of Hyperkalemia

A
  • Tall, peaked T waves
  • Widening QRS complex
18
Q

Why give heparin in patients in DIC?

A

Heparin neutralizes circulating thrombin to prevent clotting.

  • Heparin does not affect the fibrinolytic process (plasmin - the active agent of the fibrinolytic system)
19
Q

Platelet

A
  • Smallest of blood cells
  • Made in bone marrow
  • 200 billion produced per day
  • Platelet count measures platelet quantity
  • Bleeding time measures platelet function, how well platelets work
20
Q

Intrinsic Coagulation Pathway

A
  • Stimulated by vascular endothelium injury
  • Causes
    • Cell trauma (valve, IABP)
    • Sepsis
    • Shock
    • ARDS
    • Hypoxemia, acidemia
    • Cardiopulmonary arrest
21
Q

Extrinsic Coagulation Pathway

A
  • Stimulated by tissue injury
  • Releases “tissue thromboplastin”
  • Causes:
    • Extensive trauma
    • OB emergencies
    • Malignancies
    • Dissecting aortic aneurysm
    • Extensive MI
22
Q

Anticoagulant Reversal

A
  • Heparin = Protamine
  • Warfarin (Coumadin) = Vitamin K
23
Q

DIC Lab Values

A
  • Primary
    • Decrease Platelets
    • Decrease Fibrinogen
    • Decrease Hematocrit
    • Increase Fibrin split products (FSP) (D/t increase fibrinolysis)
    • Increase PT, PTT, INR, bleeding time
  • Secondary
    • Increase D-dimer assesses presence of clotting
    • Increase Antithrombin III
24
Q

Normal Fibrin split products (FSP) and Fibrinogen levels

A
  • FSP = < 10 mcg/mL
  • Fibrinogen = 200 - 400 mg/dL
25
Q

DIC Treatment

A
  • Identify and eliminate underlying cause
  • Vitamin K
  • Blood component therapy
    • Fresh frozen plasma (FFP)
    • Cryoprecipitate
    • Platelets
  • Heparin (low dose) controversial but may be used for patients with chronic, low-grade DIC who have predominantly thrombotic manifestations
  • Maintain hemodynamic stability
26
Q

Blood Transfusion Reactions Timing

A
  • Acute Transfusion Reaction: Occurs within 24 hours of administration
  • Delayed Transfusion Reaction: Occurs after 24 hours of administration
27
Q

General Management of Transfusion Reactions

A
  1. Stop the transfusion
  2. Disconnect the blood tubing at the intravenous catheter hub, begin a new normal saline and new tubing to keep the vein open.
  3. Assess the patient
  4. Monitor the patient’s vital signs until stable
  5. Perform a clerical check on the blood product and the patient’s identification
28
Q

Management of Blood Transfusion Reaction

Acute hemolytic reactions (antibody mediated)

A
  • Anticipate hypotension, renal failure, and DIC
  • Prophylactic measures to reduce the risk of renal failure may include vigorous hydration with crystalloid solutions (3,000 mL/m2/24 hr) and osmotic diuresis with 20% mannitol (100 ml/m2/bolus, followed by 30 mL/m2/hr for 12 hr)
  • If DIC is documented and bleeding requires treatment, transfusions of frozen plasma, pooled cryoprecipitate, and/or platelet concentrates may be indicated
29
Q

Management of Blood Transfusion Reaction

Acute hemolytic reactions (non-antibody mediated)

A
  • Transfusion of serologically compatible, although damanged, RBCs usually does not require rigorous management
  • Diuresis induced by an infusion of 500 mL of normal saline per hour, or as tolerated by the patient, until the intense red color of urine subsides
30
Q

Management of Blood Transfusion Reactions

Febrile, non-hemolytic reactions

A

Acetaminophen

31
Q

Management of Blood Transfusion Reactions

Allergic Reaction

A

Diphenhydramine (Benadryl) is usually effective for relieving pruritus that is associated with hives or a rash

32
Q

Management of Blood Transfusion Reactions

Anaphylactic reactions

A
  • Subcutaneous injection of epinephrine (0.3 - 0.5 mL of a 1:1000 aqueous solution) is standard treatment.
  • If patient is sufficently hypotensive to raise the question of the efficacy of the subcutaneous route, epinephrine (0.5 mL of a 1:10,000 aqueous solution) may be administered intravenously.
  • Steroids if epinephrine does not relieve symptoms
33
Q

Management of Blood Transfusion Reactions

Transfusion-related acute lung injury (TRALI)

A
  • Oxygen, mechanical ventilation if necessary
  • Diuretics (only if there is also volume overload or cardiogenic pulmonary edema)
34
Q

Management of Blood Transfusion Reactions

Circulatory (volume) overload

A
  • Oxygen
  • If practical, the unit of blood component being transfused may be lowered
  • Diuretics
35
Q

Management of Blood Transfusion Reactions

Bacterial contamination (sepsis)

A
  • Blood cultures
  • Antibiotics

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