Hematology 1 Flashcards
What are the functions of blood?
Homeostasis
Defense
Transports O2, nutrients, waste & hormones
Heat exchange
What is the primary source of blood cells?
Bone marrow (95%)
Red marrow of sternum, ribs, vertebrae & skull
What is the secondary source of blood cells, but also the primary source in PEDS?
Femur & tibia
WBC are ________, which are further categorized as_____ & ____
Leukocytes; Granulocytes; Agranulocytes
WBC action
Defend against foreign cells & infection
It is non-specific & an acquired immune response & inflammation
Comes from bone marrow
Lymphocytes from lymphatic organs
HGB is equivalent to
O2 carrying capacity
What is involved in the destruction of aged RBCs?
Destroyed by liver macrophages
Within ~4 months
Heme is broken down into iron & bilirubin
Anemia is the
Reduction in RBCs or HGB (hemorrhage or bone marrow failure)
What are the types of Anemia?
Dietary deficiency 9folic acid/iron/vitamin B12)
Kidney disease/ Nephrectomy
Sickle cell
Iron is absorbed in __________ & is increased by ____________
The diet in the small intestine
Vit C
Iron is bound to
Transferrin in the plasma
Iron is an essential component of
Enzymes necessary for energy transfer
Iron is incorporated into
New erythrocytes & reticuloendothelial cells in the liver & spleen
Plasma concentration of iron
50-150 mcg/dL
Causes of iron deficiency
Inadequate dietary intake
Increased requirements during pregnancy or blood loss
Interference with GI absorption
Iron supplements increase the rate of
Erythrocyte production & HGB concentration
With iron supplementation, levels should rise within
3 days to 3 weeks
Agglutinogen is an _________ which stimulates formation of _________
Antigen; Agglutinin
Agglutinin is an ________ or other blood substance that causes particle ________
Antibody; Aggregation
What happens to RBC as they are stored over time?
Depletion of ATP & 2,3 DPG (used to help HGB off-load O2 to tissues)
Shape change
Fragility impairs flow
Promotes inflammation, leading to ALI during transfusion, decreased O2 delivery & INCREASED hemolysis (LEFT SHIFT)
How many days place a patient at an increased risk of adverse events due to RBC storage?
> 14-21 days
A lengthy storage of RBCs can also impair
NO scavenging
Reduced NOS (dysfunctional endothelial cells)
Na/K ATPase failure–> K+ leak
Acute anemia can result in
A compensatory increase in CO & oxygen transport, but this process is limited in those with HF or flow restrictions
What kind of filter should be used with transfusing
170-260 micron
Removes clots & aggregates
Leukoreduction
One unit of PRBC will increase HBG by____
HCT by _______
HGB 1
HCT 3%
What fluids are compatible with transfusions?
NS
Albumin
Plasma often co-administered with RBC transfusion
Isotonic crystalloids (LR, Normosol & Plasmalyte)
Which fluids should be avoided when transfusing blood?
D5
Hypotonic
These fluids cause RBC lysis due to RBC taking up glucose & causing lysis
RBC, PLT, & Cryo should be
Administered separately
What defines plasma/fresh frozen plasma?
Whole blood is removed of RBCs, PLT, coagulation factors, fibrinogen & plasma proteins
FFP is plasma frozen within
8-24 hours of collection
What can be obtained from FFP
Cryo
FFP can be transfused
Interchangeably with thawed plasma
PLasma/FFP should be transfused within
24 hours of being thawed
Storage of plasma/FFP reduces factors
5 & 8
Plasma transfusions are indicated to
Replace volume & coagulation factors
Treat or prevent bleeding
Reverse warfarin anticoagulation
Treat coagulation factor abnormalities
Dose of plasma trasfusion
10-15ml/kg
Half of this when treating for warfarin
Plasma will increase the plasma factor concentration by ____
30%
What is cryoprecipitate?
Formed from show thaw of frozen plasma (residual volume refrozen & stored up to 3 years)
Cryoprecipitate is rish in factors
1, 8, & 13
What are the indications of giving cryoprecipitate?
Restore fibrinogen depleted from massive hemorrhage or coagulopathy
Treat hemophilia A & factor 13 deficiency
How should cryoprecipitate be administered?
Trasfuse with 4 hours
1 unit/10kg
What is the minimum FGN level for homeostasis?
~100 mg/dL
Cryoprecipitate will increase FGN by
50-100mg/dL
What is the average life span of PLT?
8-12 days
PLTs are involved in_________ for hemostasis
Thrombus formation
PLT & WBC recruitment
Normal PLT count
150,000-400,000/microL
How are PLT prepared?
Whole blood pooled & random donor
Single donor apheresis (4-6 pooled units)
Leukoreduced (removal of WBCs)
Leukoreduction will
Minimize sensitization & antibody reactions
Reduces risk of HLA alloimmunization, PLT refractoriness & transmission of viruses
PLT will increase plasma level to
30,000-50,000
PLT and their storage
They are stored at 22 degrees C, which increases the risk of bacterial growth
PLT transfusion risk the chance of
graft vs host disease, which is when the grafts immune cells recognize the host as foreign & attacks recipient’s cells
Which patients have a risk of graft vs host disease?
CA patients
Immunocompromised
PEDS
Graft vs host disease is common after
Bone marrow & stem cell transplant
PLTs can be ______ for certain populations & indications
Gamma-Irradiated
Surgical patients PLT typically
> 50,000-100,000microL
PLT count does not provide
Information on PLT function & quality
Adverse effects of transfusions
Acute inflammatory response
Immunomodulation
Allogeneic blood w/bioactive substance
Immunosuppressive effects
Fever
Release of inflammatory mediators & neutrophil activation
Risk post-op infection
Transfusion of transmissible infections
When should prophylactic administration of PLT be considered?
During massive transfusion
Closed surgical procedures with a high risk of hemorrhage
What does TACO stand for?
Transfusion-Associated Circulatory Overload
TACO occurs when
There is overload of a poor cardiovascular system (HF) related to transfusion of blood products
Symptoms of TACO
Acute onset of dyspnea & tachypnea
HTN
Tachycardia
HF exacerbation
Pulmonary edema
What lab value will be elevated in TACO?
BNP
An echocardiography in relation to TACO will show
Ventricular & valvular dysfunction
What does TRALI stand for?
Transfusion-related acute lung injury
How is TRALI defined?
New & acute lung injury within 6 hours of transfusion
On the cellular level int he lungs, what happens during TRALI?
Neutrophils &/or endothelial activation in the lungs
Pulmonary vascular injury
Pulmonary edema
Symptoms of TRALI
Acute onset hypoxia (<90% on RA, PaO2/FiO2<300mmHg)
Bilateral pulmonary infiltrates
NO evidence of HF or volume overload
Related factors of TRALI
Initiating inflammatory event
Lipids from stored blood
Viral infection
Cardiopulmonary Bypass
Secondary transfusion event triggers further inflammation & injury
Antibody specific
Underlying condition
Life threatening 7 uncontrolled bleeding can be caused by
Massive transfusion coagulopathy
Trauma induced coagulopathy
Thawed plasma will restore
Endothelial tight junctions
Proteins to help with osmotic maintenance
Anti-inflammation
Coagulopathy is the depletion or decrease in
The function of clotting factors & PLTs
Coagulopathy will worsen in the presence of
Hypothermia & acidosis
Coagulopathy will accelerate
Clot breakdown
Coagulopathy is the lost balance between
Physiologic anti- & pro- coaagulant effects
What is dilutional coagulopathy?
Giving too much volume by administering crystalloids, colloids, RBCs & cell salvage
Blood loss
Fibrin is needed for
Clot formation
Frbrinolysis is the break down of a clot & is excessive in
The trauma patient & can lead to increased bleeding
Hypofibrinogenemia is NOT corrected by
FFP
Hypofibrinogenemia is the
Excess reduction in fibrinogen (~80-100mg/dL), which will prolong PT/PTT
How is Hypofibrinogenemia corrected?
Giving Cryo or fibrinogen concentrate
Citrate toxicity can cause
Hypocalcemia
Hyperkalemia associated with transfusions is caused by
Potassium leakage during RBC storage, which places the patient at risk for arrhythmias, especially in ECMO, heart lung machines, or using older blood
Hypothermia occurs when?
Reduces core temperature abruptly
10 units can reduce body temperature by ~3 degrees, risking exacerbation of hemorrhage, arrhythmias & other complications
Which laboratory monitoring test is the best to monitor during transfusion
TEG/TEM
Why is TEG/TEM the better lab value to monitor?
Goal directed management
Gives information on clot formation, strength, firmness, fibrin polymerization & coagulopathy
What other lab value can be monitor but does not provide as much information as TEG/TEM?
PT/aPTT
PT–> loss of factors & hemodilution
What defines a massive transfusion?
> 10 units RBC in 24 hrs
Higher mortality
Indicative of severity of injury
Protocol to rapidly secure products
Ideal ratio
What blood products are given in the 1:1:1 ratio?
Frozen plasma/thawed plasma/other plasma product
Apheresis PLT
PRBCs
Volume of frozen plasma?
~200-300ml
Volume of apheresis PLTs
Contains ~300 billion PLTs
~25% of normal amount circulation PLTs
Only 50% is circulated
Volume of PRBCs
~325mL
Plasma is given for
Clotting factor replacement
What are the goals for plasma infusion?
PT<18
aPTT<35
ACT>128
Cryo goal fibrinogen >180
What is the indication for giving PLTs
PLT replacement (.150,000)
Goal for RBC transfusion
HGB.8-10g/dL
RBCs release________, which activates_____
ADP; Activated PLTs
When are antifibrinolytic agents given?
Preserved for clot formation
Indication is based on TEG (LY30 value)
Hypocalcemia, due to citrate toxicity is depletion of
Serum free Ca+ (ionized) concentration
Hypocalcemia risks
paresthesia & arrhythmias
There is a higher risk of hypocalcemia in
Hepatic dysfunctions
Chloride does not require
Normal liver function
10% Ca+ chloride is _____mL per blood unit
2-5
10% Ca+ gluconate is _______mL per blood unit
10-20
Large volume resuscitation risks
Dilutional coagulopathy
Severe edema
Lung stiffness
ABD compartment syndrome
When is the massive transfusion protocol used?
Trauma
Cardiac surgery
Obstetrics
Liver patient
What is the goal maintenance of fibrinogen in obstetrics?
> 200mg/dL
Obstetric patients are already in a _________ with________
Hypercoagulable state; compensatory increase in fibrinolysis
Liver patient have a reduction in
Production of normal coagulation factors
Hepatic clearance coagulation factor fragments, which increases the risk for hemorrhage
Liver patients have a dysfunction in
Vit-K dependent factors & fibrinogen
Caution with this in liver patients
Consider blood volume and portal circulation
Correct acidosis with
Bicarb
Minimize the use of
Crystalloids in massive transfusion
With massive transfusion, use these products sooner rather than later
Plasma
PLT
RBCs
What is postpartum hemorrhage?
> 500mL vaginal or >1,000mL section with ongoing bleeding; symptomatic within 24hrs
Potential causes of postpartum hemorrhage
Uterine atony
Placental retention
Uterine Abnormalities or inversion
Lacerations
Coagulopathies
PPH can be treated with
Antifibrinolytics
Uterotonics
When treating PPH, an antifibrinolytic like tranexamic acid dose is
1 gram over 10-20 min & repeat after 30 min if needed
Oxytocin MOA
Increases intracellular Ca+ for uterine contractions
10-40 units IM/IV diluted
Adverse effects of oxytocin
Maternal arrhythmias & HOTN
MOA of Methylergonovine, an uterotonic
Potent vasoconstrictor than increases the strength & frequency of uterine contractions
0.2mg IV every 2-4 hrs
The alternative to oxytocin & TXA
When is Methylergonovine, an uterotonic contraindicated?
HTN
CVD
Preeclampsia
MOA of carboprost, an uterotonic
Stimulates uterine smooth muscle contraction
250mcg IM or directly into uterine muscle
Adverse effects of carboprost, an uterotonic
Nausea
Bronchospasm
Increase in PVR
