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Health Assessment Test 2 > Heme > Flashcards

Heme Flashcards

1
Q

What are some basic questions to ask patient in order to evaluate for potential blood disorders?

A
  • Have you ever had a blood problem such as anemia?
    • these pts w/ blood disorder – anemia/hemophelia etc, generally know. Its not a silent dx process. Have had enough bleeding episodes in past that they’ve been worked up, know if have sickle cell or thalasemmia etc so just ask them .
    • murmurs?
  • Have you ever had a problem with blood clotting or a serious bleeding problem?
  • Have you received a blood transfusion?-
    • need to ask most esp if signif med hx, if freq have tx, or had recent mass tx d/t trauma etc, need to be aware bc can dev abs, have potential for blood type to change, & finding compatible donor for them can be difficult so need to know b4 surgery
  • Do you use any medications such as aspirin or vitamins such as vitamin E or supplements such as ginseng, fish oil, gingko, or garlic known to affect blood clotting? How much? How often? When did you last use such?
    • Herbal “G’s”→ anticoag properties
  • Has a family member or blood relative ever had a serious bleeding problem? Many are hereditary
  • Have you ever had prolonged or unusual bleeding from cuts, nosebleeds, minor bruises, tooth extractions, or surgery?
    • Be careful how you ask..whats normal for me may not be normal for you etc. Ask “have you had any changes in bleeding or clothing” that is more indicative of a baseline prob than asking about “unusual” which may mean something different to a provider than a patient
  • Have you ever had excessive bleeding that required blood transfusion?
    • Just like in any disease process, a good H&P is key. More diagnostic or lab values don’t really tell you anything
    • If the results of these tests wont influence your anesthetic management, don’t order them
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2
Q

Goal of anemia assessment?

What are the transfusion requirements preop based on?

What to assess for in ROS?

A
  • Goal of assessment
    • determine etiology (ie renal/liver failure, underlying dx cause), duration, stability, related symptoms, and therapy (ie steroids, especially transfusions)
  • Ask about personal or family history of anemia.
  • Keep in mind the four transfusion requirements!
    • Current Hgb/Hct
      • risk & ben of giving blood, coexisting dx that rely on blood delievery (CAD), how intense is the sx going to be & the est blood loss?
    • Rough estimate of hgb → asking patients fatigue level, exercise tolerance
  • Consider the type of surgical procedure, anticipated blood loss, and comorbid conditions that either affect oxygenation or can be affected by hypoxia (CAD)
  • May assess for:
    • Palpitations
    • Fatigue
    • Chest pain
    • Melena
    • Bloody stools
    • Weight loss
    • Pallor
    • Murmurs (high CO heart failure)
    • Hepatosplenomegaly, lymphadenopathy
  • Trying to assess if theyd benefit from preop tx or should we have T&C/T&S etc
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3
Q

Preop Diagnostics for assessing heme system?

A
  • CBC- based on surgical considerations and H/P (anemic or high BL sx)
    • Women:
      • Hgb < 12 g/dL (normal 12-15.5 g/dL)
      • Hct < 36% (normal 37-47%)
        • < 11 g/dL in pregnant patients (increased plasma volume = physiologic anemia)
    • Men:
      • Hgb < 13 g/dL (normal 13.5-17.5 g/dL)
      • Hct < 40% (normal 42-52%)
    • Hematologist to determine cause and further evaluate newly diagnosed anemia or if severely anemic to get their insight
  • Blood type and screening; crossmatch- based on surgery and H/P
    • Type = what type they have. Screen = look for antibs on pts blood.
      • T&S go together.
  • Cross match = when ID donor blood & test it w/ your pts blood & look for a rxn
    • no rxn→ donor blood good to use for given amt of time usually 3-7 days, varies w/ hosp policy
    • Preoperative transfusion depending on degree of anemia, comorbidities, anticipated surgical blood loss, and risks vs benefits
  • Elective procedures may be postponed in patients with significant anemia until a cause and treatment can be addressed/optimize preop
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4
Q

Assessment for G6PD Deficiency?

A
  • Hemolytic anemia
  • Preoperative assessment should focus on:
    • (assess the severity→ mild vs severe)
      • Mild- few anesthetic considerations
      • Severe- robust anesth consids
    • previous episodes of hemolysis
    • identification of predisposing factors
    • determination of current hematocrit
      • see what drugs they are told to avoid, look at their allergy list
  • Current medications
    • Steroids
  • CBC
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5
Q

Sickle cell disease assesment?

A
  • Disease versus Trait (trait don’t go into crises, no anesth consids. Dx- need to start thinking about all those ischemic areas that may be damaged)
  • Preoperative assessment should focus on identification of organ dysfunction and acute exacerbations
    • Renal insufficiency-
      • are they on HD? Do they urinate a lot because they’ve lost the ability to concentrate urine?
    • Dehydration (loss of renal concentration ability)
    • Splenomegaly
    • Pulmonary hypertension/ pulmonary infarctions (pulmonary components)
      • do they use O2 at night or during the day?
    • Stroke- residual deficits?
    • Heart failure
    • Infections (greater risk due to splenic infarctions)*
    • Recent hospitalizations*
    • Advanced age*

* =high risk pt predictors of perioperative vasoocclusive complications

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6
Q

Diagnostics for sickle cell disease?

A
  • Oxygen saturation
    • will tell you about their pulmonary status, and if they have decreased perfusion to their extremities
  • CBC**- hematocrit
  • BUN, Creatinine → kidney insuff
  • ECG
  • Chest xray
  • Echocardiogram and abgs as indicated
    • Cardiac ischemia probs
  • Hematologist consult – impt to discuss if they should have tx preop if high risk hip sx, tx to get normal hgb up to higher lvl than sickled hgb, etc
  • Preoperative prophylactic transfusion is controversial- discussed in co-existing heme lecture
  • +/- invasive monitors
    • dep on degree of risk that pt has to degree of risk that sx has
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7
Q

Thalassemia considerations?

A
  • Preoperative considerations:
  • Potential for difficult airway secondary to maxillary deformities
    • frontal head and maxillary growth
  • Cardiac arrhythmias due to high CO heart failure
    • Echo, Ecg may be necessary
  • Coagulopathy
    • Regional?
    • Coags – if major sx
  • Monitoring
    • Routine
    • +/- invasive monitors with presence of heart failure or invasive sx
  • Check electrolytes
  • CBC
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8
Q

Considerations for aplastic anemia?

A
  • CBC!
    • WBC differential- help Infectious Disease (ID) determine what ABX needed for coverage
  • Coags!
    • these pts definitely need labs, want to look at their WBCs too
      • May need preop infusions of RBC/Platelets/Coags etc (usually will get them to be optimized b4 sx)
  • Baseline medications?
    • Steroids?
  • Airway hemorrhage possible with DVL
    • Preoperative airway plans? Dep on your comfort lvl & how good you are at DL vs glidescope etc
  • Type and crossmatch concerns
    • Increased difficulty with multiple transfusions. Need T&C early on
  • Reverse isolation
    • Prophylactic antibiotics based on CBC studies (degree of neutropenia)
    • Bypass preop, take from room to OR
  • Monitors
    • +/- invasive monitors (a. line); based on CBC and surgical risk
    • almost always invasive monitors will be necessary. Also if you don’t plan on taking them to ICU, you should be the one taking out their A line. Anticipate staying there for at least 20 minutes to hold pressure
  • Regional? Dep on coag status, plt lvls etc
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9
Q

Normal CBC? RBC? H/H? RBC indices? WBC?

A

Nicole said this was “for our enjoyment” during lecture., I don’t think we’ll be tested on specific values…

  • RBC
    • 1.6-6.2 million/mm3 men
    • 4.2-5.4 million/mm3 women
  • Hct
    • 42-52% men
    • 37-47% women
  • Hgb
    • 13.5-17.5 g/dL men
    • 12-15.5 g/dL women
  • RBC indices (MCV, MCH, MCHC)
  • WBC
    • 5,000-10,000/mm3
  • Differential WBC –does help with surgical considerations
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10
Q

What is a trhomboelastography (TEG)?

A
  • Provides a “real time” visual representation of blood coagulation and fibrinolysis (clotting)
    • Used in Cardiac Rooms
    • Use if pt oozing and don’t know why
      • Takes 30 min to run
  • Can be assessed during surgery
  • Depicts characteristic abnormalities in clot formation and fibrinolysis
    • **Segment, problem area, and treatment *** know for exam
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11
Q

What are the various components of TEG?

A
  • R time
  • K time
  • Alpha angle
  • Maximum amplitude
  • Lysis at 30 min
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12
Q

What is the R segment? What does it monitor for? normal? problem wih? treatment?

A
  • R Segment: monitors coag factors (secondary hemostasis)
    • Does not tell you which factor has problem (1 through 13)
    • If prolonged → coagulation issue
      • TX: FFP
        (general on bc don’t know issue)

From table:

  • Normal- 5-10 minutes
  • Definition- time to start forming clot
  • problem with coagulation factors (not sure which one)
  • Treamtent= FFP
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13
Q

What is k time? alpha angle?

A
  • K Segment/alpha angle: looks at fibrinogen, strengthing of clot (fibrin crosslink)
    • Ex: if R normal and K prolonged → Factor I issue!
      • TX: Cryo
        • (specific bc known issue)

From table:

K time

  • definition- time until clot reaches a fixed strenght
  • normal 1-3 minutes
  • porblem with fibrinogen
  • treatment cryoprecipitate

ALPHA angle

  • definition- speed of fibrin accumulation
  • normal value 53-72 degrees
  • problem with fibrinogen
  • treatment cryoprecipitate
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14
Q

What is maximum amplitude (ma?)

A
  • Maximum Amplitude (MA): clot strength → plts!
    • Plt plug determines how strong clot is
    • If diminished → don’t know if plt fx or # prob (send additional tests → CBC)

Tx:

  • Low count: Plts
  • Dysfx: DDAVP or cryo (vWF)

from table:

  • definition= highest vertical amplitude of th teg
  • Normal- 50-70 min
  • problem with platelets
  • treatment- platelets and DDAVP!
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15
Q

What is lysis at 30 minutes?

A
  • LY30: also LY at 60 or 90 → breakdown of clot
    • If shows excessive breakdown of clot → Excess Fibrinolysis
      • Tx: Tranexemic Acid and/or Aminocaproic Acid (Anti-fibrolytics)

from table:

  • definition- percentage of amplitude reduction 30 minutes after maximum amplitude
  • normal 0-8%
  • problem with excess fibrinolysis
  • treament with TXA or Amicar
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16
Q

What does this TEG show?

A

Normal TEG

normal TEG – have good r & K times, AA approp, MA looks good, approp LY30. → you see a little bit of fibrinolysis (normal). We start to break down clots in about 30 minutes.

looks like brandy tumblie= do nothing

17
Q

What does this TEG show?

A

Anticoagulants/hemophilia factor deficiency

R & K times prolonged. Alpha angle diminished. Angle dec. prob w/ anticoags- Maximum amplitude is diminished d/t dec in fibrin cross linking (probs from secondary hemostasis causes this problem downstream), tells us clot isn’t strong. → Tx: FFP (don’t know what prob is). (looks like red wine glass)

18
Q

What does this TEG mean?

A

PLT Blockers thrombocytopenia/thrombocytopathy

Normal R & angle, but max amplitude in isolation is severely dec. (maybe on anti-plt medications) tx: plt # → plts, plt fx: DDAVP/Cryo/vWF (looks like test tube!)

19
Q

What does this TEG mean?

A

Fibrinolysis, presence of TPA

Classic ex of fibrinolysis – destroying a clot almost right away (excessive fibrinolysis. Maybe a pt that got TPA… Tx: amicar or TXA. ​ (looks like upside down martini glass)

20
Q

What does this TEG show?

A

Hypercoagulation

short R and K segment. Inc in angle & MA (rapid). Classic ex of hypercoagulation. Treatment would be anticoagulants (intraop → heparin)

21
Q

What does this TEG show?

A

DIC

  1. early stage of DIC when pt is hypercoaguable, using up all their coags and fibrinogen
  2. Second stage of DIC – Hypocoaguable; used up all of coagulations & now bleeding
22
Q

Treatment for TEG if resembles brandy tumbler? red wine glass? test tube? champagne flute? upside down martini glass?

A
23
Q

Coagulopathies assessment?

A
  • Determine diagnosis and the risk of bleeding ie mild vs severe

Inquire about

  • Known diagnosis (hemophilia, vWD, thrombocytopenia, polycythemia etc)
  • Coexisting conditions (renal/liver disease, malnutrition, cancer, recent drug exposure)
  • Current treatments- are they on steroids?
  • Current medications and herbals (ginseng, garlic, ginko biloba, fish oil)
  • Previous bleeding episodes
    • What kind of injury cause bleeding- is it just in tissues or joints after falling hard (severe hemophiliac) vs bleed for little longer but mild hemophiliac
  • Family history
  • Recent changes (vs whats normal) In bruising, length of bleeding with cuts etc
  • Petechiae
    • (very indicative of a coagulopathy problem)
    • multiple bruises, hematomas, jaundice and frank bleeding
24
Q

Diagnostic tests for coagulopathies?

A
  • Routine screening is not indicated, well-conducted history is more important
  • If H/P indicate bleeding disorder, or surgical risk of bleeding is high- additional laboratory testing is justified
    • Platelet count
    • CBC
    • PT/aPTT/INR
  • If specific cause of bleeding is known/suspected from coexisting dx process then follow with appropriate targeted testing
    • Liver enzymes, protein and albumin levels etc
  • Elective surgical procedures should be postponed if significant coagulopathy is present to determine cause and start treatment
25
Q

Specific considerations for hemophilia a/b?

A

Hemophilia (A or B)

  • History of unexplained bleeding, spontaneous hemorrhage involving joints and deep muscles
  • Coagulation studies: anticipate prolonged aPTT, normal PT
  • Consult hematologist
    • Detailed plan for monitoring and replacement of factors
26
Q

Specific considerations for von willebrand disease?

A

von Willebrand Disease (vWD)

  • History of easy bruising, mucosal bleeding v comm, epistaxis, menorrhagia, spontaneous hemorrhage (type III)
  • Coagulation studies: anticipate prolonged bleeding time, and aPTT, RPFA bc bleeding time not specific
    • Often factor VIII is low resulting in prolonged aPTT
  • Depending on type and severity consult hematologist (type 3 consult)

Desmopressin (in type 1 or 2), factor VIII or cryoprecipitate may be required preop

27
Q

Specific considerations for thrombocytopenia?

A
  • Thrombocytopenia: platelets < 150,000/mm3
    • Try to determine cause and current treatment
      • Idiopathic thrombocytopenic purpura (ITP)
        • Steroids
  • Platelet count: only number, not function
    • > 100,000/mm3: neuroaxial anesthesia/major sx considered safe
    • < 50,000/mm3: increases surgical bleeding risk
      • Discuss with surgical team if want preop plts (example neuro cases may require >100,000)
    • < 20,000/mm3 increases spontaneous bleeding risk
      • Transfuse
    • Each unit of Platelet transfusions generally increase count by 10,000/mm3 for every unit
  • _Anemia, fever, infections, *hypothermia,* and antiplatelet drugs can increase bleeding at any platelet coun_
    • ​my way of remembering- “hemorrhage is fucking awful (in) anesthesia”
      • ​h= hypothermia
      • i=infections
      • f= fever
      • a=anemia
      • a= antiplatelet
28
Q

Polycythemia assessment considerations?

A

Polycythemia: hematocrit > 54% r/t viscosity; inc viscosity inc r/f clots

  • Increased risk for thrombosis and cardiac diseases (heart failure, MI)
    • any history of DVT or recent infarctions
  • Preoperative h/p should focus on pulmonary and cardiovascular systems
    • cyanosis, clubbing (decrease perfusion to extremities) wheezing, murmurs, exercise tolerance
      • Exercise tolerance: MOST IMPORTANT QUESTION
  • Diagnostic studies should include: pulse oximetry, ECG, CBC, abg and chest xray (if Hgb is excessive).
  • Consult hematology and postpone elective surgery
    • poss w/ pt phlebotomized outside of the hosp to optimize for sx
29
Q

Which questions should you always ask any patient?

A
  1. Whats their exercise tolerance?
    1. Tells you everything you need to know about pulm, CV fx
  2. Any problems with anesthesia in the past?
    1. Genetic disorders → MH, acetylcholinesterase deficiency
  3. Allergies
    1. True allergy → anaphylaxis
  4. NPO status
30
Q

Which patients have increased risk for thromboembolic disorders?

A
  • Certain patients are at higher risk for perioperative thromboembolisms
    • Hereditary hypercoagulable states (antithrombin III, protein C or S deficiencies)
    • Pregnancy, obesity
    • Cancer
    • Multiple episodes of past thromboembolisms
    • Atrial fibrillation
    • Mechanical heart valves
    • Inflamm assoc w/ sx can inc r/f blood clots on its own
  • Careful history focusing on prior thrombotic events, family history and concurrent drug therapies; random screening is not beneficial
    • Ask if they’ve had DVT/blood clots
      • How long ago/tx they had
31
Q

Whens hould you postpone elective surgeries for thromboembolic d/t?

A

Postpone elective surgeries if current or recent blood clot

  • Without anticoagulation→ risk of recurrent DVT within 3 months is 50%
  • 1 month of warfarin → reduces risk to 10%
  • 3-month of warfarin → reduces risk to 5%
    • SHOULD POSTPONE 3 MONTHS IDEALLY
      • If pt hx for DVT/blood clot- wait at least 1 month before elective sx, preferably 3 months
32
Q

Assessment around patient on Coumadin?

A
  • Inhibits vit k dependent clotting factors (II, VII, IX, X)
  • Minor procedures → do NOT require d/c
    • Dental, endoscopic, cataract, superficial operations
  • Other more invasive procedures require withholding Coumadin 4-5 days preoperatively
    • Monitor INR and PT - Get 3 days prior and day of sx
      • INR < 1.5 -considered safe for surgical procedures/neuraxial blockade
        • Consult hematologist, cardiologist or treating physician concerning need for bridging treatment with heparin
  • Reversal with vitamin K, 4-factor PCCs, FFP
    • FFP- emergent reversal
    • Vit K- 12-24 hrs to start working
    • PCC (prothrombin complex concentrate)
33
Q

Consideration of patient on IV Heparin?

A
  • Discontinue:
    • 6 hours before surgical procedures
    • 6-8 hours before neuraxial block placement
      • Wait at least 1 hour after block to give/restart
  • Monitor aPTT/ACT
  • Reverse with protamine if required

Colorectal ERAS prefer epidural for postop pain control & prescribed prophylactic hep – in preop, place epidural, take pt to OR, carry out plan A prob GA w/ ETT if intra abd sx, 1 hr after admin epidural is when youd give subq hep. V impt to have that from preop nurse & talk to them & tell them youll give it in OR at approp time

34
Q

Consideration of patient on LMWH?

A
  • *Therapeutic* LMWH must be held for *24* hours preoperatively for surgical and neuraxial block placement
    • Many providers hesitant w/ lovenox + neuraxial technique.. not totally CI but have inc r/f bleed. Need to be aware
  • *Prophylactic* LMWH must be held for *12* hours preoperatively for surgical and neuraxial block placement
    • Subsequent dose of LMWH must occur > 2 hours after neuraxial block
  • Monitoring is rarely required
    • PT and aPTT normal
    • Evaluate anti-factor Xa activity if required
  • If emergent reversal is required- protamine is only partially effective
35
Q

Assessment considerations for patient on ASA?

A
  • Traditionally stopped 7-10 days preop
    • But the problem with this logic is that not all platelets are born on day 1 and die on day 7-10.
    • Enough functional platelets are around so can realistically stop aspirin 3-4 days preop
  • D/C 3-4 days preop typically
    • ALWAYS evaluate risk of bleeding versus risk of clot (high risk CAD)
  • Withdrawing ASA SUDDENLY → results in hypercoagulable state
    • If taking ASA long term → talk to cardiologist
    • Associated with threefold increase in the risk of major cardiac events; if on low dose prob shouldn’t stop it completely (if not major sx)
  • Regional anesthesia: as long as not on any other anticoags while taking aspirin→ OKAY

Health Assessment Test 2 (5 decks)

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