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Surgery > Hemostasis, Surgical Bleeding, and Transfusions > Flashcards

Hemostasis, Surgical Bleeding, and Transfusions Flashcards

1
Q

Describe Hemostasis after an injury?

5

A
  1. Vasoconstriction for about 60 seconds
  2. Next is platelets adhere to site of vascular injury
  3. After adhesion, platelets release adenosine diphosphate (ADP) causing platelet aggregation
  4. Formation of initial white thrombus
  5. Formation of permanent thrombus with fibrin
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2
Q

Coagulation pathway
1. Use of various coagulation factors to generate what?

  1. Extrinsic coagulation pathway
    - Begins with what?
    - Interacts with factors what?
  2. Intrinsic coagulation pathway
    - Requires which factors?
  3. Common coagulation pathway
    - Which factors?
  4. Bleeding may occur with deficiency of any factors except factor what?
A
  1. fibrin
    • thromboplastin
    • VII to convert factor X to Xa
  3. Requires factors XII, XI, IX, and VIII to convert factor X to Xa
4.Involves factor X, V, II (prothrombin), and I (fibrinogen)
Factor XIII (fibrin-stabilizing factor)
  1. XII
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3
Q

Evaluation of the patient
History
Most important step
Ask about medications specifically? 4

PE look for signs of what?

A
  1. OTC
  2. ASA
  3. Clopidogrel (Plavix)
  4. Warfarin (Coumadin)

Bleeding disorder

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4
Q

Evaluation of patient for high risk of bleeding
Test
5

A
  1. Platelet count
  2. Prothrombin time (PT)
  3. Partial thromboplastin time (PTT)
  4. Bleeding time
  5. Thrombin time
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5
Q
  1. Platelet count verifies what?
  2. If abnormal can order what?
  3. Normal platelet values?
A
  1. Verifies that an adequate number of platelets are available in the circulation
  2. blood smear to look at platelets under a microscope
  3. Normal values 150,00 – 400,000
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6
Q
  1. What does prothrombin time measure?
  2. Evaluates what factors? 5
    - Which pathway?
  3. Most common use for this lab?
  4. PT is reported as?
A
  1. Measures ability of the blood to form stable thrombi
  2. Evaluates factors VII, X, and V, prothrombin, and fibrinogen, and extrinsic pathway
  3. Most common use is monitoring Warfarin
  4. PT is reported with international normalized ratio (INR)
    A ratio of a patient’s prothrombin time to a normal (control) sample
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7
Q

Partial Thromboplastin Time

  1. Evaluates what? 8
    - Which pathway?
  2. Most commonly used to monitor what?
  3. Normal in patients with what disorder?
A
  1. Evaluates adequacy of fibrinogen, prothrombin, factors V,VIII, IX, X, XI, XII, and intrinsic/common pathways
  2. Most commonly used to evaluate unfractionated heparin therapy
  3. Normal in patients with factor VII deficiency
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8
Q
  1. Describe the bleeding time procedure? 2
  2. Normal range?
  3. Prolonged time may indicate what? 3
A
    • Two incisions with lancet on the forearm
    • Time from injury to cessation of bleeding from both wounds is measured
  2. Normal range is 5-10 minutes
  3. Prolonged time may indicate;
    - Thrombocytopenia
    - Medication (ASA)
    - Von Willebrand disease

UREMIA

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9
Q
  1. What does thrombin time evaluate?

2. Prolongations means? 4

A
  1. Evaluates fibrinogen-to-fibrin conversion with an external source of thrombin
  2. Prolongation;
    - Low fibrinogen levels
    - Abnormal fibrinogen
    - Fibrin and fibrinogen split products
    - Heparin

DIC and Chronic liver disease too

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10
Q

Surgical bleeding

  • Patients can loose large volumes of blood from generalized oozing post-op
  • Some operations are associated with large blood loss

Preexisting hemostatic defects
that make patients at risk for bleeding? 3

A
  1. Congenital bleeding disorders
  2. Acquired bleeding disorders
  3. Medication-Associated Bleeding
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11
Q 
Congenital Bleeding Disorders:
Von Willebrand Disease
1. Pathophysiology?
2. Site of bleeding
3. Inheritance
4. Lab studies? 3
A
  1. Reduced factor VIII activity and von Willebrand activity
  2. Mucocutaneous
  3. Autosomal dominant
    • Prolonged PTT
    • Normal PT
    • Abnormal platelet function
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12
Q

Von Willebrand
Tx?
2

A
  1. Cryoprecipitate infusions

2. Desmopressin (DDAVP)

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13
Q

Congenital bleeding disorders
Hemophilia A
1. Pathophysiology?
2. Site of bleeding?

  1. Gender?
  2. Labs? 3
  3. Treatment?
A
  1. Reduced or absent factor VIII activity
  2. Joints and intramuscular
  3. Only males
    • Prolonged PTT
    • Normal PT
    • Normal platelet function
  5. Purified factor VIII products
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14
Q

Acquired bleeding disorders
More common than congenital bleeding disorders
Causes? 5

A
  1. Advanced liver disease
  2. Anticoagulation therapy
  3. Acquired thrombocytopenia
  4. Platelet-inhibiting drugs
  5. uremia
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15
Q

Acquired bleeding disorder
Liver disease- Common cause
1. PP?
2. Which factors are affected? 4

  1. What may lead to clotting factor deficiencies? 2
  2. Respond well to what?
A
  1. Inability to synthesize proteins leads to decreased levels of
  2. prothrombin and factors V, VII, and X
    • Obstructive jaundice
    • Cirrhosis
  4. vitamin K
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16
Q

Anticoagulation therapy
Warfarin (Coumadin)
1. Depression of what factors? 4

  1. Reversed how? 2

Heparin
3. Increased speed of antithrombin III binds to and neutralizes factors what? 5

  1. Reversed with?
A
  1. Depression of clotting factors II, VII, IX, X
  2. Can be reversed with fresh frozen plasma (FFP) or vitamin K in an emergency
  3. IXa, Xa, Xia, XIIa, and thrombin
    Prolongs PTT and thrombin time
  4. Reversed with protamine sulfate
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17
Q

Acquired thrombocytopenia

3 mechanisms

A
  1. Decreased platelet production in bone marrow
  2. Increased destruction of platelets in peripheral blood
  3. Splenic pooling in enlarged spleen
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18
Q

Platelet Inhibiting drugs? 3

-When should these be stopped before surgery?

A 
Platelet-inhibiting drugs
1. ASA
Should stop 1 week before surgery
2. Clopidogrel (Plavix)
Should be stopped 7-10 days before surgery
3. NSAIDs
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19
Q

Uremia

  1. Causes what?
  2. Patients who are bleeding and need surgery require what to correct platelet dysfunction?
A
  1. Platelet dysfunction

2. dialysis

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20
Q

Medication-Associated bleeding: Causes?3

A
  1. Anticoagulants
  2. Platelet inhibiting drugs
  3. OTC Meds/Herbal
21
Q

Which drugs make up the following categories

  1. Anticoagulants? 2
  2. Platelet inhibiting drugs? 2
  3. OTC Meds/Herbal? 6
A
  1. Anticoagulants
    - Warfarin (Coumadin)
    - Heparin
  2. Platelet-Inhibiting drugs
    - Clopidogrel (Plavix)
    - ASA
  3. OTC medications
    - Herbal
    - Dong quai (Angelica)
    - Garlic
    - Ginger
    - Gingko biloba
    - Ginseng
    - St. John’s wort
22
Q

Intraoperative Bleeding
1. Shock -Can aggravate what?

  1. Massive transfusion of what?
  2. Bleeding from where? 3
  3. Controled with? 4
A
  1. consumptive coagulopathy
  2. packed RBCs
    • needle holes,
    • vascular suture line, or
    • extensive dissection
    • Gelfoam
    • Surgicel
    • Floseal
    • Tisseel
23
Q

Post-Op Bleeding

  1. 50% is caused by?
  2. Other causes? 3
A
  1. 50% is caused by poor hemostasis during surgery
  2. Other causes;
    - Residual heparin
    - Shock
    - Altered liver function
24
Q

Three main categories of post op bleeding?

A
  1. Primary bleeding
  2. Reactive bleeding
  3. Secondary bleeding
25
Q

DIC
1. Characterized by what?

  1. Results in what?
A
  1. intravascular coagulation and thrombosis that is diffuse instead of localized at the site of injury
  2. systemic deposition of platelet-fibrin microthrombi that causes diffuse tissue injury
26
Q

DIC
Etiology
4

A
  1. Release of tissue debris into bloodstream after trauma or an obstetric catastrophe
  2. Extensive endothelial damage to vascular wall
  3. Hypotension
  4. Operations will large blood loss
27
Q

Operations with large blood loss possibly promoting DIC?

3

A
  1. Prostate,
  2. lung, &
  3. malignant tumors
28
Q

DIC

  1. Diagnosed by?
  2. Labs? 4
A
  1. Diagnosed by diminished levels of coagulation factors and platelets
  2. Labs
    - Prolonged PTT & PT
    - Hypofibrinogenemia
    - Thrombocytopenia
    - Presence of fibrin and fibrinogen products
29
Q

DIC Treatment
1. Most important management?

  1. Severe DIC
    - What is best method to replace fibrinogen loss?
  2. What may be necessary ?
  3. ________ helps replace other deficits
A
  1. remove the precipitating factors
  2. Cryoprecipitate
  3. Platelet transfusion
  4. FFP
30
Q

What are the most common cause of fatal transfusion reactions?

A

ABO incompatibilities

31
Q

Typing and Cross-Matching
1. Only two groups have immunological relevance. What are they?

  1. Antigens involved in ABO? 4
A
    • ABO Group
    • Rhesus Group
    • A only has the A antigen
    • B only has the B antigen
    • AB has both
    • O has neither antigen
32
Q

Rhesus (Rh antigen)

  1. Only _____ antigen is tested
  2. What on RBC makes Rh+?
  3. What on RBC makes Rh-?
A
  1. D
  2. D antigen
  3. No D antigen
33
Q

Transfusion of RBC

5 types?

A
  1. Whole blood
  2. Packed red blood cells
  3. Washed red blood cells
  4. Leukoreduced red blood cells
  5. Divided or pediatric unit RBCs

Used for massive transfusions and life-saving transfusions

34
Q

Transfusion of RBC

Decision to transfuse is multifactorial and individualized. Factors that go into this? 5

A
  1. Reason for the anemia
  2. Degree and acuity/chronicity of anemia
  3. Underlying medical condition
  4. Anticipated future transfusions
  5. Hemodynamic instability
35
Q

One unit of packed red cells into an average 70kg person raises the hematocrit by ___% and hemoglobin by ____ g/dL

A
  1. 3

2. 1

36
Q
  1. FFP is the what?
  2. Does not contain what? 3
  3. Indication for use? 2
A
  1. platelet-poor plasma removed from whole blood\
    • RBC,
    • leukocytes, or
    • platelets
    • Lab evidence of coagulation factor deficiency with clinical bleeding
    • Need for invasive procedure
37
Q
  1. Platelets are indicated for what?
  2. Labs? 2
  3. Transfusion of six platelets raise count by what?
A
  1. Indicated for patients with thrombocytopenia due to platelet dysfunction
  2. Labs
    - Bleeding time
    - Whole blood platelet function testing
  3. Transfusion of six platelets raise count by 50,000 to 100,000
38
Q

Blood Transfusions: Side effects include?

5

A
  1. Metabolic derangements
  2. Immunologic reactions
  3. Infection complications
  4. Volume overload
  5. Pulmonary complications

Considerations on mass transfusions

39
Q

Complications with blood transfusion:

  • Metabolic derangements
    1. Seen when? 2
  1. Most common are? 3
A
    • with large volume or
    • older blood products
    • Hypocalcemia
    • Hyper and Hypokalemia
    • hypothermia
40
Q

Complications with blood transfusion:
Metabolic derangements cont.

Hypocalcemia
1. Seen with what?

  1. Presents with? 3
  2. Hyper/Hypokalemia
    - High levels of potassium are found in units of blood frozen longer than what?
  3. After transfusion infused K+ is taken up by what? Causing what?
  4. Hypothermia
    Multiple transfusions needs to be through a what?
A
  1. rapid transfusion
    • Muscle tremors
    • ST segment prolongation
    • Delayed T waves
  3. 35 days
  4. After transfusion infused potassium is taken up by the red cell causing hypokalemia
  5. fluid warmer
41
Q

Blood Transfusion Complications:
Immunologic reactions?
7

A
  1. Febrile reactions
  2. Acute and delayed hemolytic reactions
  3. Thrombocytopenia
  4. Anaphylactic shock
  5. Urticaria
  6. Graft versus host disease
  7. Immune suppression
42
Q

Immunologic reactions

  1. Febrile reaction
    - Most common as result of what?
  2. Present with? 2
  3. Pretreat with what? 3
A
  1. antileukocyte antibodies
    • Fever/Chills
    • Tachycardia
  3. Pretreat with
    - ASA,
    - antipyretics, and
    - antihistamines
43
Q

Immunologic reactions
Hemolytic reactions
1. Most caused by what?

  1. Present with what? 5
  2. Tx?
A
  1. ABO-mismatched blood
    • Hot or cold flushing
    • Chest pain
    • Low back pain
    • Fever
    • hypotension
  3. Stop transfusion and recheck blood
44
Q

Immunologic Reactions:
Graft versus host disease
1. Happens when?

  1. Onset of symptoms are what?
  2. Symptoms? 4
  3. Prevent with what? 2
A
  1. immunosuppressed patients receive donor leukocytes
  2. delayed
    • Fever
    • Rash
    • Liver dysfunction
    • Diarrhea
    • leukocyte-reduced red cells or
    • irradiated red cells
45
Q

Infectious agents
Bacteria
1. Most likely from what?
2. Present with what? 3

  1. Viruses: Which ones? 3

Parasites

A
  1. platelets
    • fever/chills,
    • tachycardia,
    • hypotension
    • Hep B: 1 in 200,000
    • Hep C: 1 in 2 million
    • HIV: 1 in 2 million
46
Q

Transfusion-related lung injury
1 in 5,000 transfusions
1. Most common with what?

  1. Characterized by what?
  2. Treatment? 2
A
  1. units that contain plasma
  2. pulmonary edema after transfusion
    • is supportive
    • May require intubation
47
Q
  1. Massive transfusions are defined as?

2. Complications? 6

A
  1. > 10 packed red cells in 24 hours or pt.’s total blood volume in 24 hours, or half pt.’s blood volume in 1 hour
    • Dilutional coagulopathy
    • Oxygen transport abnormalities
    • Electrolyte/Acid-base derangements
    • Hypothermia
    • Disease transmission
    • ARDS
48
Q
  1. What are Autologous Blood?
  2. Collection done how? 2
  3. Reasons? 4
A
  1. Collection and re-infusion of a patients own blood
    • Pre-surgical donation
    • Intraoperative cell saver
    • Fully compatible
    • No risk of transmission
    • Less dependent on blood bank
    • Patients with rare blood types

Surgery (20 decks)

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