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Surgery > Hemostasis, Surgical Bleeding, & Transfusions > Flashcards

Hemostasis, Surgical Bleeding, & Transfusions Flashcards

1
Q

Define Hemostatic Process

A

Process involves interaction between blood vessel walls, platelets, & coagulation proteins

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2
Q

Initial Hemostasis Activity After Injury

A

Vasoconstriction
Platelets adhere to site of vascular injury
After adhesion, platelets release ADP causing platelet aggregation
Formation of white thrombus
Formation of permanent thrombus with fibrin

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3
Q

Coagulation Pathway

A

Extrinsic: thromboplastin interacts with VII to covert X to Xa
Intrinsic: factors XII, XI, IX, & VIII to convert X to Xa
Common: X, V, II, & I; factor VIII

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4
Q

Deficiency of what factors causes bleeding?

A

Any EXCEPT XII

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5
Q

What can reduce the effectiveness of clotting?

A

Hypocalcemia

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6
Q

Evaluation of a Bleeding Patient

A

Hx: OTC, ASA, clopidogrel (Plavix), warfarin (Coumadin)
Look for signs of bleeding disorder
Labs: platelets, PT, PTT, bleeding time, thrombin time

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7
Q

Signs of a Bleeding Disorder

A 
Splenomegaly
Hepatomegaly
Bleeding after dental procedures
Menses
Minor cuts
Family history of bleeding
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8
Q

What does a platelet count verify?

A

An adequate number of platelets are available in the circulation

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9
Q

What is a normal platelet value?

A

150,000-400,000

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10
Q

What are some reasons for low platelets?

A

Cancer treatment
Meds: lasix, penicillins, sulfonamids, NSAIDs
Autoimmune disorders

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11
Q

What does prothrombin time measure?

A

Ability of the blood to form stable thrombi

Extrinsic & common pathway

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12
Q

When is a PT normally ordered?

A

Monitor warfarin

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13
Q

Define INR

A

Ratio of a patient’s PT to a normal (control) sample

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14
Q

What does a partial thromboplastin time (PTT) measure?

A

Adequacy of intrinsic & common pathways

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15
Q

When is PTT most commonly used?

A

Unfractionated heparin therapy

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16
Q

Define Bleeding Time

A

Time from injury to cessation of bleeding

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17
Q

What may a prolonged bleeding time indicate?

A

Thrombocytopenia
Medication (ASA)
Von Willebrand disease

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18
Q

What does thrombin time evaluate?

A

Fibrinogen to fibrin conversion with an external source of thrombin

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19
Q

What may a prolonged thrombin time indicate?

A 
Low fibrinogen levels
Abnormal fibrinogen
Fibrin & fibrinogen split products
Heparin
Blood or coagulation disorders
DIC Chronic liver disease
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20
Q

Von Willebrand’s Disease Pathophysiology

A

Reduced factor VII activity & von Willebrand activity

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21
Q

Main Site of Bleeding for Von Willebrand’s Disease

A

Mucocutaneous

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22
Q

Lab Results for Von Willebrand Disease

A

Prolonged PTT
Normal PT
Abnormal platelet function

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23
Q

Treatment of Von Willebrand Disease

A

Cryoprecipitate infusions

Desmopressin (DDAVP)

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24
Q

Pathophysiology of Hemophilia A

A

Reduced or absent factor VII activity

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25
Main Sites of Bleeding for Hemophilia A
Joints | Intramuscular
26
Lab Results of Hemophilia A
Prolonged PTT Normal PT Normal platelet function
27
Treatment of Hemophilia A
Purified factor VII products
28
Common People who get Hemophilia A
Males
29
Causes of Acquired Bleeding Disorders
``` Advanced liver disease Anticoagulation therapy Acquired thrombocytopenia Platelet-inhibiting drugs Uremia ```
30
Liver Disease as an Acquired Bleeding Disorder
Inability to synthesize proteins leads to decreased levels of prothrombin & factors V, VII, & X
31
What liver disorders may lead to clotting factor deficiencies?
Obstructive jaundice | Cirrhosis
32
Anticoagulation Therapy
Warfarin (Coumadin) | Heparin
33
MOA of Warfarin (Coumadin)
Depression of clotting factors II, VII, IX, X
34
How can warfarin (Coumadin) be reversed in an emergency?
FFP | Vitamin K
35
MOA of Heparin
Increases speed of antithrombin III binds to & neutralizes factors IXa, Xa, XIa, XIIa, & thrombin
36
Lab Results on Heparin
Prolonged PTT | Prolonged thrombin time
37
How is heparin reversed?
Protamine sulfate
38
3 Mechanisms of Acquired Thrombocytopenia
Decreased platelet production in bone marrow Increased destruction of platelets in peripheral blood Splenic pooling in enlarged spleen
39
Examples of Acquired Thrombocytopenia
``` ITP DIC Aplastic anemia Cirrhosis Platelets destroyed during surgery Cell saver ```
40
Platelet-Inhibiting Drugs
ASA Clopidogrel (Plavix) NSAIDs
41
Medication-Associated Bleeding
Anticoagulants: warfarin, heparin Platelet-inhibiting drugs: clopidogrel, ASA, NSAIDs OTC meds: dong quai (angelica), garlic, giner, gingko biloba, ginseng, St. Johns wort
42
How is intra-operative bleeding controlled?
Gelfoam Surgicel Floseal Tisseel
43
Reasons for Post-Op Bleeding During Surgery
``` Poor hemostasis Residual heparin Shock Altered liver function Malnutrition ```
44
Classification of Post-Op Bleeding
Primary Reactive Secondary
45
Post-Op Bleeding: Primary
Occurs during operation | Monitor with drains post-op
46
Post-Op Bleeding: Reactive
Occurs within 24 hours of operation | Hemorrhage-like reaction
47
Post-Op Bleeding: Secondary
7-10 days post procedure | Erosion of the blood vessels: usually due to infection
48
Define DIC
Intravascular coagulation & thrombosis that is diffuse instead of localized at the site of injury
49
What does DIC result in?
Systemic deposition of platelet-fibrin micro thrombi that causes diffuse tissue injury
50
Etiology of DIC
``` Release of tissue debris into bloodstream after trauma or obstetric catastrophe Endothelial damage to vascular wall Hypotension Operations with large blood loss Burns Sepsis Transfusion reactions ```
51
How is DIC diagnosed?
Diminished levels of coagulation factors & platelets
52
Labs for DIC
Prolonged PTT & PT Hypofibrinogenemia Thrombocytopenia Presence of fibrin & fibrinogen products
53
Treatment of DIC
Remove precipitating factors Cryoprecipitate Platelet transfusion FFP
54
5 Types of Blood Transfusions
``` Whole blood Packed RBCs Washed RBCs Leukoreduced RBCs Divided or pediatric unit RBCs ```
55
Factors in Deciding When to Infuse
``` Reason for anemia Degree & acuity/chronicity of anemia Underlying medical condition Anticipated future transfusions Hemodynamic instability ```
56
How much does 1 unit of PRBCs raise the hematocrit & hemoglobin?
Hct: 3% Hg: 1 g/dL
57
What does FFP not contain?
RBC Leukocytes Platelets
58
Indications for FFP
Coagulation factor deficiency with clinical bleeding | Need for invasive procedure
59
Indications for Platelets
Patients with thrombocytopenia due to platelet dysfunction
60
Complications with Blood Transfusions
``` Metabolic derangements Immunologic reactions Infection complications Volume overload Pulmonary complications ```
61
Most Common Metabolic Derangements with Blood Transfusions
Hypocalcemia Hyper/hypokalemia Hypothermia
62
When are metabolic derangements usually seen with blood transfusions?
Large volume transfused | Older blood products
63
How does hypocalcemia occur in blood transfusions?
Rapid rate of transfusion
64
Presentation of Hypocalcemia
``` Muscle tremors ST prolongation Delayed T waves V-fib Tachycardia ```
65
When does hyperkalemia occur in blood transfusions?
Units of blood frozen longer than 35 days
66
How does hypokalemia occur in blood transfusions?
After transfusion, potassium is taken up by the red cell
67
How to prevent hypothermia in blood transfusions?
Multiple transfusions | Need to be placed in a warmer
68
Types of Immunologic Reactions with Blood Transfusions
``` Febrile reaction Acute & delayed hemolytic reactions Thrombocytopenia Anaphylactic shock Urticaria Graft vs. host disease Immune suppression ```
69
Presentation of Febrile Reaction to Blood Products
Fever/chills | Tachycardia
70
What can you pretreat a blood transfusion with to prevent a febrile reaction?
ASA Antipyretics Antihistamines *Leukocyte reduced RBCs*
71
What are hemolytic reactions generally caused by?
ABO incompatibility
72
Presentation of Hemolytic Reactions
``` Hot/cold flushing Chest pain Low back pain Fever Hypotension Tachycardia Hematuria Acute renal failure ```
73
Treatment of Hemolytic Reactions
Stop transfusion | Recheck blood
74
When does a graft vs. host disease occur?
Immunosuppressed patients receive donor leukocytes
75
Presentation of Graft vs. Host Disease
``` Delayed reaction Fever Rash Liver dysfunction Diarrhea ```
76
Prevention of Graft vs. Host Disease
Leukocyte-reduced RBCs | Irradiated RBCs
77
Infectious Agents in Transfusion of Blood Products
Bacteria: usually platelets Viruses: Hep B, Hep C, HIV Parasites
78
Presentation of Bacteria Infection with Blood Transfusion
Fever/chills Tachycardia Hypotension
79
When do transfusion-related lung injuries usually occur?
Units transferred that contain plasma
80
What is transfusion-related lung injury characterized by?
Pulmonary edema
81
Treatment of Transfusion-Related Lung Injury
Supportive | Possibly intubation
82
Define Massive Transfusions
10+ PRBCs in 24 hours Patient's total blood volume in 24 hours 1/2 patients blood volume in 1 hour
83
Complications of Massive Transfusions
``` Dilutional coagulopathy Oxygen transport abnormalities Electrolyte/acid-base derangements Hypothermia Disease transmission ARDS ```
84
Define Autologous Blood
Collection & re-infusion of a patient's own blood
85
Collection of Autologous Blood
Pre-surgical donation | Intra-operative cell saver
86
Reasons for Autologous Blood
Fully compatible No risk of transmission Less dependent on blood bank Patients with rare blood types

Surgery (20 decks)

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