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Y5 Blood > List I - Act Core Conditions > Flashcards

List I - Act Core Conditions Flashcards

1
Q

What is anaemia?

A
  • Low (Hb) due to either low RBC mass (low production/increased loss) or
  • Increased plasma volume (e.g. pregnancy - haemodilution as increased plasma volume > increased RBC)
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2
Q

What are the normal values of Hb?

A
  • Males - 13-18g/dL
  • Females - 11.5-16g/dL

Higher in neonates, lower in younger children

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3
Q

How much iron is contained within the blood?

A
  • 1mL blood contains 0.5mg iron
  • Body stores are regulated by absorption (duodenum, jejunum)
  • No active excretion occurs (small daily losses in the urine, faeces and sweat)
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4
Q

What are the daily requirements of iron?

A
  • Adults
  • Males - 1 mg
  • Females - 2 mg if menstruating, 3 mg if pregnant
  • Absorption
  • Haem iron in meat readily absorbed, but in vegetables/cereals is part of amino/organic acid complex requiring release/reduction from Fe3+ to Fe2+ for absorption (promoted by gastric HCl acid and ascorbic acid in food)
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5
Q

What are the causes of iron deficiency anaemia?

A
  • Chronic blood loss - menorrhagia, (occult) GI bleeds (PUD, colonic angiodysplasia, gastric/colorectal Ca)
  • Increased requirements - childhood, pregnancy
  • Poor diet (developing countries) - usually babies, children, special diets, poverty (rarely adults)
  • Malabsorption (causes refractory IDA) - gastrectomy, coeliac disease
  • Malnutrition, hookworm - most common in the tropics
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6
Q

How common is iron deficiency anaemia?

A
  • Common (up to 14% of menstruating females)
  • Most common cause of anaemia worldwide
  • F>M
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7
Q

What is the pathophysiology of iron deficiency anaemia?

A
  • Latent iron deficiency (initial depletion of iron stores is asymptomatic)
  • Iron deficiency anaemia (when reticuloendothelial stores - haemosiderin/ferritin - are completely depleted)
  • Symptomatic (only when Hb falls)
  • Leads to tissue hypoxia (rate of development and commorbidity reflects severity)
  • Acute IDA has worse severity as there is no time for the body to compensate for reduced O2 carrying capacity
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8
Q

What are the presenting clinical symptoms of IDA?

A
  • Symptoms
  • Acute IDA - SOB, faintness, palpitations, headache, tinnitus, anorexia, angina/claudication (if occult co-existent disease)
  • Chronic IDA - fatigue, dysphagia (if post-cricoid mucous web), restless leg syndrome
  • PMH - menorrhagia, GI bleeds, pregnancy, gastrectomy, coeliac disease
  • SH - food diary
  • DH - PPI (can also lead to IDA)
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9
Q

What are the presenting clinical signs of IDA?

A
  • Signs
  • Mild to moderate - may be absent (even in severe), palmar/conjunctival pallor
  • Severe (signs of hyperdynamic circulation) - bounding pulse, tachycardia, ejection systolic flow murmur (loudest over apex), cardiac enlargement, retinal haemorrhage (rare), heart failure (later: rapid transfusion may be fatal)
  • Chronic IDA - koilonychias, atrophic glossitis, angular chelitis (painful cracking at corners of mouth), oesophageal / post cricoid web (Plummer-Vinson Syndrome)
  • Examination - always do GI examination and include PR
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10
Q

What is Plummer-Vinson Syndrome?

A
  • Triad of the following:
  • Dysphagia (secondary to oesophageal/cricoid webs)
  • Glossitis
  • Iron deficiency anaemia
  • Associated with chronic IDA
  • Treatment includes iron supplementation and dilation of the webs
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11
Q

What does FBC demonstrate typically in IDA?

A
  • Hypochromic microcytic anaemia
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12
Q

What are the other blood pictures of IDA?

A
  • Low MCV (microcytic)
  • Low iron (hypochromic)
  • High total iron-binding capacity (TIBC)/transferrin -reflects low iron stores
  • Low transferrin saturation
  • Low serum ferritin - correlates with iron stores
  • Blood film - anisopoikilocytosis (RBC’s of different sizes and shapes), target cells, ‘penicil’ poikilocytes
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13
Q

What are the differential diagnoses of IDA?

A
  • Anaemia of chronic disease (same but with high ferritin)
  • Serum iron low <15
  • TIBC High
  • Ferritin High
  • Chronic haemolysis
  • Serum iron High
  • TIBC Low
  • Ferritin High
  • Haemochromatosis
  • Serum iron High
  • TIBC Low / Normal
  • Ferritin High
  • Pregnancy
  • Serum iron High
  • TIBC High
  • Ferritin Normal
  • Sideroblastic anaemia
  • Serum iron High
  • TIBC Normal
  • Ferritin High
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14
Q

What can cause ferritin to rise?

A
  • Inflammation
  • Infection
  • Malignancy
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15
Q

What can cause variation in RBC size (anisocytosis)?

A
  • IDA
  • Thalassaemia
  • Megaloblastic anaemia
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16
Q

What can cause variation in RBC shape (poikilocytosis)?

A
  • IDA
  • Thalassaemia
  • Myelofibrosis
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17
Q

What is the clinical manifestation of haemolytic anaemia in blood?

A
  • Jaundice
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18
Q

What is the clinical manifestation of B12 deficiency?

A
  • Neurological symptoms/signs
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19
Q

What can cause a rise in platelets?

A
  • Acute blood loss

* Anaemia of chronic disease (due to inflammatory process)

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20
Q

What can cause a fall in platelets?

A
  • Bone marrow failure/megaloblastic anaemia (WCC fall)
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21
Q

What are the appropriate blood investigations of IDA?

A
  • Bloods
  • FBC (Hb low, MCV low, MCH low, MCHC low, normal WCC/platelets
  • Ferritin low
  • Serum iron low
  • TIBC (total Fe-binding capacity) high
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22
Q

What imaging can be done for IDA?

A
  • Barium enema
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23
Q

What special tests should be done to investigate IDA?

A
  • PR examination
  • Endoscopy
  • Gastroscopy (OGD)
  • Colonoscopy (or sigmoidoscopy)
  • Stool for OC and P (ova: hookworm, cysts, parasites)
  • Bone marrow aspiration - rare
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24
Q

What is the conservative approach to management of IDA?

A
  • Conservative - management with dietary intake increase e.g. dark green leafy vegetables, meat, iron fortified bread
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25
Q

What is the medical management of IDA?

A
  • Treat underlying cause if found
  • Oral iron supplements
  • If MCV low and good history of menorrhagia - ferrous sulphate 200mg/8h PO
  • Each tablet contains 67mg iron
  • SE’s - nausea, diarrhoea, constipation, abdo discomfort, black stools
  • If not tolerated can try ferrous fumarate or SR preparations
  • Aim for increase in Hb by 1g/dL/week (with modest reticulocytosis
  • Continue until Hb is normal for at least 3 months to replenish stores
  • IV iron (risk anaphylaxis) - only use if oral not possible/ineffective (functional Fe deficiency in CKD - inadequate mobilisation of iron stores in response to acute demands of EPO therapy
  • Packed cell transfusion - if significant blood loss (Hb <7-8/severely symptomatic
26
Q

What are the complications of IDA?

A
  • Prognosis is good once there is resolution of the cause
27
Q

What is a group and save?

A
  • Sample tested for ABO/Rhesus group and standard Ab screen (available for cross match if required)
28
Q

What is a cross match?

A
  • ABO/Rhesus group and standard Ab screen performed and blood is made available
29
Q

For how long are group and save and cross match samples valid?

A
  • Up to 3 months (if no prior transfusion)

* 3 days (if transfused in the last 3 months or pregnant)

30
Q

What is a massive transfusion?

A
  • Replacement of the entire blood volume (>10U) in 24 hrs

* Complications include low platelets, low calcium, low clotting, high potassium, low temperature

31
Q

What are the requirements for FFP/cryoprecipitate/platelets?

A
  • Needs to have been grouped previously
  • Telephone requests accepted
  • Allow for thawing (with cryoprecipitate/FFP)
  • Allow for delivery if platelets
32
Q

What are the blood transfusion related complication types?

A
  • Immunological
  • Acute haemolytic
  • Non-haemolytic febrile
  • Allergic/anaphlaxis
  • Infective
  • Transfusion related acute lung injury (TRALI)
  • Transfusion associated circulatory overload (TACO)
  • Others
  • Hyperkalaemia
  • Iron overload
  • Clotting
33
Q

What are the features of a non-haemolytic febrile reaction?

A
  • Thought to be caused by anti-bodies reacting with white cell fragments in the blood product and cytokines that have leaked from the blood cell during storage
  • Features - fever, chills
  • Incidence - 1-2% in red cell transfusion, 10-30% in platelet transfusion
  • Management - slow or stop the transfusion, give paracetamol, monitor the patient
34
Q

What are the features of a minor allergic reaction to blood transfusion?

A
  • Thought to be caused by foreign plasma proteins
  • Features - pruritis, urticaria
  • Management - temporarily stop the transfusion, give anti-histamine, monitor the patient
35
Q

What are the features of anaphylaxis related reaction to blood transfusion?

A
  • Can be caused by patients with IgA deficiency who have anti-IgA anti-bodies
  • Features - hypotension, dyspnoea, wheezing, angioedema
  • Management - stop the transfusion, IM adrenaline, ABC support, anaphylaxis protocol, O2, fluids
36
Q

What are the features of acute haemolytic reaction to ABO incompatibility?

A
  • Features - Fever, abdominal pain, hypotension
  • Management - stop the transfusion, check the identity of the patient/name on blood product, send for direct Coombes test, repeat typing and cross-matching , supportive care, fluid resuscitation
37
Q

What are the features of transfusion related circulatory overload?

A
  • Excessive rate of transfusion, pre-existing heart failure
  • Features - Pulmonary oedema, hypertension
  • Management - slow or stop the transfusion, consider IV loop diuretic e.g. furosemide and oxygen
38
Q

What are the features of transfusion related acute lung injury?

A
  • Non-cardiogenic pulmonary oedema thought to be secondary to increased vascular permeability caused by host neutrophils that become activated by substances in donated blood
  • Features - hypoxia, pulmonary infiltrates on chest x-ray, fever, hypotension
  • Management - stop the transfusion, give oxygen and supportive care
39
Q

Why could CMV be a risk in blood products?

A
  • Cytomegalovirus (CMV) is transmitted in leucocytes
  • Most blood products are now leucocyte depleted therefore CMV products are rarely required
  • Exception to this is granulocyte transfusions
40
Q

Why are blood products irradiated?

A
  • To deplete them of T-lymphocytes to avoid transfusion associated graft versus host disease (TA-GVHD) caused by viable donor T lymphocytes
41
Q

Which situations require CMV negative blood products?

A
  • Pregnancy: Elective transfusions during pregnancy (not during labour or delivery)
  • Neonates up to 28 days post exposure date of delivery
  • Intra-uterine transfusions
  • Granulocyte transfusions
  • HIV?
42
Q

Which situations require irradiated blood products?

A
  • Patients with/previous Hodgkins Disease
  • Immunocompromised (e.g. chemotherapy or congenital)
  • Bone marrow /stem cell transplants
  • Neonates up to 28 days post exposure date of delivery
  • Intra-uterine transfusions
  • Granulocyte transfusions
  • HIV?
43
Q

If a patient refuses a blood transfusion e.g. Jehovah’s Witnesses, what are the alternatives that can be offered?

A
  • Intra-operative cell salvage / post-operative cell salvage (may not be acceptable to some Jehovah’s Witnesses)
  • Anaesthetic techniques such as induced hypotension
  • Surgical techniques such as argon beam diathermy
  • Radiology guided arterial occlusion (pre or post operative)
  • Anti-fibrinolytics such as tranexamic acid
  • Clotting promotors such as Desmopressin
  • Prothrombin Concentrate Complex e.g. Octaplex to reverse warfarin
  • Local haemostatics such as Fibrin glue and sealants (Tisseel)
  • Volume expanders such as crystalloids or some colloids
  • Pharmaceutical options such as EPO, ferrous sulphate, B12 and / or folic acid
44
Q

What are the risks of receiving a blood transfusion?

A
  • Receiving incorrect blood (normally due to failure of the patient ID check at the bedside) 1/13000
  • Contracting HIV 1/5.9 million donations
  • Contracting Hep. B 1/2.2 million donations
  • Contracting Hep. C 1/39 million donations
  • Risk of HTLV (Human T-Lymphotrophic Virus - rare, no cases since before 1996
  • Syphilis - extremely low
  • Contracting vCJD extremely low 4 cases, the last being 1999
  • TAGvHD (transfusion associated graft versus host disease - only 14 cases since 1996
  • Context - in the UK there are around 2.6 million units of blood transfused each year
45
Q

How are the risks of transfusion managed?

A
  • Blood is collected from unpaid volunteers who are in good health
  • Each donated unit of blood is rigorously tested for: hepatitis B, hepatitis C, HIV, HTLV and syphilis
46
Q

Which types of transfusion is transfusion related lung injury more likely to happen in?

A
  • Plasma rich components such as Fresh Frozen Plasma (FFP) and / or platelets
47
Q

What are the important details to cover when consenting a patient for blood transfusion?

A
  • Is transfusion necessary and why?
  • Can anaemia be corrected with iron / B12 / folic acid / EPO?
  • Are there alternatives to transfusion for this particular patient?
  • Have you stopped anti-coagulants?
  • Have you considered Warfarin reversal therapy and or commenced tranexamic acid where necessary?
  • Explain how the benefits outweigh the risks of transfusion for this particular patient in this situation?
  • Explain the risks of transfusion
  • Inform the patient that once transfused they will not be able to donate blood again
  • Ensure the patient understands the above
48
Q

What are the clinical features of acute haemolytic reaction to transfusion?

A
  • Agitation, pain (abdominal/chest), flushed, increase temperature, low BP, oozing venepuncture sites, DIC
49
Q

What are the clinical features of non-haemolytic febrile reaction to transfusion?

A
  • (0.5-1 hr after starting transfusion): shivering / high temperature
50
Q

What are the clinical features of anaphylaxis reaction to transfusion?

A
  • Cyanosis, bronchospasm, low BP, soft tissue swelling
51
Q

What are the clinical features of bacterial contamination reaction to transfusion?

A
  • Rapid fever, low BP, rigors
52
Q

What are the clinical features of allergic reaction to transfusion?

A
  • Itch, urticaria, mild temperature rise
53
Q

What are the clinical features of fluid overload reaction to transfusion?

A
  • SOB, hypoxia, tachycardia, raised JVP, bi-basal lung crepitations
54
Q

What are the clinical features of transfusion related lung injury reaction to transfusion?

A
  • SOB, cough, chest x-ray ‘white out’
55
Q

What is the management of acute haemolytic reaction to transfusion?

A
  • STOP transfusion
  • Check patient details on unit
  • Inform haematologist / blood bank
  • Send Unit, giving set and FBC (platelets), U and E’s (renal failure), clotting (DIC), cultures, urine (HB-uria)
  • Keep IV line open with 0.9 % NaCl
  • Supportive care
  • DIC therapy - Platelets if <50, cryoprecipitate replaces fibrinogen, FFP replaces clotting factors
  • Monitor urine output
56
Q

What is the management of non-haemolytic febrile reaction to transfusion?

A
  • STOP/SLOW transfusion
  • Give antipyretic (paracetamol 1g)
  • Monitor closely (if recurrent, use leucocyte depleted blood or WCC filter
  • Exclude bleeding wound
  • If no improvement, stop and get senior help
57
Q

What is the management of anaphylaxis reaction to transfusion?

A
  • STOP transfusion
  • Maintain airway
  • Give 100% O2
  • Contact anaesthetist
  • Give adrenaline 0.5ml 1:1000 IM
  • Give chloramphenamine 10mg IV
  • Give hydrocortisone 200mg IV
58
Q

What is the management of a bacterial contamination reaction to transfusion?

A
  • STOP transfusion
  • Check the patient details on the Unit
  • Inform haematologist
  • Send the Unit and giving set
  • Send FBC, U and E’s, clotting, cultures, urine (Hb-uria)
  • Start broad spectrum antibiotics
59
Q

What is the management of an allergic reaction to transfusion?

A
  • STOP/SLOW transfusion
  • Give chloramphenamine 10 mg slow IV/IM
  • Give hydrocortisone 200mg IV stat
  • Monitor closely (more frequent obs)
60
Q

What is the management of a fluid overload reaction to transfusion?

A
  • STOP/SLOW transfusion
  • Give O2
  • Give diuretic (furosemide 40mg IV initially)
  • Consider CVP line and exchange transfusion
61
Q

What is the management of TRALI reaction to transfusion?

A
  • STOP transfusion
  • Give 100% O2
  • Inform seniors/haematology/ICU (CPAP, mechanical ventilation circulatory support/nutritional support)
  • Treat as ARDS
  • Monitor ABGs
  • Fluid resuscitate
  • Remove donor from donor panel

Y5 Blood (3 decks)

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