Miscellaneous

Question 1

What bleeds constitute WHO grade 1 bleeding?

Answer 1

Oropharyngeal bleeding (<30min)
Epistaxis (<30min)
Petechiae
Purpura (<1in)
Positive hemeoccult

Question 2

What bleeds constitute WHO grade 2 bleeding?

Answer 2

Epistaxis (>30min)
Purpura (>1in)
Hemoptysis
Melena
Gross hematuria
Visible blood in body cavity
Bleeding at invasive sites

Question 3

What bleeds constitute WHO grade 3 bleeding?

Answer 3

Bleeding requiring RBC transfusion over routine needs

Bleeding associated with moderate hemodynamic instability

Question 4

What bleeds constitute WHO grade 4 bleeding?

Answer 4

Bleeding associated with severe hemodynamic instability
CNS bleeding on imaging study
Fatal bleeding

Question 5

What is the difference between V-V and V-A ECMO?

Answer 5

In V-V, only veins are connected and the blood oxygenated across the circuit, so the patient’s heart must provide pressure drive. In V-A, there is also hemodynamic support.

Question 6

What is the consequences of DEHP plasticizer in ECMO and other settings?

Answer 6

May have some patient hormonal effect…

Question 7

What are transfusion thresholds in ECMO?

Answer 7

Transfuse to about 8g/dL (7-8 for VA, 8-10 for VV)
Platelet goals >80k by ELSO guidelines, but usually 50k.
Fibrinogen goal of 150k.

Question 8

How should a Jehovah’s witness be approached about blood transfusion?

Answer 8

In private; 10-12% may be willing to actually receive blood transfusion.

Question 9

What products are generally permissible for transfusion in Jehovah’s witnesses?

Answer 9

Autologous blood if not held outside the body for long. Acellular products such as cryo, FFP, albumin. HBOCs.

Question 10

What are HBOCs?

Answer 10

Hemoglobin based oxygen carriers. Cell-free alternatives to blood transfusion that are inferior to red cell transfusion. eg, Hemopure and SANGUINATE

Question 11

How can Jehovah’s witnesses be managed in the pre-op and peri-op period?

Answer 11

Pre-op: Optimize with EPO and supplements.

Peri-op: ANH, cellsaver, bloodless protocols, acellular products like PCCs, cryo, Amicar, desmopressin…

Question 12

How should children of Jehovah’s witnesses be managed?

Answer 12

Overrule parental autonomy in unambiguous cases of child endangerment. Note that you are legally obligated to provide lifesaving interventions. If a teenager; consider “mature minor” clauses.

Question 13

How is ATG produced?

Answer 13

Usually rabbit or equine derived; animal is exposed to human lymphocytes and antibodies collected (polyclonal).

Question 14

How is IVIG produced?

Answer 14

Human-derived; collected from WB or source plasma sources. Subjected to infectious mitigation.

Question 15

How is RhIg produced?

Answer 15

Human-derived, produced by cold alcohol fractionation and pathogen-reduced.