Other Flashcards
Red blood cells
Red blood cells should be stored at 4 degrees prior to infusion
Non-urgent scenario → unit of RBC is usually transfusion over 90-120 minutes
Fresh frozen plasma (FFP)
PT ratio or APTT ratio > 1.5
Can be used prophylactically in patients undergoing invasive surgery where there is a risk of significant bleeding
Cryoprecipitate
Contains clotting factors, most commonly use to replace fibrinogen
Fibrinogen concentration <1.5 g/L
E.g. DIC, liver failure, hypofibrinogenemia secondary to massive transfusion
Can be used prophylactically in patients undergoing invasive surgery where there is significant bleeding where fibrinogen concentration < 1g/L
Prothrombin complex concentrate
Used for emergency reversal of anticoagulation in patients with either severe bleeding/head injury with suspected intracerebral haemorrhage
Can be use prophylactically in patient undergoing emergency surgery
CMV negative blood indications
Granulocyte transfusions
Intra-uterine transfusions
Neonates up to 28 days post EDD
Pregnancy - elective transfusions
Irradiated blood indications
Granulocyte transfusions
Intra-uterine transfusions
Neonates up to 28 days post EDD
Bone marrow/stem cell transplants
Immunocompromised (e.g. chemo/congenital)
Patients with/previous Hodgkin lymphoma
Transfusion complications classification
Immunological - acute haemolytic, non-haemolytic febrile, allergic/anaphylaxis
Infective
Transfusion-related acute lung injury
Transfusion-associated circulatory overload
Other - hyperkalaemia, iron overload, clotting
Non-haemolytic febrile reaction
Thought to be caused by antibodies reacting with white cell fragments in the blood product & cytokines that have from the blood cell during storage
Fever, chills (more common in platelet transfusion)
Mx - slow/stop transfusion, paracetamol, monitor
Minor allergic reaction
Thought to be caused by foreign plasma proteins
Pruritus, urticaria
Mx - temporarily stop the transfusion, antihistamine, monitor
Anaphylaxis
Can be caused by patients with IgA deficiency who have anti-IgA antibodies
Hypotension, dyspnoea, wheezing, angioedema
Mx - stop the transfusion, IM adrenaline, ABC support
Acute haemolytic reaction
ABO-incompatible blood eg. secondary to human error
Fever, abdominal pain, hypotension
Mx - stop transfusion, confirm diagnosis (send blood for direct Coombs test, repeat typing & cross-match), supportive care
Transfusion-associated circulatory overload
Excessive rate of transfusion, pre-existing heart failure
Pulmonary oedema, hypertension
Mx - slow/stop transfusion, consider IV loop diuretic & oxygen
Transfusion-related acute lung injury
Non-cardiogenic pulmonary oedema thought to be secondary to increased vascular permeability caused by host neutrophils that become activated by substances in donated blood
Hypoxia, pulmonary infiltrates on CXR, fever, hypotension
Mx - stop the transfusion, oxygen & supportive care
Pain mx
Follows the analgesic ladder - stay at the lowest effective step
Paracetamol and NSAIDs - ibuprofen, naproxen, diclofenac
Weak opioids - tramadol, codeine, dihydrocodeine
Strong opioids - fentanyl, morphine sulphate, oxycodone
Analgesic adjuncts can be added at any stage if pain is not fully controlled or from nerve pain (burning/tingling)
- pregabalin, gabapentin, amitriptyline, duloxetine, benzodiazepines
Opioids SEs
Common initial - N&V, drowsiness, light-headedness/unsteadiness, cognitive impairment
Common on-going - constipation, dry mouth
Less common - neurotoxicity, sweating, urinary retention, pruritus
Rare - respiratory depression, psychological dependence
Pain relief in CKD
Opioids used in caution
Oxycodone is preferred to morphine in palliative patients with mild-moderate renal impairment
Renal impairment severe → buprenorphine & fentanyl
Metastatic bone pain
May respond to strong opioids, bisphosphonates or radiotherapy
Consider referral to a clinical oncologist for consideration of further treatments such as radiotherapy
Conversions between pain relief (oral to oral)
Breakthrough dose of morphine is one-sixth the daily dose of morphine
Oral codeine → oral morphine (divide by 10)
Oral tramadol → oral morphine (divide by 10)
Oral morphine → oral oxycodone (divide by 1.5-2)
Conversions between pain relief (oral to subcut)
Oral morphine → subcutaneous morphine (divide by 2)
Oral morphine → subcutaneous diamorphine (divide by 3)
Oral oxycodone → subcutaneous diamorphine (divide by 1.5)
N&V common causes
Infection - UTI, pneumonia, gastro-enteritis, thrush
Metabolic - renal impairment, hepatic impairment
Drug related - opioids
Gastric stasis - ascites, opioids, pyloric tumour/nodes
GI disturbance - constipation, gastritis
Organ damage - distension, obstruction
Neurological - raised ICP, motion sickness
Psychological - anxiety/fear
N&V non-pharmacological mx
Advice & realistic aims
Smell
Taste - small appropriate meals
Hypnosis? Acupuncture?
N&V pharmacological mx
Chemical - haloperidol, metoclopramide
Gastric stasis - metoclopramide, domperidone
Bowel obstruction - cyclizine, dexamethasone
Raised ICP - cyclizine, dexamethasone
Psychological - non-pharmacological, benzodiazepines
Post-op/RT - ondansetron
Constipation - laxatives
Intractable breathlessness mx
Position patient:
- use gravity to aid & not hinder weak diaphragm/chest wall muscles
Air flow across the face - fan/open a window
Trial of oxygen (if hypoxic)
Medications: morphine, lorazepam, midazolam
Constipation
Hard faeces, which are uncomfortable/difficult to pass; reduced frequency compared with normal pattern
Sense of incomplete evacuation after defecation; leakage of faecal fluid, faecal incontinence
Constipation causes
Disease related - immobility, reduced food intake/low residue diet, intra abdominal and pelvic disease
Fluid depletion - poor fluid intake, increased fluid loss
Weakness - inability to raise intra-abdominal pressure
Intestinal obstruction
Medication - opioids
Biochemical - hypercalcaemia
Other - pain on defecation
Laxatives
Stimulant (Senna, bisacodyl) - reduce bowel transit time
Softener (Docusate) - increase water penetration of stool
Stimulant/softener (sodium picosulfate)
Osmotic (lactulose, movicol, laxido)
Suppositories (glucerin, bisacodyl) - softener, stimulant
Psychological distress non-pharmacological mx
Talking to someone they trust
Psychological therapies
Practical management - help with making plans, housing or finances
Spiritual care - supporting people to feel a sense of meaning, comfort, strength & connection in their life
Psychological distress pharmacological mx
Anti-depressants
Benzodiazepines - midazolam
Confusion & delirium mx
Underlying causes of confusion need to be looked for & treated as appropriate eg. hypercalcaemia, infection, urinary retention, medication
Specific treatments:
- first choice - haloperidol
- other options - chlorpromazine, levomepromazine
