Other

Question 1

Red blood cells

Answer 1

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

Question 2

Fresh frozen plasma (FFP)

Answer 2

PT ratio or APTT ratio > 1.5

Can be used prophylactically in patients undergoing invasive surgery where there is a risk of significant bleeding

Question 3

Cryoprecipitate

Answer 3

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

Question 4

Prothrombin complex concentrate

Answer 4

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

Question 5

CMV negative blood indications

Answer 5

Granulocyte transfusions

Intra-uterine transfusions

Neonates up to 28 days post EDD

Pregnancy - elective transfusions

Question 6

Irradiated blood indications

Answer 6

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

Question 7

Transfusion complications classification

Answer 7

Immunological - acute haemolytic, non-haemolytic febrile, allergic/anaphylaxis

Infective

Transfusion-related acute lung injury

Transfusion-associated circulatory overload

Other - hyperkalaemia, iron overload, clotting

Question 8

Non-haemolytic febrile reaction

Answer 8

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

Question 9

Minor allergic reaction

Answer 9

Thought to be caused by foreign plasma proteins

Pruritus, urticaria

Mx - temporarily stop the transfusion, antihistamine, monitor

Question 10

Anaphylaxis

Answer 10

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

Question 11

Acute haemolytic reaction

Answer 11

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

Question 12

Transfusion-associated circulatory overload

Answer 12

Excessive rate of transfusion, pre-existing heart failure

Pulmonary oedema, hypertension

Mx - slow/stop transfusion, consider IV loop diuretic & oxygen

Question 13

Transfusion-related acute lung injury

Answer 13

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

Question 14

Pain mx

Answer 14

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

Question 15

Opioids SEs

Answer 15

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

Question 16

Pain relief in CKD

Answer 16

Opioids used in caution

Oxycodone is preferred to morphine in palliative patients with mild-moderate renal impairment

Renal impairment severe → buprenorphine & fentanyl

Question 17

Metastatic bone pain

Answer 17

May respond to strong opioids, bisphosphonates or radiotherapy

Consider referral to a clinical oncologist for consideration of further treatments such as radiotherapy

Question 18

Conversions between pain relief (oral to oral)

Answer 18

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)

Question 19

Conversions between pain relief (oral to subcut)

Answer 19

Oral morphine → subcutaneous morphine (divide by 2)

Oral morphine → subcutaneous diamorphine (divide by 3)

Oral oxycodone → subcutaneous diamorphine (divide by 1.5)

Question 20

N&V common causes

Answer 20

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

Question 21

N&V non-pharmacological mx

Answer 21

Advice & realistic aims

Smell

Taste - small appropriate meals

Hypnosis? Acupuncture?

Question 22

N&V pharmacological mx

Answer 22

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

Question 23

Intractable breathlessness mx

Answer 23

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

Question 24

Constipation

Answer 24

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

Question 25

Constipation causes

Answer 25

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

Question 26

Laxatives

Answer 26

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

Question 27

Psychological distress non-pharmacological mx

Answer 27

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

Question 28

Psychological distress pharmacological mx

Answer 28

Anti-depressants

Benzodiazepines - midazolam

Question 29

Confusion & delirium mx

Answer 29

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