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NA 1 > Patient Blood Managment: Transfusion Therapy > Flashcards

Patient Blood Managment: Transfusion Therapy Flashcards

1
Q

indications for transfusions

A

increased oxygen carrying capacity in the only true reason for RBC transfusion

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2
Q

oxygen delivery equation

A

oxygen delivery = CO x arterial O2 content

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3
Q

normal O2 deliery exceeds O2 consumption by __ fold

A

4

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3
Q

ways that the body compensates for anemia

A
  • erythropoesis (make more hgb)
  • rightward shift of ODC
  • increase CO
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4
Q

normal oxygen delivery is

A

1 L/min

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5
Q

oxygen extraction ratio

A

VO2/DO2

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6
Q

normal O2 consumption is

A

250mL/min

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6
Q

critical Hgb

A

the threshold below which the body’s O2 consumption becomes dependent on O2 delivery

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7
Q

Class I acute hemorrhage

A

750cc
15% of blood volume
HR 100
BP normal
PP normal or increased
cap refill normal
RR 14-20
UO 30mL/hr
CNS: slightly anxious
fluid replacement: crystalloid

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8
Q

Class II Acute hemorrhage

A

750-1500cc
15-30% of blood volume
HR 100
BP normal
PP decreased
cap refill positive
RR 20-30
UO 20-30mL/hr
CNS: mildly anxious
fluid replacement: crystalloid

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9
Q

Class III Acute hemorrhage

A

1500-2000cc
30-40% of blood volume
HR 120
BP decreased
PP decreased
cap refill positive
RR 30-40
UO 5-10mL/hr
CNS: anxious/confused
fluid replacement: crystalloid + blood

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9
Q

Class IV Acute hemorrhage

A

2000cc or more
40% or more of blood volume
HR 140 or higher
BP decreased
PP decreased
cap refill positive
RR 35
UO negligible
CNS: confused/lethargic
fluid replacement: crystalloid + blood

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10
Q

the decision to transfuse should be based on the overall status of the pateint

A
  • inadequate perfusion to tissue organs
  • anticipated blood loss
  • estimated blood loss
  • amount of fluid given
  • Hgb
  • Transfusion indicators
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11
Q

monitoring for inadequate perfusion and oxygenation of vital organs

A
  • hemodynamics: HR as an insensitive indicator of hypovolemia
  • U/O: declines during moderate to severe hypovolemia
  • ECG
  • O2 sats: not a good indicator
  • ABGs: pH decreased during severe hypo perfusion
  • mixed venous oxygen saturation
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12
Q

monitoring for blood loss

A
  • visual estimation
  • based on suction devices, sponges, and drapes
  • a study in patients undergoing spinal surgery showed that anesthesiologists tended to overestimate blood loss by as much as 40%
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13
Q

allowable blood loss (ABL) equation

A

EBV x (Hi-Hf) / Hi

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14
Q

EBV women

A

65 mL/kg

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15
Q

EBV men

A

70 mL/kg

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16
Q

what is spectrophotometric finger technology?

A

standard parameters: pulse ox, pulse rate, perfusion index

optional parameters: pleth variability index, total hgb, methemoglobin saturation, carboxyhemoglobin

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17
Q

1988 NIH consensus conference

A
  • Hgb >10: rarely require transfusions
  • Hgb < 7: almost always require transfusions
  • Hgb 7-10: decision to transfuse should be based on patients risk for complications of inadequate oxygenation
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18
Q

TRICC Trial

A

Research question: among critically ill patients, how does a restrictive transfusion strategy (hgb 7-9) compare to a liberal transfusion strategy (hgb 10-12) in decreasing mortality?

Restrictive: hgb maintained at 7-9, avg 2.6 unit pRBC’s

Liberal: hgb 10-12, avg 5.6 units pRBCs

bottom line: restrictive strategy is associated with less mortality

transfusion requirements in critically care

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19
Q

replacement ratio for blood w/ crystalloid

A

1:3 (LR or NS)

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20
Q

replacement ratio for blood w/ colloid

A

1:1 (albumin, plasmanate, dextran)

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20
Q

replacement ratio for blood w/ whole blood

A

1:1

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21
Q

types of blood collection

A
  • allogenic (homologous)
  • Autologous
  • perioperative blood salvage
  • acute normovolemic hemodilution
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21
Q

replacement ratio for blood w/ pRBCs

A

1:1

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22
Q

allogenic blood collection

A

taken from different individuals of the same species

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23
Q

bank blood additives increase

A

storage time

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24
Q

Blood preservatives- CPDA

A
  • citrate: prevents clotting by binding with calcium
  • phosphate: buffer
  • dextrose: RBC energy source
  • adenine: allows RBCs to resynthesize ATP, extends storage time (35 days)
    adsol(AS-1): adenine, glucose, mannitol NaCl, increases storage time to 42 days
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25
Q

past generation additives

A
  • CPD: citrate, phosphate, dextrose (21 days)
  • CPD-A: adenine added (35 days/5 weeks)
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26
Q

current generation additives (storage time = 42 days)

A
  • AS-1(Adsol): adenine glucose, mannitol, and sodium chloride
  • AS-3 (Nutricel): glucose, adenine, citrate, phosphate & NaCl
  • AS-5 (optisol): glucose, adenine, NaCl and mannitol
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27
Q

ABO blood typing

A

blood typing-looks at what is in the plasma to see if it will react with the RBCs that you are giving

antigens- surface markers (RBCs), able to trigger an immune response

antibodies- in the plasma

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28
Q

if you are giving antibodies, you are giving?

A

giving plasma

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29
Q

if you are giving antigens, you are giving?

A

pRBCs

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29
Q

Rh factor

A

are another group of antigen found on the surface of RBCs

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30
Q

Rh Isoimmunization

A
  • Rh-neg woman and a Rh-pos man conceive a child
  • Rh-neg woman with Rh-pos fetus
  • cells from Rh-pos fetus enter the woman’s bloodstream
  • woman becomes sensitized - antibodies form to fight Rh-positive blood cells
  • in the next Rh-pos pregnancy, maternal antibodies attack fetal RBCs
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30
Q

what is the main Rh+ factor?

A

Rh(D)

85% of ppl have these antigens are Rh+

unlike ABO system, antibodies to Rh factor are not developed until you are exposed

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31
Q

giving plasma =

A

giving antibodies

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32
Q

selection of donor plasma according to ABO group
AB
A
B
O

A

AB 1st
A 1st AB 2nd
B 1st AB 2nd
O 1st A 2nd B 3rd AB 4th

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33
Q

Type and screen

A
  • to ‘type’ blood: mix with serum from O blood (known to have anti-A and anti-B antibodies). also treated with anti-D antibodies to determine Rh status
  • to ‘screen’ blood (called indirect Coomb’s test): mix the patient’s serum with the most commonly known antibodies
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34
Q

when is a T/S needed?

A
  • performed with the scheduled procedure is unlikely to require blood transfusions, blood should still be available
  • most cost-effective use of stored blood
  • blood is available to more than one patient
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35
Q

type and cross

A
  • mimics the transfusion
  • donor cells are mixed with the recipient’s serum
  • detects the presence of less common antibodies not usually tested for in a screen
  • performed for elective surgeries when the risk of transfusion is high
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36
Q

major cross-match

A
  • 2 drops of patient serum with 1 drop of 5% of donor RBC –> incubation at 37 degrees C for 1 hr
  • then into the centrifuge with 2 drops of AHG… will have (2) outcomes.. agglutination which is not compatible or no agglutination which is compatible
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37
Q

infectious disease testing for blood transfusions
conservative measures

A
  • no donations taken from exposed or symptomatic patients
  • wait 14 days after symptom resolution to donate blood
  • if donated blood and develop symptoms within 28 days of donation, blood is discarded

are we testing for COVID?

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38
Q

autologous blood collection is?

A

the patients own blood

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39
Q

3 types of autologous blood transfusions

A

1.) preoperative autologous donation
2.) Acute normovolemic hemodilution
3.) Intraoperative and postoperative blood salvage

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40
Q

Preoperative autologous donation considerations

A
  • patient scheduled for elective surgery predonates blood
  • Hgb concentration must be greater than 11
  • most patients can donate 10.5 mL/kg blood 5-7 days before surgery with a max of 2-3 units
  • last unit must be collected 72 hours before surgery
  • permits restoration of plasma volume
  • PO iron may be given within a few days of surgery
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41
Q

not everyone can pre-donate blood
list contraindications

A
  1. evidence of infection and risk of bacteremia
  2. scheduled surgery to correct aortic stenosis
  3. unstable angina
  4. active seizure disorder
  5. MI or CVA within 6 months of donation
  6. high-grade left main CAD
  7. cyanotic heart failure
  8. uncontrolled htn
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42
Q

acute normovolemic hemodilution involves withdrawal of blood early in the intraoperative period

A
  • loss of blood with low hematocrit
  • replace withdrawn blood with 3cc crystalloid for every cc of blood
  • Hct endpoint = 27-33%
  • depends on pt’s CV and respiratory reserve
  • reinfusion- use 40-micron filter to avoid palette elimination
43
Q

Intraoperative blood salvage

A

“cell saver”

44
Q

what is the process of the cell saver?

A

involves “washing” of salvaged material and return of only RBCs (hct = 50-60%)

45
Q

where does the blood collect from?

A

surgical field and would drians

46
Q

when is the cell saver re-infused?

A

post-surgery

47
Q

T/F Autologus blood is not used much anymore

A

true

48
Q

potential complications with autologous blood

A
  • anemia d/t lack of time for RBC reconstitution
  • possible reinfusion of fat, micro aggregates (platelets, WBCs, air, red cell stroma, bacteria, etc.)
  • massive air embolism
  • dilutional coagulopathy r/t large transfusions
  • no clotting factors: all clotting factors and platelets are removed by washing process (ANH-exception)
  • reinfusion of excessive anticoagulant (heparin)
  • HD
  • DIC
49
Q

whole blood is separated into components, and when whole blood is centrifuged turns into what?

A

packed red blood cells

  • frozen red cells (freeze -80 deg C)
  • leukocyte-poor red cells
50
Q

whole blood is separated into components, and when platelet-rich plasma is centrifuged at 20 deg C, turns into what?

A

platelets

51
Q

whole blood is separated into components, and when platelet-poor plasma is frozen at -20 deg C turns into what?

A

fresh frozen plasma

52
Q

whole blood is separated into components, and when platelet-poor plasma is frozen at -70 deg C and then thawed it is?

A

Cryoprecipitate

53
Q

whole blood is separated into components, and when platelet-poor plasma is frozen at -70 deg C what is it?

A

Factor VIII- poor plasma

54
Q

1 unit of pRBCs will increase the hct by how much?

A

3%

54
Q

1 unit of pRBCs will increase the hgb by how much?

A

1gm/dL

55
Q

1 unit pRBCs

A
  • plasma is removed
  • 250-350 mL volume with a 60% hct (whole blood has a hct of 40%)
  • same amount of hgb as whole blood
  • stored 21-43 days @ 1-6 deg C
  • any crystalloid that contains calcium will cause clotting
  • infusion with any crystalloid that contains Ca will cause clotting
56
Q

how long should you wait to check a hgb?

A
  • takes 24 hours for full equilibrium
  • earlier measures reflect steady-state values in persons who have not bled recently
  • only 6% of patients had a statistically significant between hgb/hct levels drawn at 15 mins and 24 hrs
56
Q

ASA 2015 Practice Guidelines

A

1.) rarely need transfusion when hgb > 10 and always need when < 6
2.) A restrictive strategy (hgb > 8) should be used
3.) Multimodal protocols should be used to reduce intraop blood loss. should chk hgb between units
4.) Consider factors other than hgb when deciding to transfuse. remember pRBCs are given to increase O2 carrying capacity
5.) use blood salvage, acute normovolemic hemodilution and other measures to decrease blood loss when possible

57
Q

one unit of platelets increase platelet count how much?

A

7,000-10,000 cells/mm^3

58
Q

how long are platelets good for?

A

7 days

but risk for sepsis goes up at the end of this time, so try to use earlier

recommend 2.5 - 3 days

58
Q

how many pooled donors does it take to make 1 unit of platelets?

A

4-6 donors

or apheresis from one donor

59
Q

what is the only blood product stored at room temp?

A

platelets

stored at 20-24 deg C

60
Q

what is the third leading cause of transfusion-related deaths?

A

bacterial contamination (mainly from platelets)

61
Q

guideline for platelet transfusion

A
  • prophylactic platelet transfusions are rarely indicated when platelets are > 100 x 10^9 and are usually indicated when platelets are < 50 x 10^9
  • adequate plt count but known plt dysfunction (with antiplt agents and CPB). consider desmopressin first
  • pts with severe thrombocytopenia ( < 20,000) and clinical signs of bleeding
  • HELLP & neuraxial anesthesia - 70,000 plts (UpToDate)
  • should be ABO compatible
62
Q

FFP contains all coagulation factors except

A

platelets

63
Q

what is the most frequently used plasma product?

A

FFP

64
Q

what does FFP have?

A
  • factor V and VIII
  • fluid portion contained from a single unit of whole blood
  • frozen within 6 hrs of collection
  • stored for 5 days*
65
Q

2 units of FFP (10/15 mL/kg) achieve __ factor activity

A

30%

66
Q

effective coagulation occurs with clotting facotr levels of

A

20-30% normal

67
Q

guidelines for FFP transfusion

A
  • transfuse if INR > 2 in the absence of heparin
  • transfuse if the pt has been transfused with pRBCs > 1 total blood volume (70cc/kg)
  • transfuse for urgent reversal of warfarin therapy when prothrombin concentrate complex is not available
  • prior to the administration of FFp, obtain coag studies
68
Q

Cryoprecipitate is

A

fraction of plasma that precipitates when FFP is thawed

68
Q

coagulation factors in cryo

A
  • factor VIII: C (procoagulant activity)
  • factor VIII: vWF
  • Fibrinogen (cryo has the highest content of fibrinogen)
  • factor XIII (fibrin stabilizing pattern)
  • fibronectin (helps clean up foreign particles and bacteria from the blood)
69
Q

cryo is rarely indicated when fibrinogen is >

A

150 mg/dL

70
Q

indications for cryo

A
  • fibrinogen < 80 -100 in the presence of excessive bleeding
  • OB patients experiencing excessive bleeding despite fibrinogen level > 150
  • massive transfusions (best to measure fibrinogen, but if you can’t it is ok to give cryo)
  • bleeding in von Willebrand dx who don’t respond to desmopressin or vWF/factor VIII concentration
71
Q

how to give cryo

A
  • through a filter
  • as rapid as possible (at least 200mL/hr)
  • complete the infusion within 6 hrs of thawing
  • 10 units of cryo will increase fibrinogen 70 mg/dL
72
Q

does cryo need to be ABO compatible?

A

cryo contains extremely low concentrations of antibodies so probably not very important

73
Q

physiologic effects of massive transfusions

A
  • alkalosis: d/t citrate metabolism to bicarb in the liver
  • hypothermia: d/t transfusion of cold blood
  • hyperglycemia: d/t dextrose additive
  • hypocalcemia: d/t binding of calcium to citrate
  • hyperkalemia: d/t administration of older blood and leaky K (caution in neonates and RF)
73
Q

Rh factor with cryo:

A

if cryo from Rh + pt is given to Rh - pt, could sensitize the patient

73
Q

fibrin glue

A

made from cryo b/c of a large amount of fibrinogen. thrombin is added to make it work

74
Q

what happens to blood with decreased storage

A

decreased with storage: pH, Ca, Factor V & VIII, (2,3 DPG)

75
Q

what happens to blood with increased storage

A

increased with storage: K, Hgb, LA & CO2, fragility of RBC –> cell lysis

76
Q

citrate intoxication manifests as

A

hypocalcemia

77
Q

increased risk of citrate intoxication

A
  • peds
  • with hyperventilation
  • liver dx/transplant
78
Q

citrate intoxication occurs when

A

giving blood rapidly ( 1 > unit every 10 mins)

even with giving blood quickly you do not bind enough Ca ro cause bleeding problems

79
Q

signs of hypocalcemia

A
  • hypotension
  • narrow pulse pressure
  • increased CVP and intraventricular EDP
80
Q

giving blood products increases the patient’s risk for?
what does it do to the heart?

A

hypothermia

  • it can cause cardiac irritability and interfere with coagulation
  • if the body temp falls < 30, ventricular irritability/cardiac arrest may occur
81
Q

blood is stored at

A

4-6 deg C

82
Q

coagulation abnormalities

A
  • DIC-like syndrome (called consumptive coagulopathy in Miller) is caused by tissue hypoperfusion
  • Thrombocytopenia (defined as plts < 150)
  • low levels of fibrinogen, factor V & factor VIII
  • these coagulation abnormalities are often seen with the administration of large amounts of blood (6-10 units)
83
Q

signs of dilutional coagulopathy

A
  • oozing into the surgical field
  • hematuria
  • gingival bleeding
  • petechial bleeding from venipuncture sites
  • ecchymosis
84
Q

DIC-like syndrome

A
  • deranged clotting system leading to disseminated fibrin deposition
  • un-clottable blood (severe hemorrhagic diathesis)
  • severely altered microcirculation leading to ischemic necrosis in various organs (esp. kidney)
85
Q

most frequent infection associated with blood transfusions

A

Hepatitis (viral) risk: 1:103,000

cryo is most likely blood product to transmit hepatitis

86
Q

TRALI means

A

transfusion related acute lung injury

87
Q

1 cause of transfusion-related fatalities (TRALI) ?

A
  • respiratory distress syndrome occurring within 6 hours after transfusion of pRBC’s or FFP

manifests like non-cardiogenic pulmonary edema

BUT no excessive intravascular volume and no cardiac failure

causes: all blood products, highest risk FFP

88
Q

S/S of TRALI

A
  • fever
  • dyspnea
  • fluid in endotracheal tube
  • severe hypoxia
  • during Ga - persistent decrease in blood O2 saturation
89
Q

how to diagnose TRALI

A
  • pulm edema in the absence of HF / circulatory overload
  • pulm fluid has high protein content
90
Q

treatment of TRALI

A
  1. stop transfusion
  2. support VS
  3. determine protein concentration of pum edema fluid via ETT
  4. obtain CBC & CXR
  5. notify blood bank (quarantine-associated units)
91
Q

what does TACO mean

A

transfusion related circulatory overload

92
Q

unlike TRALI, TACO is __ __ with excessive intravascular volume

A

pulmonary edema

high volume or rate of transfusion exceeds ability of patients cardiovascular system to handle additional workload

93
Q

at risk for TACO

A
  • cardiopulmonary dx
  • RF
  • extremes of age
94
Q

TACO symptoms: (signs of overload)

A
  • dyspnea, orthopnea
  • hypoxemia
  • pulmonary edema
  • HTN ( > 50 mmhg in SBP)
  • increased CVP
95
Q

3 types of transfusion reactions

A
  • febrile
  • hemolytic
  • allergic
96
Q

what adverse transfusion reaction is the most common?

A

febrile reaction

97
Q

febrile reaction S/S

A

fever, chills, headache, myalgia, nausea, non-productive cough

less frequently: hypotension, chest pain, dyspnea

98
Q

cause of febrile reaction

A

the release of intracellular contents of donor leukocytes causes symptoms. the use of Leuko-reduced blood lowers the incidence of febrile reactions

99
Q

treatment of febrile reaction

A

slowly infuse blood (but no clear consensus if the transfusion should be stopped)

100
Q

allergic reaction can be

A

minor, anaphylactic, or anaphylactoid

101
Q

allergic reaction S/S

A
  • uticaria (most common)
  • increased temp
  • pruritus
102
Q

cause of allergic reaction

A
  • can be anaphylactoid or anaphylactic
  • anaphylactic reactions are caused by transfusion of IgA to patients who are IgA deficient and have developed antibodies
  • there is no cell destruction
103
Q

treatment of allergic reaction

A
  • IV antihistamines
  • severe cases –> d/c blood
  • observe urine for free hgb to rule out hemolytic reactions
104
Q

what type of allergic reaction is a hemolytic reaction?

A

type II allergic reaction

105
Q

cause of hemolytic reaction

A

administration of wrong blood type (ABO incompatibility), most times it is d/t a clerical error

106
Q

s/s of hemolytic reaction

A

classic signs: fever, chills, chest pain, flank pain, nausea

107
Q

S/s of hemolytic reaction under A

A
  • hemoglobinuria (usually a persisting sign)
  • hypotension
  • bleeding diathesis
108
Q

what to do with hemolytic reaction

A
  1. stop the transfusion
  2. maintain UO (75-100mL/hr) give fluids/maybe mannitol–> last case lasix if the other 2 don’t work
  3. alkalinize the urine: b/c bicarb is preferentially excreted in the urine, give bicarb drip to bring urine pH to 8
  4. assay urine and plasma hgb concentrations
  5. determine plt count, partial thromboplastin time, and serum fibrinogen level
  6. return unused blood to blood bank for repeat crossmatch
  7. send pt.s blood and urine to blood bank for examination
  8. prevent hypotension to ensure adequate renal blood flow

NA 1 (15 decks)

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