Peri-operative Medicine/Anaesthesia Flashcards
What is Virchows triad
Abnormal blood flow- stasis
Abnormal blood components- hypercoagubility
Abnormal vessel wall- endothelial injury
What are risk factors for VTE?
older age previous VTE smoker malignancy pregnancy recent prolonged immobility
How may a DVT present?
Unilateral calf swelling Tender Painful Low grade pyrexia Pitting oedema 65% are asymptomatic
How do you investigate a possible DVT?
Ultrasound
D-dimer
Wells score
d-dimer is not specific to DVT
Explain the wells score
Each is worth one point Clinical signs of DVT Heart rate > 100bpm Recent surgery or immobilisation Previous PE or DVT Haemoptysis Malignancy Alternative diagnoses less likely than PE
Less than or equal to one- DVT is unlikely and need a D-dimer to exclude
Greater than 1- DVT needs to be confirmed using ultrasound
How would you treat a patient with a confirmed DVT
DOACs, however in some cases vitamin K antagonist. Patients with a provoked DVT will need it for 3 months .
Unprovoked DVT or recurrent DVT may need lifelong anticoagulation
Which drugs need to be stopped pre-op?
CHOW:
Clopidogrel- stop 7 days pre-op
Hypoglycaemics- most sto pped 24 hours before. Metformin stopped the morning of . Sub cut insulin, stopped, reduce dose by 1/3 and omit morning insulin
Oral Contraceptive pill or HRT- stop 4 weeks before
Long term steroids- may be switched to IV to reduce risk of Addisonian crisis
What drugs do you start pre-op
LMWH
TED stockings
Abx prophylaxis
What is the ASA score?
Determine if a patient is healthy enough to tolerate anaesthesia
ASA1: normal, healthy patient
ASA2: A patient with mild systemic disease e.g. obesity, well controlled DM/HTN, smoker
ASA3: A patient with severe systemic disease e.g. poorly controlled DM,HTN, COPD morbid obesity,
ASA4: A patient with a severe systemic disease that is a constant threat to life e.g. recent MI, TIA, sepsis, ESRD not undergoing regular dialysis
ASA5: Moribund patient, not expected to survive without the op e.g.ruptured AAA, massive trauma
ASA5: A declared braindead patient who’s organs are being donated
What investigations would you do pre-op?
Bloods- FBC/ U+Es/LFTs/ condition specific e.g.TFTs, HbA1c, clotting
ECG- if hx of cardiac disease or major surgery
Spirometry e.g. COPD and asthma patients
Urinanalysis- identify a UTI
MRSA swab
Briefly outline the WHO pain ladder
Simple analgesics: paracetamol–> NSAIDS
Weak Opiates: codeine and tramadol
Strong opiates: fentanyl and morphine
What are the two types of fluids available?
Crystalloid, colloid.
For each patient, what should you consider when prescribing fluids?
Age, weight, cardiac function, co-morbidities. Reason for admission. Electrolytes recently given?
What is the aim of maintenance fluids?
To hydrate - all distribute into all compartments.
What is the aim of resuscitation fluids?
To improve tissue perfusion - will stay in intravascular space.
What are the 5R’s of fluid prescribing?
Resuscitation, Routine maintencence, Replacement, Redistribution, Reassess.
A patient is depleted of fluids. What signs should you look for when assessing fluid status?
Dry mucous membranes, reduced skin turgor, decreased urine output, orthostatic hypotension, increased cap refill time, tachycardia, hypotension.
A patient is overloaded with fluids. What signs should you look for when assessing fluid status?
Raised JVP, sacral odema, peripheral oedema, pulmonary oedema.
In what circumstances may you replace ongoing losses?
Third space losses (i.e. fluid losses into spaces that are not visible e.g. bowel lumen in bowel obstruction). In diuresis. When pt is tachypnoeic or febrile. When pt is losing electrolyte-rich fluid.
In what conditions are electrolyte imbalances common?
Dehydration - high urea:creatine ratio.
Vomiting - low K+, low Cl-, alkalosis,
Diarrhoea - low K+ and acidosis.
What fluids would you prescribe for patient with sepsis?
Fluids that get into intravascular space
What is the 4, 2, 1 rule regarding paediatric fluid maintenance?
First 10kg = 4ml/kg/hr. Next 10kg = 2ml/kg/hr. Thereafter = 1ml/kg/hr.
Why is hyponatremia so important to correct?
Can lead to transient or permanent brain damage due to cerebral oedema.
How do you manage a patient on long term oral steroids in the peri-operative period?
Switch oral steroids to 50-100mg IV hydrocortisone
If any associated hypotension, fludrocortisone can be added
Minor ops- oral prednisolone can be restarted immediately post op. If surgery is major than they may require IV hydrocortisone for up to 72 hours post op
What might you find on physical examination of a pt in pain?
Tachycardia, tachypnoea, hypertensio, sweating, flushing, agitation, unwilling to mobilise
Why is the WHO pain ladder used?
To titrate analgesia
A pt is already on NSAIDs and they are not aiding in their role as pain relief. What would you think of prescribing next? (on who pain ladder)
Weak opiates - codeine, tramadol.
What is the mechanism of action of NSAIDs?
Inhibit COX enzymes needed to convert arachidonic acid to downstream products in the prostanoid pathway. This stops the synthesis of prostaglandins so reeduces inflammatory response
Name 3 side effects of NSAIDs
I-GRAB Interactions with other meds (e.g. warfarin) Gastric ulceration Renal impairment Asthma sensitivity (trigger!) Bleeding risk
How do NSAIDs increase the bleeding risk of a pt?
Reduce platelet function (they stop prostacyclin which usually promotes platelets)
If you are worried of a patient having NSAIDs for a long time due to side effects, what can you prescribe alongside it?
PPI
Why do NSAIDs cause renal impairment?
Prostaglandins are inhibitied in this pathway. Usually, prostaglandin cause vasodilation of the afferent arteriole of the kidney to help maintain GFR. When your pt takes NSAIDS, they inhibit this vasodilation. SO you get poor renal perfusion - and kidney is more unable to respond to a reduced GFR
What are two side effects of opiates?
Constipation, nausea, sedation, confusion, pruritus, respiratory depression
What can you prescribe alongside opiates if a pt suffer with their side effects?
Laxatives and anti-emetics
Why wouldn’t you co prescribe a weak opiod with a strong opiod?
They inhibit the same receptor !! (Mop u)
Which opioids would you consider giving to someone who had eGFR of 50?
Oxycodone or Fentanyl as pt has renal impairment
What is patient controlled analgesia?
- Used when analgesia required exceeds the capacity of the nursing staff.
- So, an IV pump is used to provide a bolus of analgesia when a button on the pump is pressed.
- This allows the analgesia to be tailored to the pt’s requirements.
- The device records the opiod being administered.
Why may a pt present with neuropathic pain after an operation?
Irritation to a nerve or nerve injury during the procedure.
What drugs can be used to manage peri-operative neuropathic pain?
Gabapentin, Amitriptyline, Pregabalin
How can pain be assessed?
Subjectively - use SQITARS/SOCRATES. Objectively - HR, HTN?, Sweating, flushing? Agitiated, unwilling to mobilise?
Can assess in multiple environments - in bed, when taking a deep breath in, when mobile.
How does surgery affect the stress response?
Heightens it !! Huge increase in stress hormone and sympathetic response.
What hormones are involved in stress response? Describe this process
Increase in adrenaline, ACTH, cortisol, glucagon, GH = all catabolic (to create more glucose). Insulin tries to counteract this.
What are risks of a diabetic pt having anaesthesia and surgery?
- During surgery: Stress of surgery/trauma/infection can make hyperglycaemia harder to control as there is insensitivity to insulin
- Before and after surgery:GA/NBM before surgery/ post surgery vomiting means keeping glucose in normal range is challenging
- Increased risk of hospital infections
- Renal impairment
- MI and cardiac ischamia can be painless in a DM pt.
- Ketoacidosis can be mistaken
What is the target blood glucose in peri-operative /anaesthesia management?
Target capillary blood glucose 6-10mmol/L (for DM pt).
What three groups are DM pt divided into peri-operatively?
Insulin dependent, oral hyperglycaemic managed, diet controlled.
How do you (peri-operatively) manage insulin dependent DM pt?
- Establish good diabetic control before the operation.
- Give insulin as a continuous iv infusion during operative period
- Give infusion of dextrose through op (to balance the insulin or to make up dietary intake)
- Add potassium to dextrose
- Monitor blood glucose and electrolytes in op and after.
How do you manage DM pt’s who have oral hyperglycaemia?
Stop metformin - risk lactic acidosis. Stop Sulphonylureas can be stopped on the day of the op.
If blood glucose rises a little bit, can do sub-cut insulin to control insulin.
If patient has diet controlled DM, how would you manage them peri-operatively?
Do blood glucose. May not need intervention.
How do you manage poorly controlled DM on emergency admission?
Risk of DKA. Aim is to control glucose with rehydration and infusion of insulin, glucose and potassium.
What should be given alongside VRIII?
IV glucose, K, NaCl substrate solution
What is the aim of a pre-assessment before an operation?
- Assess good glycaemic control <8.5% Hba1c.
- Determie safest anaesthetic
- Timing of operation on the list (i.e. do they need to be first to limit starvation)
- VTE assessment risk
- Need for home support after surgery
- Assess other co-morbidities and complications
- Bloods
Regarding blood sugar, what are your aims whilst in the operating theatre?
- Regular blood glucose measurements.
- Feet visible, limit pressure sores, ensuring fluids are given.
What are post theatre aims for pt with DM?
- Maintain blood glucose.
- Maintain electrolyte balance
- Optimise renal and cardiac function
- Anti-emetics
- Fluids - Hartmann’s
What is the half life of IV insulin?
6mins. Some are 15 mins.
Why is insulin having a fast half life an advantage in surgery?
Fast half life = easy to adjust in surgery where there can be haemodynamic changes,
How many kcal in 1L of 5% dextrose?
170 kcals
Why are anticoagulants used in surgical patients?
Prevention of stroke, VTE embolism, PE, DVT, non-valvular AF
With regard to warfarin, what measurements mean a patient is fit for surgery?
INR of 1.5 or below.
Why might a surgical pt be on warfarin?
May have a mechanical heart valve. May have had a recent VTE?
How is warfarin reversed in emergency surgery?
- IV Vit K if surgery can be delayed by 6-12hrs and INR is >1.5.
- If surgery can not be delayed, human prothrombin complex (1 hr reversal).
- Fresh frozen plasma if HPC not available. FFP- contraindicated in fluid overload
A high risk pt usually on warfarin has had it reversed for surgery. What do you prescribe to ensure their blood does not clot?
LWMH for high risk pts. Can be stopped shortly before surgery then restarted after.
A pt on rivaroxiban is due to have surgery soon. When should they stop taking it?
24-72hrs before surgery. This depends on their kidney function, half life and the surgical procedure
What is the name of the antidote for dabigatran?
Idarucizumab - rapid reversal for emergency surgery or bleeding
What is the name of the antidote for apixaban?
Andexanet alfa
When should he COCP be stopped before surgery?
4 weeks before
Why should COCP be stopped before surgery?
Risk of VTE
What is commonly used as DVT prophylaxis?
Dalteparin
How is dalteparin administered?
Subcut injection
What should be given alongside LWMH prophylaxis?
Graduated compression stockings
Why should you wait 4 hours after inserting an epidural anaesthetic before giving LWMH?
Risk of epidural haematoma - blood accumulates in the epidural space which mechanically compresses the spinal cord - not good.
Which surgical procedures would need extended dalteparin/lwmh prophylaxis after surgery?
Major procedures such as orthopaedic (THR/TKR) as they have a higher risk of VTEs —> DVT/PE
A pt is already taking prednisolone. How should they be managed during surgical procedures (including pre and post)?
IV Hydrocortisone at induction AND immediately post op for first 24 hours.
Double normal steroid dose once eating/drinking fro 24-72 hours depending on the operation
What happens when a pt’s (who has been taking steroids) steroids are stopped suddenly?
Addisonian crisis
Describe what happens in addisonian crisis?
Reduced glucocorticoid and mineralcorticods. Hyponatraemia Hyperkalaemia Hypoglycaemia Reduced consciousness Low BP/blood vol
Why is addisonian crisis hard to detect post surgery/in surgery?
- Manifestations = hypotension, tachycardia, hypoxia and fever. These mimic common post op complications
- Can present as nausea, vomiting, diarrhoea = similar to effects of anaesthetic drugs
What are the 7 sources of pyrexia (7 C’s)?
Chest (infection) Cut (wound infection) Catheter (UTIs) Collections (abdo, pelvic) Calves (DVT) Cannula (infection) Central line
When should prophylactic abc be given?
Before clean surgery involving prosthesis or implants.
Clean-contaminated surgery
Contaminated surgery
How are abx given for a surgical procedure?
Single dose IV 60mins before first incision
What is involved in the safe use of abx in surgical procedures?
Check pt details, check allergies, check the surgery being done. Given prophylactically to counter the high risk of wound infection or where infection causes severe infections (prosthesis)
Define septic shock
Sepsis with hypotension despite adequate fluid resuscitation or requiring use of inotropic agents to maintain a normal systolic BP
How is septic shock managed?
Aggressive fluids resusc and abx therapy. Need to involve the critical care team
Distinguish between inotropes and chronotropes
Inotropes increase contractility whereas chronotropes increase heart rate
What investigations would you do to ID source of infection in septic patient?
Stool culture Cerebrospinal fluid sample Operative site assessment - US or CT Swabs of surgical wound CXR Urine dip and cultures
What should be done after you have completed sepsis 6?
Escalate to seniors.
What are involved in sepsis 6?
GIVE Oxygen, IV fluids, IV abx.
TAKE Routine bloods and lactate, urine output, blood cultures
In sepsis 6, how much urine are you aiming for per kg/hr?
0.5ml/kg/hr
With regard to sepsis 6, when should blood cultures be taken?
BEFORE abx are given
What are you ordering in routine bloods for sepsis6?
FBC, U&Es, LFTs, clotting, CRP, glucose
What is the SOFA score used for?
To monitor treatment for sepsis
What is involved in the SOFA score?
Respiration, Coagulation, Liver function, CVS function, CNS, Renal function
What clinical signs might you see with pt with suspected sepsis?
RR>22, altered mental state, SystBP <100mmHg
What are blood products?
Any part of the blood that is collected from a donor for use in a blood transfusion
What are blood products?
Any part of the blood that is collected from a donor for use in a blood transfusion
How is haemolytic disease of the newborn caused?
Second child - who is RhD+.
Mum is RhD-. Exposed to RhD+ blood antibodies produced in pregnancy.
Rhesus D- antibodies cross placenta and cause haemolytic disease of the newborn - as child is RhD+
How is haemolytic disease of the newborn caused?
Second child - who is RhD+.
Mum is RhD-. Exposed to RhD+ blood antibodies produced in pregnancy.
Rhesus D- antibodies cross placenta and cause haemolytic disease of the newborn - as child is RhD+
What is the purpose of doing a group and save blood test?
Determines patients ABO and Rh status.
Screens blood for atypical antibodies.
What is the purpose of doing a cross match blood test?
Mixing patients blood with donor blood to ID an immune response.
If there is no immune response, can issue the blood to the patient.
Who MUST be given cytomegalovirus (CMV) negative blood? And why?
WHO - Pregnant women, intra-uterine transfusing, neonates (up to 28days).
WHY - CMV is a common congenital infection which can cause sensorineural deafness and cerebral palsy.
Why are irradiated blood products used (i.e. blood from 1st or 2nd degree relatives)
To reduce the risk of graft-vs-host disease in at risk populations.
For administering blood products, when should observations be taken?
Before administering, 15-20mins after administration of blood, at 1 hour then at completion of administration. (However, NICE say give 1 unit in a surgical pt with no active bleeding then reassess).
What are the four types of blood products that can be given?
Packed red cells
Platelets
Fresh frozen plasma
Cryoprecipitate
In what circumstances should packed red cells be given?
In acute blood loss
In anaemia where Hb<70g/L or <100g/L in pts with CVD.
When should platelets be given?
In haemorhagica shock, profound thrombocytopenia, bleeding with thrombobytopenia, pre-op platelet feels of <50 x10(9)
What does fresh frozen plasma contain?
Clotting factors
What does Cyroprecipitate contain?
Fibrinigen, vWF, FVIII, Fibronectin.
When is FFP used?
DIC, haemorrhage secondary to liver disease, all massive haemorrages
When is cyroprecipitate used?
DIC with fibrinogen, vWF disease, massive haemorrhage
What are the three main categories of haemorrhage?
Primary bleeding, reactive bleeding, secondary bleeding
What clinical features would you look for in suspected haemorrhage?
Tachycardia, elevated RR, reduced urine output, increased cap refill, hypotension (v late sign)
What does NEWS2 measure?
RR, Oxygen sats, Systolic BP, Pulse rate, Level of consciousness or new onset confusion, Temperature
Why is NEWS2 score used?
Improve detection and response to clinical deterioration to critically ill patients
A pt has a score of 3 in one parameter of the NEWS2 score. What is your next management step?
Urgent review by ward based doctor to determine cause and decide on changing frequency of monitoring the patient./Escalate to critical care.
A patient is said to be high risk from their NEWS2 score. What score must they be on/above?
7 or above.
In initial resuscitation, what is involved in A of A-E assessment?
Talk to pt - if can talk - airway is patent. Examine the oropharynx - if liquid is present, can suction liquid out.
Can do jaw thrust. Use airway adjuncts
In initial resuscitation, what is involved in B of A-E assessment?
Listen to chest.
Sats?
RR?
Cyanosis
Chest deformity/chest asymmetry
O2 therapy - 15L/min through non-rebreath mask.
ABG/VBG
CXR
Wheeze? Give nebuliser salbutamol 5mg and ipratropium 500mg. Wheeze can be due to HF - so check fluid status.
Resp arrest - call cardiac team and use bag valve mask to oxygenate patient until they arrive
In initial resuscitation, what is involved in C of A-E assessment?
Cap refill, BP, pulse, assess limb temp, oliguria, 12 lead ECG.
Insert wide bore cannula and take blood from cannula.
Start IV fluid replacement - 500ml in less than 15mins of warm crystalloid solution
In initial resuscitation, what is involved in D of A-E assessment?
Check pupils, temp, blood glucose, AVPU. Electrolyte status - especially hyponatraemia
What can pin point pupils demonstrate, if seen during A-E?
Opiod toxicity
What is anisocoria a sign of?
Increasing intracranial pressure
When is naloxone used?
Opiod induced resp depression, bradypnoea or coma.
A patient has N&V post op. What are possible differentials?
Post op N&V due to anaesthesia Rising ICP (pls add more if you thought of something different pain opiate use infection ileus
In your A-E assessment, the patient you see is having a seizure. What is your 1st line treatment?
10-20mg PR diazepam (benzodiazepines)
What is main sign/symptom of post op fever?
Core body temp>38 degrees for 2 consecutive days
or
>39 degree for 1 day
What are 5Ws ? (causes of post op fever)
Wind - chest infection Water - urine infection Walking - VTE Wound - surgical site infection Wonder drugs - abx, anaesthesia, analgesia
Name a differential for post op fever?
Pyretic stress response of surgery
What are SIRS?
Systemic inflammatory response syndrome - an exaggerated defense response of the body to a noxious stressor.
What is involved in SIRS criteria?
Temp >38 0r <36.
HR > 90bpm
RR>20/min
WCC >12 or <4
How many of the SIRS criteria is required to diagnose SIRS?
At least 2.
How can severe sepsis be defined?
SIRS + Source of infection + organ dysfunction
complication of long term mechanical ventilation in trauma patient?
Trachea-Oesophageal fistula formation
How long before op should patient stop drinking fluids?
Can have clear fluids up to 2 hours before the op.
Presentation of malignant hyperthermia?
Often seen following administration of anaesthetic agents.
Hyperpyrexia
Muscle rigidity
Management
dantrolene - prevents Ca2+ release from the sarcoplasmic reticulum
Investigations of malignant hyperthermia?
- CK - will be raised
- Halothane caffeine contracture test (google this to find out how to do this)
Management of malignant hyperthermia?
Dantrolene sodium - given by rapid IV.
2-3mg/kg initially, then 1mg/kg repeated if needed (max of 10mg/kg per course)
This drug prevents Ca2+ release from the sarcoplasmic reticulum (as in malignant hyperthermia, get excessive release of Ca2+ which leads to contraction - i.e. muscle ridigity)
Causative agents of malignant hyperthermia?
- halothane
- suxamethonium
- other drugs: antipsychotics (neuroleptic malignant syndrome)
Pathophysiology of malignant hyperthermia?
- Caused by excessive release of Ca2+ from the sarcoplasmic reticulum of skeletal muscle
- Associated with defects in a gene on chromosome 19 encoding the ryanodine receptor, which controls Ca2+ release from the sarcoplasmic reticulum
- Susceptibility to malignant hyperthermia is inherited in an autosomal dominant fashion
Where are the following regional anaesthetic techniques administered?
- Spinal
- Epidural
- Field
- Spinal - injected into intrathecal space in the lower lumbar region usually at L3/L4
- Epidural - L4/5 epidural space via catheter and left for at least duration of surgery
- infiltrated into the inguinal region - e..g inguinal hernia surgery
What is the principal difference between general and regional anaestheisa?
General - agents that induce general anaesthetic act on the brain and therefore - “abolishes consciousness”
Regional anaesthesia- effect is limited to a region of the body. often give sedative drugs so not ‘awake’
Regional anaesthetic agents DO have an effect on the central nervous system - TRUE / FALSE
FALSE
DO NOT have an effect on CNS unless they are combined with a spinal anaesthesia.
What is the most commonly used local anaesthetic in regional anaethetics?
Bupivacaine
trade name Marcaine - long duration of action.
What is a peri-op assessment?
Used to determine pt’s ability and capacity to undergo stress of surgery
A time to optimise physiological condition by reversing or minimising effects of co-existing morbidities/ primary pathological process
What is included in peri-op assessment?
- General assessment:
History - comorbidites/PMH, previous surgery, tooth extractions
SH - religion and cultural practice
DH and allergies
Examine - pallor, dehydration, previous surgical scars, petechiae, purpura
Investigations e.g. U+Es etc - Haematological assessment:
O2 capacity of blood. Hb, anaemia check
Platelet count, peri-op bleeding before, FHx of bleeding disorders, blood thinners
VTE risk assessment
Cellular immune competence - is pt neutropenic?
What pre-op investigations are done to aid peri-op assessment?
FBC - Hb, platelets, WBC, Oxygen carrying capacity
Group and Save. Cross match (if high bleeding risk)
Why is it important to investigate for anaemia before surgery?
Anaemia = bleed more during surgery.
Poor wound healing
Name surgeries that are high bleeding risk?
Vascular Cardiothoracic Polypectomy Liver or spleen op Urological procedures
What is Group and save?
Blood sample taken from patient - confirms blood group and ant antibodies on the RBC.
Info is saved if needed for transfusion
What is Cross match?
Patient’s sample is mixed with sample from actual blood unit in the stock fridge = ensures compatibility.
How is haemostatic competence assessed?
Need to know whether a pt’s blood will clot in good time when surgeon makes cut.
Need to know Hx of bleeding/bruising (spontaneous) and of any bleeding disorders or unusual bleeding (e.g. menorrhagia)
Need to know current medications - DOAC, warfarin, aspirin, clopidogrel, steroids.
Need to know FBC, platelet count.
Which patient groups need a coagulation screen (PT, APTT, TT, Fibrinogen) before surgery?
- PMH of unusual bleeds
- post surgical or post-dental procedure bleeding
- unexplained persistent menorrhagia
- FHx of bleeding disorder
- Unexplained thrombocytopenia
- Emergecny Ops including pts with severe sepsis
What is involved when assessing need for post-op thromboprophylaxis ?
Patient factors
- Pt age
- BMI
- Personal or FHx of VTE
- Personal or FHx of thrombophilia
Factors related to the procedure
- Orthopeddic op
- plaster cast immobilisation
- spinal surgery
- pelvic operations
- prolonged anaesthesia
- op for malignancy
When are red cells used for transfusion?
In symptomatic and/or actively bleeding patients
What does red cell transfusion do in terms of Hb?
Increases oxygen carrying capacity
Replaces blood loss
When are platelets used for transfusion?
Prophylactically in non-bleeding pts with thrombocytopenia
Describe storage of red cells?
Stored at 4 degrees celcius
Stored for up to 35 days from collection
No platelets or coag factors
Describe storage of platelets?
Stored at room temp
Stored up to 7 days
Describe storage of FFP and Crytoprecipitate?
Stored at -30 degrees Celsius for 2 years
Use of FFP?
Contains clotting factors! Used in general coagulation factor deficiencies e.g. DIC
Use of Cryoprecipitate?
Source of fibrinogen and factor VIII
Dose of FFP?
10-15ml/kg
Dose of Cyroprecipitate?
10 units for adult
In blood, where are antigens present?
Red cells
In blood, where are antibodies present?
In plasma.
If a pt is blood group A, what antigens on RBC? What antibodies will be present in plasma?
Antigen A on RBC
Anti-B antibody in plasma
Antigens present on RBC for blood group AB?
Antigens A and B
Antibodies in plasma of pt with blood group ABO?
Anti-A and Anti-B
Clinical significance of ABO blood group?
ABO incompatible blood transfusion can be life threatening.
Causes intravascular haemolysis
A never event.
What does production of Alloantibodies depend on?
Immunogenicity
Recipients immune repsonse capability
Amount and frequency in transfusion
In what circumstance is all antibodies (Alloantibodies) produced ?
When pt is exposed to blood of a different group via transfusion in pregnancy
They are immune antibodies only produced following exposure to foreign blood cell antigens
How is sensitisation to Rh D and risk of haemolytic disease of the foetus and newborn prevented?
D negative (and K negative) girls and women of child bearing potential are NOT transfused with D or K positive red cells.
Note: this rule is overriden in an emergency
What is universal blood that can be given in emergency?
Group O negative
What are critical points in the blood transfusion process?
Decision to transfuse Prescription/request Pre-trasnfusion sampling of blood Lab testing on blood Collection of blood from storage site Bedside administration
Symptoms and signs of acute haemolytic transfusion reaction?
Fever Chills Hypotension Tachycardia Pyrexia Flank pain Haemoglobinuria
S+S of allergic reaction to foreign plasma proteins or antibodies to IgA?
Urticaria, pruritus, wheezing, hypotension, angiodema
Anaphylaxis reaction
What happens in febrile non-haemolytic transfusion reaction?
> 1˚C temp rise with no other medical explanation.
S+S of transfusion related acute lung injury (TRALI)?
Dyspnea, hypoxia, non-cariogenic pula oedema
Transfusion reaction symptoms?
Increase in temp 1.5˚C< Collapse Pain - chest, loin, back, extremities Rigors Anaphylaxis Shivering Hypotension Flushing SOB Burning or pain at the drip site Bleeding from drip site Non-specific deterioration Dizziness
How to manage acute transfusion reactions?
Based on S+S, and severity Stop the transfusion Do rapid clinical assessment - A-E Check pt ID and compatibilty Then assess whether mild, moderate or severe reaction and manage accordingly
How to optimise pt’s Hb before a scheduled surgery?
Oral iron
EPO
Consider stopping anticoagulant/antiplatelets
How to optimise pt’s Hb in surgery and post-op?
Cell salvage
Meds - tranexamic acid
What long term treatment to give pt with if they have VTE and no cancer?
ACCP guidance 2016 - DOAC !!
What long term treatment to give pt with if they have VTE and cancer?
LMWH
instead of DOAC
How to manage pre-op anaemia in pre-op clinic?
- correct any cause - B12, iron replacement, EPO injection
- may not need correction - B that or in minor op
- investigate underlying cause
- specialist pre-op anaemia clinic
- liaise with GP and other specialists and delay surgery
What needs to be considered in management of pre-op anaemia in an emergency setting?
Need to consider:
- current physiological state
- rate of fall in Hb
- anticipated blood loss
- underling co-morbidity e.g. cardiac disease.
Options for red cell transfusion in an emergency?
Packed red cells
Group specific (but non-crossmatched) blood
Group O- red cells
When should G&S be sampled within 28 days?
If patient has:
Never previously transfused
Last transfusion >3months ago
Not pregnant
No known red cell antibodies.
ASA 1 means?
ASA1: normal, healthy patient
ASA 2 means?
ASA2: A patient with mild systemic disease e.g. obesity, well controlled DM/HTN, smoker
ASA 3 means?
ASA3: A patient with severe systemic disease e.g. poorly controlled DM,HTN, COPD morbid obesity,
ASA 4 means?
ASA4: A patient with a severe systemic disease that is a constant threat to life e.g. recent MI, TIA, sepsis, ESRD not undergoing regular dialysis
ASA 5 means?
ASA5: Moribund patient, not expected to survive without the op e.g.ruptured AAA, massive trauma
ASA 6 means?
ASA6: A declared braindead patient who’s organs are being donated
