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Perf tech III > test 4 > Flashcards

test 4 Flashcards

1
Q

What is a significant predictor of mortality in cardiac surgery

A
  • RBC transfusion
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2
Q

AABB recommends

A
  • looking at symptoms rather than just the hgb number
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3
Q

Transfusion risks: Infectious

A

◦ Bacterial
◦ Hepatitis
◦ HIV

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4
Q

Transfusion risks: Non Infectious - Febrile Reactions

A

 Fever, chills
 Pt antibodies are reacting with white cell antigens or white cell fragments in the transfused blood products.
 -OR- due to cytokines which accumulate during storage.
 Most common with platelet transfusions

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5
Q

Transfusion risks: Non Infectious - Uticarial (Allergic) Reactions

A
  • rash
     1% of population
     Urticaria, puritis, flushing
     Caused by foreign proteins
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6
Q

Transfusion risks: Non Infectious - Anaphylactic Reactions

A

 Hypotension, tachycardia, cardiac arrhythmia, shock, cardiac arrest
 caused by patients who have IgA deficiency who have anti-IgA antibodies.
 Require special washed/ tested blood products

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7
Q

Transfusion risks: Non Infectious - Acute Hemolytic Reactions

A

 Caused by transfusion of ABO incompatible blood

 Chills, fever, pain, hypotension, dark urine, uncontrolled bleeding due to DIC

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8
Q

Transfusion risks: Non Infectious - Volume Overload

A
  • not seen on bypass
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9
Q

Transfusion risks: Non Infectious - Hypothermia

A
  • not seen on bypass

 Caused by transfusion of too many cold blood products

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10
Q

Transfusion risks: Non Infectious - Citrate Toxicity

A

 Metabolized by liver
 Rapid transfusion of large quantity of blood products
 Binds calcium and magnesium – depleting stores
 Myocardial depression
 Coagulopathy
- combat by giving Ca2+

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11
Q

Transfusion risks: Non Infectious - Potassium Effects

A

 Stored RBC leak K+
 Irradiation increased the rate of leak
 Cardiac effects
- combat by washing the cells or Z-buff

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12
Q

Transfusion Related Acute Lung Injury (TRALI)

A

◦ Symptoms: Similar to ARDS (Acute respiratory distress syndrome)
 Hypotension, Fever, Dyspnea, Tachycardia
◦ Non-Cardiogenic pulmonary edema with diffuse bilateral pulmonary infiltrates on CXR (chest xray)
◦ Occurs within 6 hours of tx
 Most cases present w/in 1-2 hours
◦ All blood products are culprits
◦ Occurs 1/2000 transfusions

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13
Q

Transfusion Related Acute Lung Injury (TRALI) Pathophysiology

A

 Pathophysiology: Unclear.
◦ Attributed to HLA Antibodies, Granulocyte antibodies and biologically active mediators in the blood.
 Treatment: Ventilator support for ~96 hours
 Mortality: 5-10%

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14
Q

Transfusions associated with:

A

◦ Longer hospital stays
◦ Longer time to extubation
◦ Morbidity
◦ Mortality

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15
Q

Techniques to help minimize our impact on blood usage?

A 
◦ Autologous transfusion
◦ Pre-bypass autologous donation
◦ Intraoperative Cell Saver use
◦ Shed mediastinal blood recovery
◦ Accept lower hematocrit
◦ Retrograde Autologous Priming
◦ Hemoconcentration
◦ Plasma/Platelet Pheresis
◦ Mini-circuits
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16
Q

Blood conservation techniques (2)

A

 Bloodless Medicine

 Blood Conservation

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17
Q

What is Bloodless Medicine

A

◦ MULTIMODALITY and MULTIDISCIPLINARY approach to patient care without the use of allogenic blood.
 AKA: Transfusion-Free Medicine
- USE EVERYTHING IN YOUR POWER TO NOT GIVE TRANSFUSION

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18
Q

What is Blood Conservation

A

◦ Global concept aimed at REDUCING (doesn’t exclude the use) patient exposure
to allogenic blood products. Does not exclude use.

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19
Q

History of giving blood

A

 Bloodless medicine used to be associated with Jehovah’s Witnesses
 Jehovah’s Witnesses refrain from accepting blood products due to religious beliefs
 Now Bloodless Medicine is used b/c studies have shown better patient outcomes

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20
Q

History of giving blood with Jehovah’s Witnesses

A

 Jehovah’s Witnesses decision to refuse blood was religious, but they used scientific information regarding the side effects.
 A Booklet Blood, Medicine, and the law of God (1961) addressed the issues related to tx:
◦ Transfusion reactions
◦ Transfusion related syphilis, malaria, hepatitis

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21
Q

1960’s

A

 1960’s – Not easy to refuse blood on religious grounds
◦ Frequently obtained court orders to give blood
 JW Representatives started meeting with doctors to explain why transfusions were refused
◦ Offered literature with techniques JWs accepted
◦ “Transfusion alternatives”
- it must be one continuous circuit and needs to be primed

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22
Q

Denton Cooley (Early 1960’s)

A

 Published article in the American Journal of Cardiology (1964) titled Open heart surgery in the Jehovah’s Witness”
 Described his techniques for treating these patients
 1977 – reported experience with 500 JW patients
 Adoption of bloodless surgery spread worldwide
 Not a particular technique, but the spirit and attitude toward the approach

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23
Q

Military and blood management

A

 Did surgery on wounded soldiers before transfusions were even available
 Confronted with blood loss, but no way to replace the blood
◦ Stopped the hemorrhage promptly and effectively
◦ Avoid further blood loss
 Surgical skill is a major factor in need of blood!!

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24
Q

World War I

A

◦ Blood Anticoagulation
 Allowed for transport of blood to the wounded
 PROBLEM: Storage!

25
Q

World War II

A

◦ Storage problem overcome with the advent of blood banks

26
Q

Military and blood management: 1953

A

 Use of blood alternatives
◦ Switched from plasma to Dextran (volume expander)
 Sugar substrate
 Due to incidence of hepatitis transmittal

27
Q

Military and blood management: 1985

A

 Started looking into “blood substitutes”

◦ Searched for oxygen carrier

28
Q

Military and blood management: Introduction of Cell Savers

A

◦ Surgeon Gerald Klebanoff (Vietnam Vet) introduced the first cell saver in a military hospital.

29
Q

Military and blood management: Recombinant Factor VIIa

A

◦ Hemopheliacs

◦ Israeli army discovered potential to stop life threatening hemorrhage

30
Q

What you need for a bloodless management program

A

 Hospital Commitment
- EVERYONE (Administration, Physicians, Nurses, etc.)
 Coordinator to recruit physicians dedicated to the mission in a variety of specialties

31
Q

What can be done pre-op: Obtain a focused history

A

◦ Age – tolerance of anemia is age dependent
 Elderly don’t tolerate
 As age increases, risk of transfusion increases
◦ Gender – women are more likely than men to get transfused
 Lower hct and prone to blood loss with menses
◦ Weight/Height – required to do calculations
 Small patients and obese patients are at risk for transfusion
 Race/ Ethnicity/ Background/ Religion
 Anemia and Coagulation disorders are associated with certain races

32
Q

What can be done pre-op: Ask about patient-related obstacles to transfusion-free therapy

A 
◦ Anemia
◦ Hemostatic disturbances
◦ Medical conditions increasing perioperative blood loss
◦ Obstacles to surgical hemostasis
◦ Factors decreasing anemia tolerance
33
Q

What can be done pre-op: Lab work

A

◦ Hgb
◦ PT/INR / PTT
◦ Platelet Count and Platelet Function Tests

34
Q

What can be done pre-op: Treat any anemia

A

◦ Optimize Hgb prior to surgery

35
Q

What can be done pre-op: Treat Polycythemia (increased number of red blood cells in the blood)

A

◦ Risk of hemorrhage during surgery (hyperviscosity)

◦ Plebotomy

36
Q

What can be done pre-op: Avoid pharmacological coagulopathies

A

◦ Drugs (not anticoagulants) that have increased bleeding risk

37
Q

What can be done pre-op?

A 
 Obtain a focused history
 Ask about patient-related obstacles to transfusion-free therapy
 Lab work
 Treat any coagulopathies
 Treat any anemia
 Treat Polycythemia
 Avoid pharmacological coagulopathies
38
Q

Anesthesia resource to help blood management

A

 Help correct any coagulopathies/anemia preop.
 Help position the patient to decrease blood loss
 Provide controlled hypotension
 Keeping patient warm
◦ Optimizes clotting
 Choice of Drugs
 Timing of fluid administration
◦ Restrict until surgical hemostasis is achieved
 Intravascular pressure is not too high

39
Q

Autologous Donation

A

◦ Donation where the donor and recipient are identical
 Patient donates blood to be used on themselves during surgery.
 Avoids use/ risks of donor blood
 May not be practical or cost effective for most cardiac surgeries
 Requires a hematocrit of 33%
 Donation of whole blood can be split
◦ Allows not only donation of RBC, but also FFP
◦ Requires special order from physician
 Plateletpheresis and Plasmapheresis
◦ Allows the donation of platelets and plasma

40
Q

Autologous Donation Contraindications

A 
◦ Recent MI
◦ CHF
◦ Aortic Stenosis
◦ Transient Ischemic Attacks
◦ Hypertension
◦ Unstable Angina
◦ Bacteremia
41
Q

Prebypass autologous normovolemic hemodilution

A
  • donate to yourself but do not change your volume by adding crystalloid
     Spares platelets from bypass
    ◦ Retain/ preserve function
     Requires a hct of 35%
     Remove about 500-1000mL (1-3 units)
    ◦ Depends on starting hct
    ◦ Depends on age of patient
    ◦ Depends on BSA
    ◦ Depends on coexisting conditions
     Blood is placed in a bag with anticoagulant
    ◦ Usually CPD (citrate-phosphate-dextrose)
     Reinfused after protamine is administered
42
Q

Prebypass autologous normovolemic hemodilution Contraindications

A 
◦ COPD
◦ CHF
◦ CAD (CABG)
◦ Unstable Angina
◦ Renal Insufficiency
◦ Severe Aortic Stenosis
◦ Coagulopathy
43
Q

Retrograde autologous priming (RAP)

A

 Performed prior to bypass
 Arterial and venous cannula are in place
 Use the patient’s blood pressure to displace prime.
 Remove prime via:
◦ Stopcock on ALF
◦ Arterial sampling manifold
◦ Y’s in circuit
 Can be done quickly
 Must closely watch patient’s pressures
◦ Remove about 200-600mL of Prime

44
Q

Dry venous Line

A

 Requires the use of VAVD
 Venous line is emptied prior to connection to
the venous cannula
 Volume is removed to a bag and discarded or
sequestered
 Eliminates about 400-1000mL
 Cautions:
◦ Only works if patient has adequate volume pre-op
◦ If patient is dry (not a lot of volume), will need the volume anyways

45
Q

Mini-circuits

A 
 AKA: Miniaturized Extracorporeal Circuits
 Decreases foreign surface area
 Decreases prime volume
 Decreases blood-air contact
 Attempt to:
        ◦ Decrease hemodilution
        ◦ Decrees inflammatory response
        ◦ Decrease volume shifts
46
Q

What are mini-circuits

A

 Closed A-V Loop with centrifugal pump, membrane oxygenator, coated tubing
◦ No venous reservoir
◦ No cardiotomy
◦ Often no heat exchanger or arterial line filter
◦ Centrifugal pump provides kinetic assisted venous drainage and blood flow
 Prime volume is about 500mL
◦ Can be decreased with RAPing
 Used mostly for CABGs
◦ Some valves have been done

47
Q

Types of Mini-circuits (2)

A

◦ Totally Integrated Devices
 Include air handling and elimination systems, centrifugal pump and membrane oxygenator.
◦ Combination of components

48
Q

Benefits of Mini-circuits

A

◦ Less inflammatory reaction
◦ Less activation of coagulation and fibrinolysis
◦ Less hemodilution
◦ Less use of autologous blood
◦ Marginally improved renal and neurological function
 Results in the studies are mixed

49
Q

Concerns of Mini-circuits

A

◦ Air handling
◦ Requires surgeon to take care to avoid air entrapment around the cannula
◦ More microemboli with MECCs compared to normal circuits
◦ No reservoir = no way to handle excess volume
◦ No immediate volume infusion
◦ No heat exchanger (on most)
◦ Use of separate cell saver (Delay in processing, loss of factors/platelets)
◦ Increased cost
◦ Adaptability when surgical complications/ need requires normal ECC

50
Q

Ways of making our regular circuits mini without using a mini-circuit

A 
 Cut lines short
 Get as close to the table as possible
 Elevate the reservoir
        ◦ Use VAVD
 Put modular pump heads near outlet/inlet of oxygenator
 Dry venous line
        ◦ Requires VAVD
 Go on with low prime volume
51
Q

Ultrafiltration / Hemoconcentration

A

 Filtration of water across a semipermeable membrane via hydrostatic pressure gradient
 Water crosses the membrane which creates a solute concentration gradient
 Solutes have a higher concentration in blood so they move to the water side which has a lower solute concentration
 So, we’re removing “water”
 And electrolytes

52
Q

Modified Ultrafiltration (MUF)

A

 Withdrawing blood from the patient via the arterial line (post bypass)
 Running the blood through a hemoconcentrator
 Pumping the blood back into the patient via the venous line.
 Can use the cardioplegia circuit
◦ Make sure to flush out the cardioplegia solution with blood
◦ Pump flow rate less than MUF flow rate

53
Q

Cell Salvage intraoperative

A

 Use heparinized saline or CPD as an anticoagulant
 Cells are separated from the fluid by a centrifuge
◦ RBC fall to the bottom, Plasma on top
 RBC washed with 3x bowl volume (min)
 Put in a reinfusion bag for administration
 Removes: Fat, air, tissue debris, potassium, hormones, bioactivators, etc.

54
Q

Limitations of cell salvage

A 
◦ Delay in processing
◦ Loss of plasma proteins
◦ Loss of coagulation factors and platelets
◦ Expense
◦ Operator attention and time
55
Q

Reinfusion of shed blood

A

 Blood collected from the mediastinum and pleural cavities post op can be reinfused
◦ Doesn’t clot due to defibrination
◦ Increased level of free Hgb
◦ Contains activated products
 ***NOT ideal
◦ Used in urgent situations
◦ Can be processed

56
Q

Cardiopat

A

 Shed blood can be collected and processed by a cell processing device – Cardiopat
 Uses a dynamic disk to process.
◦ Processes a variable volume of blood
 Consistently delivers washed RBCs w/ hct of 70-80%
 Processes up to 2 liters per hour or as little as 5 mL of RBCs

57
Q

ACCEPTANCE OF LOWER HEMATOCRIT

A

 Acceptable level varies by institution
 Healthy, Good LV Function
◦ Tolerate 20-25%
 Those with limited coronary flow, increased metabolic needs, respiratory issues will require increased hematocrits

58
Q

Overall conclusion for blood conservations

A

 Blood conservation is a team approach
 Everyone involved in each step of a patient’s care need to be on board
◦ Primary care physicians, nurses, surgeons, anesthesiologists, perfusionists, residents/ fellows
◦ One player not on board can significantly alter the course of that patient’s care.

Perf tech III (55 decks)

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