- non infectious risks - Metabolized by liver - Rapid transfusion of large quantity of blood products - Binds calcium and magnesium–depleting stores - Myocardial depression - Coagulopathy

Topic 7 - Blood conversion Flashcards by Rachel ramella

Average units of blood used during heart surgery?

6 units of blood

6 units of platelets

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Average units of blood used during organ transplant?

40 units of blood
30 units of platelets
20bags of Cryo
25 units FFP

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% of open heart patients require transfusions

30-70%

Leads to 2-4 donor exposures

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% of RBC units transfused in US occur during

CABG procedures

10%

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Blood transfusions can lead to complications?

Lead to complications–post op infections, ventilator-acquired pneumonia, central line sepsis, Increased LOS, mortality rates

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Blood transfusions Infectious risks (3)

Bacterial
Hepatitis
HIV

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Blood transfusions non-Infectious risks (8)

febrile reactions
uticarial (allergic) reactions
anaphylactic reactions
acute hemolytic reactions
volume overload
hypothermia
citrate toxicity
potassium effects

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Febrile reactions

-non infectious
-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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uticarial (allergic) reactions

non infectious
1%
Urticaria, itching , flushing
Caused by foreign proteins

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Anaphylactic Reactions

non infectious
-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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Acute Hemolytic Reactions

Symptoms?

-Non infectious
-Caused by transfusion of ABO incompatible blood
-Chills, fever, pain, hypotension, dark urine,
uncontrolled bleeding due to DIC

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Hypothermia

-non infectious risks

Caused by transfusion of too many cold blood products

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Citrate Toxicity

non infectious risks
Metabolized by liver
Rapid transfusion of large quantity of blood products
Binds calcium and magnesium–depleting stores
Myocardial depression
Coagulopathy

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Potassium effects from bagged RBCs

-non infectious risks
-Stored RBC leak K+
-Irradiation increased the rate of leak ( irradiation is
the process or fact of irradiating or being irradiated)
-Cardiac effects

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TRALI (transfusion related acute lung injury)

– symptoms

Similar to ARDS

- Hypotension, Fever, Dyspnea, Tachycardia

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TRALI occurs within what time frame and how often?

-Occurs within 6 hours of tx
Most cases present w/in 1-2 hours
-Occurs 1/2000 transfusions

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TRALI (transfusion related acute lung injury)

Non-Cardiogenic pulmonary edema with diffuse bilateral pulmonary infiltrates on CXR

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TRALI attributed to?

Pathophysiology: Unclear.
Attributed to HLA Antibodies, Granulocyte
antibodies and biologically active mediators in the blood

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TRALI treatment?

Treatment: Ventilator support for ~96 hours
Mortality: 5-10%

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MULTIMODALITY and MULTIDISCIPLINARY

approach to patient care without the use of allogenic blood

Bloodless medicine

Transfusion Free

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Blood conservation

Global concept aimed at reducing patient exposure to allogenic blood products. Does not exclude use

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Surgeon Gerald Klebanoff (Vietnam Vet) introduced

the first cell saver in a military hospital

Recombinant Factor VIIa

For Hemopheliacs
Israeli army discovered potential to stop life
threatening hemorrhage

tolerance of anemia is ___ dependent

Age dependent
Elderly don’t tolerate
As age increases, risk of transfusion increases

Gender and transfusion

women are more likely than men to get transfused Lower hct and prone to blood loss with menses

Weight and Height affect on tranfusion?

Small patients and obese patients are at risk for transfusion

Pre-Op lab work

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

Treat Polycythemia pre-op

Risk of hemorrhage during surgery (hyperviscosity) | Plebotomy

Pre-op pharmacological coagulopathies to avoid ? (7 ish)

Drugs (not anticoagulants) than have increased bleeding risk NSAIDs, PCN, NTG, High dose Vitamin C, St. John’s Wort, Ginger, Garlic, etc.

Fluid administration

Restrict until surgical hemostasis is achieved | Intravascular pressure is not too high

Autologous Donation

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

pre-op autologous donation avoided | unless at least ...

2 weeks/unit of blood removed to regenerate lost RBC

Autodonation requires a hematocrit of what?

Requires a hematocrit of 33%

Autodonation contraindications (7)

``` Recent MI CHF Aortic Stenosis Transient Ischemic Attacks Hypertension Unstable Angina Bacteremia ```

Plateletpheresis and Plasmapheresis in Autodonation

Allows the donation of platelets and plasma

Prebypass autologous normovolemic hemodilution | - hct%

requires a hct of 35%

Prebypass autologous normovolemic hemodilution | -- removes how many mls? depending on what?

about 500-1000mL (1-3 units) Depends on starting hct Depends on age of patient Depends on BSA Depends on coexisting conditions

Prebypass autologous normovolemic hemodilution

- Used to remove blood from the patient pre-bypass for transfusion later in the case - Removed volume is replaced with crystalloid

Prebypass autologous normovolemic hemodilution | -- Contraindications (7)

``` COPD CHF CAD Unstable Angina Renal Insufficiency Severe Aortic Stenosis Coagulopathy ```

Prebypass autologous normovolemic hemodilution | -- reinfused when?

Reinfused after protamine is administered

retrograde autologous priming

Performed prior to bypass Arterial and venous cannula are in place Use the patient’s blood pressure to displace prime.

retrograde autologous priming | -- Remove prime via: (3)

- Stopcock on ALF - Arterial sampling manifold - Y’s in circuit

Dry venous line technique - - how? - - how much volume?

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

Dry venous line technique | --- Only works if

Only works if patient has adequate volume pre-op

Mini Circuits do? (3)

Decreases foreign surface area Decreases prime volume Decreases blood-air contact

Mini Circuit attempt to ? (3)

Decrease hemodilution Decrees inflammatory response Decrease volume shifts

Mini Circuits is 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

Mini Circuits prime volume ?

Prime volume is about 500mL | ◦Can be decreased with RAPing

Mini Circuits used mostly for what procedures?

CABG

Mini Circuits | -- 2 Types

Totally Integrated Devices | Combination of components

Mini Circuit: Totally Integrated Devices

Include air handling and elimination systems, centrifugal pump and membrane oxygenator. CorX (Cardiovention) Cobe Synergy

Mini circuit: Combination of components

MECC System (Jostra) MCPB DeltaStream ERP (Medos) Resting Heart System (Medtronic)

Mini circuit | Benefits: (5)

Less inflammatory reaction Less activation of coagulation and fibrinolysis Less hemodilution Less use of autologous blood Marginally improved renal and neurological function

Mini Circuit | variables impacting outcomes: (5)

``` steroids Aprotinin degree of heparinization type of tubing coating patient population ```