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Pharmacology > Transfusion and Anticoagulants > Flashcards

Transfusion and Anticoagulants Flashcards

1
Q

What are the three goals of blood transfusion?

A
  1. increase oxygen carrying capacity
  2. restore volume
  3. maintain hemostasis
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2
Q

What value of hemoglobin is blood transfusion always indicated?

A

<6

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3
Q

Which type of transfusion has less risk and there may be administer more liberally?

A

Autologous

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4
Q

What impact does giving PRBC’s have on coagulation factors?

A

Dilutes coagulation factors. Give together with RBCs.

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5
Q

What labs monitor coagulopathy?

A

PTT, Pt/INR, platelet count, fibrinogen, TEG

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6
Q

What side effects of massive transfusion also complicate bleeding?

A

hypothermia and acidosis

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7
Q

Platelet counts of <50,000 cause what complication?

A

microvascular bleeding, requiring replacement

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8
Q

What blood product is used for urgent warfarin reversal?

A

FFP

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9
Q

What blood product is used to treat vW disease when patients are unresponsive to DDAVP?

A

Cryoprecipitate

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10
Q

What type of transfusion is when a patient donates their own blood in the weeks leading up to surgery to be administered if needed?

A

Preoperative Autologous donation

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11
Q

What are some risks/complications of Pre-op autologous transfusion?

A

bacteremia, hemolytic, allergenic, and antigenic reactions, anemia, incorrect blood administration.

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12
Q

What type of transfusion involves extracting several units of blood prior to incision and then replacing volume with crystalloids or colloids?

A

Acute normovolemic hemodilution

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13
Q

What are the benefits of acute normovolemic hemodilution?

A

normal Hct and clotting factors, no risk of contamination, storage problems or incorrect transfusion.

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14
Q

What type of transfusion involves collection of shed surgical blood that is filtered/washed and reinfused?

A

intraoperative blood salvage (cell saver)

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15
Q

What is the range of Hct we will see with administration of cell saver?

A

50-80%

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16
Q

What is the benefit or cell saver over banked blood?

A

better O2 carrying capacity

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17
Q

What does type and screen identify?

A

ABO and Rh group, expected antigens

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18
Q

What does type and crossmatch identify?

A

incompatibility between donor and recipient blood, by mixing them together.

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19
Q

How do antibodies and antigens interact?

A

Antibodies in the plasma of one blood type will react with the antigens on RBC surface of another

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20
Q

What are the two types of antigens?

A

AB antigens and the Rh system

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21
Q

What makes AB blood the universal recipient?

A

AB blood has both A and B antigens on the RBCs, and lack anti-A and anti-B antibodies`

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22
Q

What makes O blood the universal donor?

A

Type O blood lacks any of the AB antigens and has both A and B antibodies in the serum

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23
Q

What happens when Rh factor positive blood is given to an individual with Rh negative blood?

A

Anti-Rh agglutinins develop slowly. No reaction the first time, but second time exposure causes a reaction.

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24
Q

An Rh-positive babies with Rh-negative mothers carry a risk of developing what?

A

Erythroblastosis Fetalis, where agglutination and phagocytosis of fetal RBC’s occur

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25
Q

What do hemolyzed RBCs cause?

A

jaundice, anemia and kernicterus

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26
Q

What is the most common risk of transfusions?

A

non hemolytic reaction

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27
Q

How do we treat non hemolytic reactions?

A

anti-inflammatory and antipyretic

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28
Q

What are the sigs of major allergic reactions?

A

hemodynamic instability, bronchospasm, rash, flushing, angioedema

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29
Q

What does transfusion of mismatched blood lead to?

A

hemolytic reaction with agglutination of the donor blood and not the recipients blood

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30
Q

What is the most common infectious risk with blood transfusions?

A

cytomegalovirus

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31
Q

How do you differentiate TRALI from TACO?

A

TACO has left atrial HTN, PAOP <18

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32
Q

What are the two phases of TRALI?

A

1st is inflammatory response to stress with pulmonary sequestration of neutrophils, 2nd is neutrophil activation by transfusion, capillary leakage

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33
Q

How do we treat TRALI?

A

100% O2, max PEEP, low Vt, avoid volume overload

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34
Q

How do we treat TACO?

A

diuretics, afterload reduction

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35
Q

What happens to 2,3 DPG levels with long storage times?

A

decreases DPG levels, (less O2 carrying capacity)

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36
Q

Why can transfused PRBCs lead to Ventricular arrhythmia and arrest?

A

high levels of potassium

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37
Q

Citrate accumulation in the plasma from transfusion can result in what electrolyte derangement?

A

hypocalcemia

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38
Q

What affected does temperature have on coagulation?

A

coagulability decreases 10% for every 1 degree celsius drop in temperature

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39
Q

What blood product is Indicated for bleeding, and

Increases O2 carrying capacity?

A

Red Blood Cells

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40
Q

1 unit of PRBCs will increase Hgb and Hct by how much?

A

Hgb by 1 gram

Hct by 2-3%

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41
Q

What is the concentration of hematocrit in one unit of PRBCs?

A

60-80%

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42
Q

What blood product is indicated for PT/PTT >1.5x normal with bleeding, Massive blood transfusions, vitamin K deficiency, reversal of warfarin, von Willebrands, AT3 def

A

FFP

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43
Q

What blood product contains all clotting factors and inhibitors, and antithrombin III?

A

FFP

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44
Q

What is the dose of FFP? Dose for warfarin reversal?

A

10-15mL/kg

5-8mL/kg for warfarin

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45
Q

Coagulation factors need to be within what percentage of normal to produce adequate coagulation?

A

25%

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46
Q

What blood product is indicated for massive blood transfusion and active bleeding

A

Platelets

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47
Q

What is the most common cause of post-op bleeding?

A

platelet dysfunction

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48
Q

What is the dose of platelets?

A

1 unit/10kg of body weight.

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49
Q

1 unit of platelets increases the level of platelets in the body by how much?

A

5,000-10,000

50
Q

Which blood product has the highest rate of bacterial contamination due to storage temperature?

A

Platelets

51
Q

Which blood product is indicated for von Willebrands unresponsive to DDAVP, fibrinogen deficiency, and microvascular bleeding?

A

Cryoprecipitate

52
Q

What coagulation factors does Cryoprecipitate contain?

A

Factor 1, vWF, 8, and 13

53
Q

1 unit/5kg will raise fibrinogen by how much?

A

100 mg/dL

54
Q

What is the most common inherited coagulation disorder?

A

Von Willebrands Disease

55
Q

What are the two main function of vWF?

A

facilitate platelet adhesion, plasma carrier for factor 8

56
Q

Von Willebrands Disease will have deficiencies in which coagulation factors?

A

vWF and factor 8

57
Q

Which type (1,2 or 3) of vWD will cause spontaneous bleeding?

A

type 3

1 and 2 cause bleeding if surgery or trauma

58
Q

What is the treatment of choice for vWD?

A

DDAVP. It increases plasma levels of vWF and augments platelet aggregation

59
Q

What blood product can be given for more severe forms of vWD?

A

cryoprecipitate or recombinant factor 8, vWF concentrate

60
Q

Which type of hemophilia is a deficiency in Factor 8?

A

Hemophilia A

61
Q

How do we treat hemophilia A?

A

DDAVP, FFP, cryoprecipitate

62
Q

Which type of hemophilia is a deficiency in Factor 9?

A

Hemophilia B

63
Q

How do we treat hemophilia B?

A

FFP, factor 9 concentrate

64
Q

Which type of hemophilia is a deficiency in Factor 11?

A

hemophilia C

65
Q

How do we treat hemophilia C?

A

FFP, or factor 11 concentrate

66
Q

What are some common complications that happen to people with hemophilia?

A

spontaneous bleeding, muscle hematoma, pain at joints from bleeding

67
Q

What lab derangements of aPTT, PT and bleeding time will occur with hemophilia?

A

prolonged aPTT, normal PT and bleeding time

68
Q

What type of hemophilia can occur with connective tissue disorders, pregnancy, or malignancy and stems from antibody production against FVIII?

A

acquired

69
Q

what are the side effects of liver disease related to coagulation?

A

thrombocytopenia, decrease in clotting factors made in the liver, and a decrease in protein C, S, and antithrombin III

70
Q

Patients with liver disease will have increased levels of which clotting factors?

A

8, vWF (up regulation)

71
Q

Will aPTT and PT be accurate representations of the patient with liver disease coagulability? what is used?

A

no. Use viscoelastography

72
Q

What is DIC?

A

Systemic coagulation disorder with systemic inflammation and coagulation

73
Q

DIC causes multi-organ failure due to what?

A

widespread microvascular clotting

74
Q

What causes DIC?

A

Ineffective tissue factor pathway inhibitor and antithrombin

75
Q

What is the preferred treatment for DIC?

A

platelets

76
Q

Should you treat DIC with anticoagulants?

A

yes, especially early

77
Q

How does UFH and LMWH exert their anticoagulant effect?

A

binding with antithrombin and enhancing antithrombin 1000X

78
Q

What pathway(s) do the Heparins inhibit and what factors?

A

Common and Intrinsic

2, 9, 10, 11, 12

79
Q

How is heparin monitored intra-op?

A

ACT

80
Q

What are the LMWHs?

A

enoxaparin, and dalteparin

81
Q

LMWHs can cause what with epidural catheters or repeated spinal/epidural anesthesia?

A

spontaneous hematoma

82
Q

What is the most important compilation of heparin therapy?

A

HIT

83
Q

What are the presenting symptoms of HIT?

A

thrombocytopenia, resistance to heparin, and thrombosis

84
Q

Which type of HIT is more severe?

A

Type 2, heparin dependent IgG antibodies produced

85
Q

What anticoagulant can be used as a alternative for patients with a history of HIT?

A

fondaparinux

86
Q

When do you stop fondaparinux prior to surgery?

A

4 days

87
Q

What is the class, MOA, and surgical stop time of bivalrudin?

A

Direct thrombin inhibitor
inhibits thrombin
stop 4-6 hours prior

88
Q

What is the class, MOA, and surgical stop time of argatroban?

A

direct thrombin inhibitor
inhibits thrombin
stop 4-6 hours prior

89
Q

What is the class, MOA, and surgical stop time of Lepirudin?

A

direct thrombin inhibitor
inhibits thrombin
stop 24 hour prior

90
Q

What is the class, MOA, and surgical stop time of desirudin?

A

direct thrombin inhibitor
inhibits thrombin
stop 24 hours prior

91
Q

What is the class, MOA, and surgical stop time of Dabigatran?

A

direct thrombin inhibitor
inhibits thrombin
stop 2-4 days prior

92
Q

What is the most frequently used anticoagulant?

A

Warfarin

93
Q

What is the class, MOA, and surgical stop time of warfarin?

A

Vitamin K antagonist
Inhibits vitamin K epoxide reductase which converts vitamin K dependent coagulation factors to their active form (II, VII, IX, and X)
Stop 3-5 days prior

94
Q

How is warfarin metabolized?

A

metabolized into active compounds

95
Q

What inhibits and potentiate warfarin therapy?

A

dietary vitamin K (leafy greens) inhibits

liver disease, old age, alcohol potentiate

96
Q

What is the goal INR for patients on warfarin?

A

2-3

97
Q

What is the class, MOA, and surgical stop time of rivaroxaban?

A

Direct factor Xa inhibitor
inhibit free, clot bound, and bound to prothrombinase complex Xa
stop 1-2 days prior

98
Q

What is the class, MOA, and surgical stop time of apixaban?

A

Direct factor Xa inhibitor
inhibit free, clot bound, and bound to prothrombinase complex Xa
stop 1-2 days prior

99
Q

When can a epidural catheter be removed after giving a direct factor X inhibitor?

A

18 hours after the last dose, or 6 hours prior to the next dose

100
Q

What class of drugs are the mainstay treatment for patients with atherosclerotic disease and CAD?

A

platelet inhibitors

101
Q

What is the class, MOA, and surgical stop time of aspirin?

A

platelet inhibitor
irreversibly acetylates cyclooxygenase, preventing the formation of prostaglandin & thromboxane A2
stop 7-10 days prior

102
Q

What is the class, MOA, and surgical stop time of the thienopyridines (clopidogrel, prasugrel, and ticagrelor)?

A

Platelet inhibitors
bind to P2Y12 receptors blocking ADP binding mediated platelet activation and aggregation
stop 7 days prior, avoid regional

103
Q

What is the class, MOA, and surgical stop time of Abciximab?

A

Platelet Inhibitors
bind and competitively inhibit the IIb/IIIa binding sites of fibrinogen to platelets
stop 72 hours prior

104
Q

What is the class, MOA, and surgical stop time of tirofiban, eptifibatide?

A

Platelet Inhibitors
bind and competitively inhibit the IIb/IIIa binding sites of fibrinogen to platelets
stop 24 hours prior

105
Q

What is the class, MOA, and surgical stop time of Streptokinase, urokinase, and tPA ?

A

Fibrinolytics
activate plasminogen to plasmin which degrades fibrin and factors V and VIII
stop 1-3 hours prior

106
Q

What drugs are the antifibrinolytics?

A

Aminocaproic acid, TXA, aprotinin

107
Q

What is the MOA of anti-fibrinolytics?

A

competitively inhibit activation of plasminogen to plasmin

108
Q

What is the drug class of choice for mucosal bleeding from nose, oropharynx, and genitourinary tract because something the secretions contain?

A

antifibrinolytics

109
Q

What is a significant complication of TXA administration?

A

seizures

110
Q

Why is TXA thought to cause seizures?

A

blockade of GABA receptors in the frontal cortex

111
Q

Which medication forms an ionic bond with and neutralizes UFH?

A

Protamine

112
Q

What type of reaction is the one between heparin and protamine?

A

chemical antagonism

113
Q

What is the dose of Protamine?

A

1mg/100 units of heparin

114
Q

What dose of Protamine would you give if you previously gave 5,000 units of heparin?

A

50 mg

115
Q

Why should we try to avoid excess administration of protamine?

A

has some anticoagulant effects on its own by inhibition of platelets and serine proteases

116
Q

Why might you have to redose protamine?

A

Heparin rebound, short half life. Bump with 5-15mg.

117
Q

Why do we administer Protamine slowly?

A

histamine release from mast cells can cause hypotension

118
Q

Which patients have an increased risk of anaphylaxis with protamine?

A

Allergy to fish, NPH insulin use, prior exposure to protamine, vasectomy

119
Q

What is Desmopressin?

A

V2 analog of arginine vasopressin.

120
Q

What does Desmopressin do?

A

stimulates the release of vWF from endothelial cells

121
Q

What patients are treated with DDAVP?

A

Hemophilia A, vWD

122
Q

What is the dose of DDAVP?

A

0.3mg/kg over 15-30 minutes

Pharmacology (6 decks)

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