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Heme 2 > Transfusion CC > Flashcards

Transfusion CC Flashcards

1
Q

70 yo pt admitted with lower GI bleed, HgB of 5.0 and given 2 units blood; 2 hours in she has fever, chills, increased HR, slight anxiety, significant change in BP no dysnpea and back pain: what are our concerning symptoms and what should we do?

A

Stop transfusion

fever/ chills/ change in BP/ no worsening dysnpea all important to note

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2
Q 
Which of following arent related to fever in transfusion rxn?
A. FNHTR = Febrile Nonhemolytic
Transfusion Reaction
B. Hemolytic Transfusion Reaction
C. TACO = Transfusion Associated
Circulatory Overload
D. TRALI = Transfusion Related Acute Lung
Injury
A

C!!

All the other are related to fever!

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3
Q

List of DDx in fever after transfusion

A

Differential Diagnosis
• FNHTR = Febrile Nonhemolytic TransfusionReaction
• Hemolytic Transfusion Reaction
• Septic Transfusion Reaction
• TRALI = Transfusion Related Acute Lung Injury
• Related to underlying Disease in Patient
• Allergic Reaction (infrequent)

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4
Q

– Chills/rigors
– Fever (at least 1ºC or 2increase F elevation and ≥ 38ºC/100.4ºF)
– increased blood pressure; increased heart rate
– Hypotension not seen
– Headache, malaise, vomiting
– Back or chest pain

A

Febrile Nonhemolytic Transfusion Reaction

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5
Q

Febrile Nonhemolytic Transfusion Reaction
•____ of red cell transfusions
• Typically see in :
• Usually occurs at

A

0.5 -1.0 %
multiparous females or multi-transfused patients
end of transfusion or beginning of 2nd unit (if given back-to-back)

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6
Q

Cause of FNHT:
• Antibodies in recipient directed against :
—-Triggers phagocytes to release____ cause fever and chills or rigors

A

donor WBCs
endogenous pyrogens
*also caused by passive infusion of cytokines

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7
Q

Treatment - FNHTR

A

Antipyretics initially (DO NOT GIVE BENEDRYL)
• If significant rigors - 25-50 mg Demerol IV
• Often see resolution of fever and chills within 30 minutes of discontinuation of unit

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8
Q

Prevention of FNHTR for future transfusions-

A

Leukoreduced blood products

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9
Q

You remember that although hemolytic reactions are rare;
80% or more have predominant symptom of fever thus order a Transfusion Reaction workup to r/o Hemolytic
Reaction (in previous pt) You are told pt is peeing red and was given the wrong unit of blood! you suspect what?

A

Acute Hemolytic Transfusion Reaction

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10
Q 
Child bearing females who
are Rh(D) Negative Rh(D)  should Avoid
A

Rh(D)+ if at all possible

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11
Q

Incidence of Acute hemolytic transfusion reaction

A

Incidence:
– Approximately 1 in 40,000
– Fatal Acute HTR: 1 in 600,000 – 2,000,000

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12
Q

Whats happening in AHTR: Accelerated clearance of transfused red cells due to

A

red

cell incompatibility

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13
Q

Deaths from AHTR caused by ABO incompatibility are
declining; but ________increasing!
• Clerical/human errors major contributing cause!

A

non-ABO incompatibility

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14
Q

Signs/ Symptoms of AHTR

A
  • Fever, chills, nausea
  • “Impending doom”
  • Hypotension
  • Back pain, chest pain. orpain at infusion site
  • Hemoglobinemia, hemoglobinuria
  • Coagulopathy and/or DIC
  • Renal failure
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15
Q 
Labs in AHTR:
Coombs:
Hemolysis:
Bilirubin:
Haptoglobin
Hemoglobin:
LDH:
A 
Positive Direct Coombs – May be Neg if all transfused cells
destroyed
• Visible hemolysis in serum/plasma
• Increased Bilirubin
• Decreased haptoglobin
• Fall in hemoglobin; hemoglobinuria
• Increased LDH
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16
Q

Time relationship for clearance of Hgb and its
byproducts following acute hemolytic episode
Haptoglobin:
LDH:
Plasma HgB

A

Haptoglobin: immediate decline
LDH: Peak at 18 then decline
Plasma HgB; Peak at 6 then decline

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17
Q

Tx for Acute hemolytic Transfusion Reaction

A 
• Promote adequate renal blood flow
– Keep urine output >100mL/hr with
IVFs and IV diuretics, as necessary
• Support blood pressure with low dose dopamine, as necessary
• Administer platelets, FFP, and/or
cryoprecipitate as needed for DIC
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18
Q

Most common cause of ABO AHTR:

A

clincal error with 2/3 d/t pt misidentification

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19
Q

Shortly after start of FFP transfusion (only 40 mL
infused) your patient notices a couple hives on his
arm and then abruptly develops difficulty breathing
with wheezing. He becomes hypoxic (O2 sats drop
to 80% on RA) and his BP declines to 80/55 from
120/65. He remains afebrile
You suspect the patient is having a transfusion
reaction. What clues do we look at?

A 
Hives
hard to breath/wheezing
Hypoxic
Hypotension
afebrile
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20
Q 
Pt has:
Hives
hard to breath/wheezing
Hypoxic
Hypotension
afebrile
What do we suspect as transfusion related issue (pt from before)
A

Severe Allergic anaphylactic reaction

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21
Q

What symptoms are present in pts with Circulatory overload (TACO)?

A 
Dysnea
pulmonary edema
Hypertension
TAchycardia
Increased CVP
peripheral edema
responds to meds
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22
Q

When reaction presents with predominant symptom of dyspnea or SOB –
Your Top 3 Diagnosis Should Be:

A
  1. TACO = Transfusion Associated Circulatory
    Overload
  2. TRALI = Transfusion Related Acute Lung
    Injury
  3. Severe Allergic/Anaphylactic Reaction
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23
Q

leading causes for transfusion related fatalities reported to FDA

A
  • TACO and TRALI
24
Q

Symtoms we see in TRALI?

A 
Dysnea
pulmonary edema
HYPOtension
fever
tachycardia
25
Q

Telling difference btwn TRALI and TACO
CXR:
– Bilateral infiltrates? Yes
• Enlarged heart; vascular prominence :
• Normal heart size and vasculature :
– Unchanged or hyperinflated
Dx:

A

TACO

TRALI

Allergic/Anaphylactic

26
Q

Response to medication: ( to differentiate btwn SOB transfusions)
– Did symptoms improve or resolve?
• Quickly improve after steroids, antihistamines,
epinephrine :
• Improve after given Lasix (diuretic) 

A

Allergic/Anaphylactic

TACO

27
Q

Thrombotic microangiopathy

A non-specific pathogenic process seen in:

A

DIC
TTP/HUS
HTN

28
Q

Pt with TTP will have blood smear with:

A

schistocytes and spherocytes

29
Q

What do we see on PB smear in Vit B 12 deficiency

A

A. Bizaare RBC morphology
 Lack sharp points
B. Macro-ovalocytes
C. Hypersegmented neutrophil

30
Q

These three things all occur d/t what syndrome?
• Consumptive Thrombocytopenia
• Red Cell Fragmentation
- Hemolytic Anemia, hyperbilirubinemia
• Multiple organ ischemia

A

Microvascular occlusion syndrome

– Small vessel platelet aggregates

31
Q 
Labs suggestive of Thrombotic microantiopathy
CBC smear:
LDH:
Coagulation studies:
DAT, Coombs test:
A

CBC smear: abnormal
LDH: ELEVATED
Coagulation studies: nl
DAT, Coombs test: Negative

32
Q

Labs suggestive of Thrombotic microantiopathy
Haptoglobin:
Bilirubin
Creatinine:

A

Haptoglobin: Decreased
Bilirubin: Increased
Creatinine: +/-

33
Q

At what HgB level do we consider givng pt RBC transfusion?

A

When HgB is 6-8 IF symptoms are present

34
Q

• Anemia due to nutritional deficiency
– Iron deficiency
– Vitamin B12 or Folate deficiency
Should this pt get RBC transfusion?

A

Consider AVoiDING

35
Q

• Endocrine deficiency
– Chronic renal insufficiency
–should this pt get RBC transfusion

A

consider avoiding

36
Q 
Should teh below get RBC transfusion
• Hemolytic anemias if “compensated”
– Sickle Cell Anemia
– Autoimmune hemolytic anemia
– Paroxysmal nocturnal hemoglobinuria (PNH)
A

surprise, NO

37
Q 
Thrombocytopenia
Situations where prophylaxis is NOT recommended
• Consumptive states with thrombosis
– Heparin-induced thrombocytopenia
– Thrombotic thrombocytopenic purpura
• Consumptive states refractory to prophylaxis
– Immune thrombocytopenia
--WHen would I transfuse?
A

• Only transfuse for active bleeding

38
Q

Does this pt need transfusion?
Replacement of Plasma Proteins for hemostasis:
– Abnormal bleeding with documented
coagulopathy

A

YES

39
Q

Do we do transfusion for these pts?
– Multiple factor deficiency
• Liver Disease
• Vitamin K deficiency/reversal of warfarin
• DIC
• Isolated factor deficiency if no factor concentrate available
(factor XI)

A

YES

40
Q

Does this require prophyslaxsis plasma transfusion:
• Replacement Fluid in Therapeutic Plasma
exchange (TTP)

A

yes

41
Q

ADAMTS13 is usually very low in

A

TTP

42
Q

Absence of ADAMTS13 allows formation of unwanted

VWF/platelet thrombi: results in

A

• Resulting in microvascular obstruction

43
Q

efficacy of treatment of TTP

  1. ____ depletes auto-antibody to ADAMTS13
  2. Plasma infused during TPE replaces
  3. Immunotherapy suppresses____ production
A

TPE
ADAMTS13
auto-antibody

44
Q

Does this dude get plasma transfusion?
Nutritional coagulation defects
– Vitamin K deficiency or inhibition (warfarin)
• Supplement vitamin K or withhold warfarin
• If bleeding: consider prothrombin complex concent

A

NO

45
Q

• Coagulopathy due to an inhibitor
– Bleeding related to heparin, target-specific anticoagulants
Plasma transfusion?

A

NO

46
Q

Congenital defects where there is a concentrate
– Hemophilia, von Willebrand disease, AT deficiency
–Get a plasma transfusion?

A

NO

47
Q

What transfusion is used for the following:

– Fibrinogen, von Willebrand Factor, Factor XIII

A

Cryoprecipitate

48
Q

Fresh frozen plasma is used for:

A

– Myriad coagulation factors

49
Q

Platelets

– May or may not be necessary if you give cyro or FFP, why?

A

– Bleeding/oozing may cease once cryo and FFP are given

50
Q

If a patients INR increases while on Warfarin, what are some causes?

A

dietary or damage to bacterial flora
~ in this case pt started on antibiotics
(if you add this to poor diet, you can increase INR)

51
Q

• Two sources of Vitamin K

A
  • Dietary

* Synthesized by intestinal flora

52
Q

What effect can antibiotics have on Vit K

A

• Broad spectrum antibiotics can decrease
number of bacteria in intestine
• Coupled with poor diet, this can lead to
increased INR
• Frequently occurs in hospitalized patients
• Oral supplementation
• Add to parenteral nutrition

53
Q

What tx can we do for elevated PT/ INR

A
  • Hold or decrease warfarin dose
  • Replace Vitamin K
  • Replace coagulation factors
54
Q

If we were going to replace coag factors in pt with elevated PT or INR what would we give and why?

A

• Fresh frozen plasma – risks associated with
transfusion, large volume required
• Prothrombin complex concentrates – expensive,
concern for thrombosis, currently for patients who
are bleeding or cannot tolerate FFP

55
Q

In patient w/ artificial heart valve on warfarin with elevated INR, what is our best way to lower INR?

A 
• Hold warfarin dose, recheck INR before
restarting
• In a non-bleeding patient use the least
aggressive treatment with fewest side
effects
56
Q

What benefit would FPP or PCC offer pt with elevated INR?

What about Vit K?

A

temorary reversal

long term reversal, takes time

Heme 2 (14 decks)

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