Transfusions - Exam 4 Flashcards
T/F The leading cause of transfusion-related morbidity and mortality is infections
false!
-TRALI
Most commonly transfused blood product is _
RBCs
A transfusion ratio of 2:1:1 would include how any of which blood component?
2 units of plasma
1 unit of platelets
1 unit of PRBCs
T/F Transfusion ratios are ratios of blood components to be given, including plasma, cryoprecipitate, and PRBCs.
false
-platelets, not cryo
What does the following sentence define?
“The timely application of evidence-based medical and surgical concepts designed to maintain hemoglobin concentration, optimize hemostasis, and minimize blood loss in an effort to improve patient outcomes.”
Patient Blood Management (PBM)
-modern method to consider transfusions; acknowledges transfusions are a band-aid on a larger, multifactorial, underlying issue
-has reduced the dependence on allogenic blood admin after its implementation
T/F The WHO provides regulatory oversight for blood banks and donation centers within the US
False
-FDA Center for Biologics Evaluation and Research
T/F The WHO stands in support of financially incentivized blood donation due to continuous blood shortages
False
-WHO is strongly against paid blood donations/involuntary donations; may pose a risk to blood product safety
Minimum age and weight in the US to be considered as a potential blood donor:
16yo
110lbs
Hgb levels that are acceptable for blood donation are _ g/dL in men and _g/dL in women
13g/dL in men
12.5g/dL in women
2 ways in which blood that is donated is collected:
-whole blood separated by a centrifuge or apheresis
_ as a donation collection method is helpful for donors with type _ blood bc they are universal plasma donors and can donate plasma more frequently while having their red cells returned
Aphaeresis
AB
T/F Pts with type AB blood can only receive blood from AB donors
False
-AB is a universal recipient
How does blood donor screening protect both the recipient and the donor?
-reduce risk of transfusion transmissible diseases
-helps donor avoid adverse reactions from donation
Medical history causes for deferment of blood donation:
-significant travel history
-history of IV drug abuse
-recent tattoos
-men who have sex with men (MSM) in last 12 months - recent HIV epidemiology is changing to a point where this is being reconsidered
Which disease is tested specifically in first-time donors that are not included in following blood donation tests?
Chagas disease (Trypanosoma Cruzi)
_ _ _ detects the Zika virus RNA in donor blood and is mandated by the FDA.
Nucleic Acid Test (NAT)
Using _ _ technology has decreased the window of infectivity (time of being infected to a positive test result) which is a major reason for the decrease in infectivity with hepatitis, HIV, west Nile, and Zika.
Nucleic acid
Infectious Agents tested in blood donations as of 2018
-HIV(1+2)
-Human T Lymphotropic virus (HTLV)
-hepatitis c (HCV)
-hepatitis b (HBV)
-west Nile (WNV)
-Zika
Primary concern with infectious agents from blood transfusion is hepatitis:
Hep B
Hep C (most often)
Sometimes Hep D
Less than 1/3 of these pts will develop jaundice
T/F A pt with a history of Hep B can donate but not Hep C
False
Neither can donate, regardless of their cured status
Antiviral drugs that can slow the progression or even cure certain genotypes of Hep C include:(4)
Mavyret
Harvoni
Epclusa
Vosevi
Cytomegalovirus (CMV) is a double-stranded DNA virus belonging to the _ family and is common in healthy adults.
herpesviridae
T/F Cytomegalovirus comes from mice and is transmitted thru infected surfaces.
false
-exclusive to humans
-spread via body fluids of individual with history of infection
Cytomegalovirus persists in its latent phase in the ______ of people with antibody evidence of previous infections
monocytes
T/F: cytomegalovirus seroconversion typically occurs within the first infectious transfusion
False, usually takes multiple transfusions
Primary blood product recipients at risk for CMV are:
Pts who have had multiple pregnancies, immaturity, and immunosuppression.
CMV-safe blood components include:
Plasma
FFP
cryoprecipitate
leukoreduced components from positive donors
When giving blood to preterm and newborn infants, use _____ blood
CMV-seronegative
Zika is transmitted via ________ and is associated with ______ syndrome and ______ in newborns whose mothers were infected during pregnancy.
Mosquitos
Guillain-Barre
Microencephaly
Y. Enterocolitica is a bacteria that can thrive in blood stored at ____ in ____buffers
4 Deg C
Phosphate
Syphilis is most likely to be transmitted via which component?
Platelets because they’re stored at room temp
Infectious diseases of concern that theoretically can be transmitted via transfusions:
Y Enterocolitica
Syphilis
Malaria
Chagas
Variant Creutzfeldt-Jakob disease
Parvovirus B19
SARS
-These don’t have specific tests but can be screened out
____is an anticoagulant preservative used to store blood at 1-6C
Citrate Phosphate dextrose adrenire-1 (CPDA-1)
Citrate prevents clotting of stored blood by binding to _____
calcium
Phosphate in CPDA-1 serves as a _____, while dextrose is a red cell _____ ______ (this allows RBCs to continue glycolysis for ATP)
buffer
energy source
Adenine in CPDA-1 prolongs the sruvival of ____, helping them recycle ATP for metabolic reactions, which extends their storage time from ___ to ___ days
RBCs
21 to 35 days
Storage at 1-6C helps reserve blood by reducing the rate of ____ by about 40x the rate of body temperature
glycolysis
The shelf life of PRBCs can be extended to ___ days if AS-1 (Adsol), AS-3 (Nutricel), or AS-5 (Optisol) is used
42
Nutricel contains ____, ____, ____, ____, and ____
Adenine, glucose, citrate, phosphate, and NaCL
Adsol contains ____, ____, ____, and ____
Adenine, glucose, mannitol, and NaCL
-extends storage to 42days
Optisol contains ____, ____, ____, and ____
Adenine, dextrose, mannitol, and NaCL
About 85% of RBCs collected are in ____.
AS-1 (Adsol)
-42 day shelf life
Adenine as an additive extends RBC life to _ days
35
Blood product storage temp
-pRBC
1-6*C
Blood product storage temp
-Plt
room temp
-infection risk!
Blood product storage temp
-FFP
Frozen
Thawed = 1-6*C
Shelf life of blood products
pRBC
-no additive
-with adenine
-with AS-1
nothing - 21 days
Adenine - 35 days
AS-1 - 42 days
Shelf life of blood products
-Plt
7 days
Shelf life of blood products
-FFP
5 days when thawed
Which blood product is most likely to transmit hepatitis?
Cryo
What happens with red cell lesions from storage/ old age?
-lactate buildup from glucose use
-more acidic, high H+
-damage to protein/lipids
-low temp forces K out of cells and Na into cells
-low conc of ATP, NO, and 2,3 DPG
-higher Hgb conc bc other cells have died :(
-some cells deform, become rigid, or lyse (microvasc occlusions and decreased O2 delivery)
Giving a ton of blood to pt can shift OxyHgb curve to the _
Left
Which is better to give to a bleeding pt, pRBC or individual components?
pRBC unless theyre hemorrhaging
T/F pRBC have less Hgb than whole blood
false, its equal, pRBC just have less plasma so Hct is 60%
T/F pRBC can be given with crystalloid and colloids
true
What happens when blood is given with hypotonic solution?
cells swell, then lyse
pRBC should be given with:
-D5 + 0.45
-D5 + 0.9
-0.9
-Normosol-R
Purpose of giving pRBC is=
increase O2 carrying capacity
What should one expect when treating an active hemorrhage with crystalloids and colloids?
dilutional anemia
Factors in RBC that decrease with storage
-pH
-Calcium
-Factor V and VII
-2,3 DPG
Factors in RBC that increase with storage
-K
-Hgb
-Lactate and CO2
-fragility of cells, causing lysis
Changes in K+ in stored blood
-day 0, day 35, day35 pRBC
0= 4.2
35= 17.2
35 PRBC= 76
% Hct in blood products
-pRBC + CPDA
65%
% Hct in blood products
-pRBC + AS-1
55-60%
% Hct in blood products
-Whole blood
normal Hct levels ~ 36-54%
Effects of massive transfusion=
Alkalosis (citrate metabolism + bicarb in liver)
Hypothermia (cold blood admin)
Hyperglycemia (dextrose additive)
Hypocalcemia (calcium binding with citrate)
Hyperkalemia (old blood and leaky K, watch for neonates and renal pts)
EBL based on sponges
1 sponge = 10ml
larger sponge = 10-20 ml
abd pad = 150ml
1gm=1ml
cannister = 1L
What is the gold standard for measuring blood loss?
there isnt one
-predicted blood loss (often underestimated)
-visualization
-weighing/counting pads
ABL formula=
ABL = [Estimated blood volume x (Hi-Hf)] / Hi
Hi = initial Hct
Hf = final Hct
EBV:
woman = 65mL/kg
man = 70mL/kg
When to give blood:
Hgb > 10g/dL = almost never
Hgb 7-10g/dL = maybe, depends
Hgb > 7g/dL =almost always (or less than 6 for ASA)
1 unit of plt increases count by how much?
7-10x10^9 - Miller (10 units plt = increase of 100x10^9)
7,000-10,000 cells/mm^3 - ppt
Recommended way to monitor Hgb=
O2 extraction ratio, but it requires invasive monitoring and is not practical
Noninvasive spectrophotometric finger tech (SpHgb) depends on:
-blood flow to finger
-temperature
-increase accuracy if warm, and bupivacaine nerve block is given; want a perfusion index (PI) score of >4-5 for good accuracy
-SpHgb is good to monitor for changes in Hgb, look into situation if changes of 1-2g/dL are noted
-Hemocue is more accurate, works in <5 min but is invasive POC testing
Which blood product has the highest rates of infection not hepatitis?
Plt
-room temp
What blood products do you give in trauma or when the pt’s blood type is unknown?
O NEGATIVE blood (lacks antigens)
AB POSITIVE plasma (lacks antibodies)
if more than 2 units of O neg uncross matched blood is given, must stick with it and not switch to their blood type if its discovered bc can cause hemolysis of donor blood
O blood can be given to:
O, A, B, AB
A blood can be given to:
A and AB
B blood can be given to:
B and AB
AB blood can be given to:
AB
T/F AB blood lacks antigens
false , lacks antibodies in PLASMA
T/F O blood lacks antibodies
false, lacks antigens on the CELL
O blood recipient can receive:
O blood only
Rh positive blood is compatible with:
both Rh + and - blood
Rh negative blood is compatible with:
only Rh - blood
D antigen exists on which type of RBC?
Rh +
-can have both Rh+ and Rh - blood
Anti-D antibody exists on which type of RBC?
Rh - that are sensitized already!
can only have Rh - blood
TRALI
patho:
resp distress within 6hr after pRBC or FFP
looks like noncardiogenic pulm edema-no excessive intravasc volume/heart failure
TRALI
causes:
ALL blood products
FFP highest risk
TRALI
s/s
-fever
-dyspnea
-fluid in ETT
-severe hypoxia
-persistent drop in blood O2 sat during GA
TRALI
dx
Pulm edema in absence of HF/circulatory overload
Pulm fluid with a high PROTEIN conc
TRALI
treatment
- stop transfusion
- support VS (CPAP, BiPAP, vent settings etc)
- Determine protein conc of pulm edema
- Get CBC and CXR
- Tell blood bank to quarantine the rest of the units from that donor
-PEEP 5-10, TV ~6-8 avoid volu/barotrauma, want UO > 1mL/kg/hr so give fluids, hemodynamic monitoring?
TACO
Patho
High volume/rate of infusion, heart cant keep up
pts at risk: cardiopulm disease, renal failure, age extremes
TACO
Cause
All blood products
TACO
s/s
FLUID OVERLOAD!
- dyspnea, orthopnea
-hypoxemia
-pulm edema
-HTN (>50mmHg increase)
Increased CVP
TACO
dx
Pulm edema with evidence of higher L sd filling pressures
-increased BNP, CVP, new or worse HF)
TACO
treatment
- stop transfusion
- diuresis
- O2
like HF
Pt receives platelets and develops a fever within 6hr, what is likely happening, TRALI or infection?
infection/sepsis from platelets
Class I Hemorrhage
-750mL loss / 15%
HR = 100
BP = ok
PP = ok/ high
RR = 14-20
UO = 30mL/hr
Cap refill = ok
mental= slight anxiety
fluid replacement= crystal
Class II Hemorrhage
-750-1500mL loss/ 15-30%
HR = 100
BP = ok
PP = low
RR = 20-30
UO = 20-30mL/hr
Cap refill= +
mental= mild anxiety
fluid replacement = crystal
Class III Hemorrhage
-1.5-2L loss/ 30-40%
HR =120
BP = low
PP = low
RR = 30-40
UO = 5-19mL/hr
Cap refill = +
mental= anxious + CONFUSED
Fluid replacement = blood + crystal
Class IV Hemorrhage
-2L + loss/ 40% +
HR = 140
BP = low
PP= low
RR = 35+
UO = minimal
Cap refill = +
mental = confused + LETHARGIC
Fluid replacement= blood + crystal
Why would Hgb not be low initially if drawn when pt is bleeding?
Volume loss has not been replenished by body so Hgb is not diluted yet
If pt is anemic and there is little prep time before surgery, is it ok to prophylactically give pRBC if expecting moderate blood loss in case?
yes! don’t proph give fluids
if you had more time (weeks) give IV or PO iron supp
Where do transfusable platelets come from?
4-6 different donations worth of concentrations OR apheresis from 1 donor
What to give in excessive bleeding when platelet dysfunction is suspected?
Desmopressin
When to give platelets:
100x10^9/L =none
<50x10^9/L = if pt increased risk for bleeding prolly give
<20x10^9/L AND bleeding = give
<20x10^9/L and NOT bleeding = don’t give (that’s cray)
Most commonly used PLASMA product:
FFP
FFP must be frozen in _ - _ hr
8-24hr - becomes PF24 then (has less factor V and VII)
Can a pt be sensitized to FFP?
yes
Risks of FFP:
TRALI
TACO
allergy
anaphylaxis
When to give FFP:
-get coags before if poss
-use for INR >2 when pt is not on heparin
-use to reverse Warfarin ONLY if pt is bleeding and PT not available
-give if pt has received >70mL/kg in blood products if coags aren’t available
-use to replace clot factor deficits ONLY with bleeding, DIC, or both
Cryo is made when _ is thawed and precipitate is reconstituted
FFP
Cryo has these clotting factors:
-Factor VIIIc
-Factor VIIIvWF
-Fibrinogen
-Factor XIII
-Fibronectin (glycoprotein that helps clean blood)
Why is cryo given when ABO compatible?
bc altho there is a low antibody count, it still has fragments of RBCs in it, so if donor was Rh + it can sensitize the recipient
How to admin cryo:
FILTERED AND FAST (200mL/hr)
-within 6hr of thawing
What clotting factors are in FFP?
-all coag factors EXCEPT platelets
-good source of factor V and factor VIII
Leading cause of transfusion mortality:
TRALI
Indications for pRBC=
increasing O2 carrying capacity
Indications for platelets=
-<50x10^9/L or rarely if 100
-severe thrombocytopenia (<20x10^9/L or 20,000cells/mm3) AND clinical s/s of bleeding
Indications for cryo=
-Fibrinogen <80-100mg/dL WITH excessive bleed
-OB pt WITH excessive bleed despite fibrinogen level >150mg/dL
-massive transfusions (check fibrinogen if poss)
-von Willebrand disease WITH bleeding WITHOUT response from desmopressin or vWF/factor VIII conc
Hemolytic reaction is a type _ reaction
II
Hemolytic Transfusion reaction
causes
giving wrong type of blood (ABO incompatible)
-clerical error
Hemolytic Transfusion reaction
s/s
-fever
-chills
-cp
-flank pain
-N
ANESTHESIA: hemoglobinuria (PRESENTING SIGN), HoTN, bleeding diathesis
Hemolytic Transfusion Reaction
treatment
1.stop transfusion
2.keep UO 75-100mL/hr by:
-give fluids and possibly mannitol 12.5-50g over 5-15min
-if fluids and mannitol not working, give lasix 20-40mg
3. Alkalinize the urine by giving bicarb 40-70mEq per 70kg
4. Assay urine and plasma Hgb conc
5. Check platelet count, PTT, and serum fibrinogen
6.Return unused blood to bank for a repeat crossmatch
7.Send blood bank pts blood and urine to sample
8.Prevent HoTN and ensure good renal blood flow
How much does a unit of pRBC raise Hgb/Hct
unit of pRBC = 1 gm/dL Hgb increase and Hct increase by 3%
Altered coags during bleed/ treatment:
-low platelets, or suspicion of thrombocytopathy
give 5-10 units of platelets
consider DDAVP
Altered coags during bleed/ treatment:
-increased PT, PTT, platelets normal, fibrinogen normal/high
give FFP
Altered coags during bleed/ treatment:
-high PT, PTT, LOW platelets, low fibrinogen
Fibrin split products + cryo + platelets
-WORK UP FOR DIC!
