Unit 9: Fluids & Blood Flashcards
What is the distribution of body water?
Water represents 60% of the total body weight (42L in 70kg male)
Intracellular Volume = 40% of total body weight (28L)
Extracellular Volume = 20% of total body weight (14L)
-interstitial fluid = 16% (11L)
-plasma fluid = 4% (2L)
Which populations tend to have a greater percentage of TBW% by weight? Which have less?
- Higher TBW% = Neonates
- Lower TBW% = Females, Obese, and Elderly
What are the 2 most important determinants of fluid transfer between the capillaries and interstitial space?
Movement of fluid between intravascular space and the interstitial space is determined by:
-Starling Forces
-The Glycocalyx
What are the Starling forces in the context of capillary fluid transfer?
Forces that move fluid from the capillary to the interstitium:
- Pc = capillary hydrostatic pressure (pushes fluid out of capillary)
- πif = interstitial oncotic pressure (pulls fluid out of capillary)
Forces that move fluid from interstitium into the capillary:
- Pif = interstitial hydrostatic pressure (pushes fluid into capillary)
- πc = capillary oncotic pressure (pulls fluid into capillary)
*net filtration pressure > 0 = filtration (fluid exits capillary)
*net filtration pressure < 0 = reabsorption (fluid is pulled into capillary
What is the glycocalyx? What factors disrupt it?
Endothelial glycocalyx = protective layer on the interior wall of blood vessels
-determines what can pass from the vessel into the interstitial space
Disruption = Capillary Leak – accumulation of fluid and debris in the interstitial space reduces tissue oxygenation
-Conditions that impair the integrity = sepsis, ischemia, DM, major vascular surgery
What is lymph, and how does the lymphatic system work?
Lymphatic system removes fluid, protein, bacteria, and debris that has entered the interstitium
Accomplishes this with a pumping mechanism that propels lymph through a vessel network lined with one-way valves
-creates a net negative pressure in the interstitial space
*edema occurs when lymphatic system is unable to do its job
How is lymph returned to the systemic circulation?
Returned to the venous circulation by way of the thoracic duct at the juncture of the IJ and subclavian vein
*thoracic duct can be injured during venous cannulation – greater risk of chylothorax during left sided IJ insertion
What is the difference between osmosis and diffusion?
Osmosis = net movement of WATER across a semipermeable membrane (direction of water movement is driven by the difference in solute concentration on either side of the membrane)
Diffusion = net movement of MOLECULES from a region of high concentration to a region of low concentration (solvent and solute move)
What is osmotic pressure, and what is its primary determinant?
The pressure of a solution against a semipermeable membrane that prevents water from diffusing across that membrane
-osmotic pressure is a function of the number of osmotically active particles in a solution
-it is NOT a function of their molecular weights
What is the difference between osmolarity and osmolality?
Both are measures of concentration – the amount of solvent within a defined space
Osmolarity: measures the number of osmoles per liter of solution
Osmolality: measures the number of osmoles per kilogram of solvent
What is the normal plasma osmolarity? What are the 3 most important contributors?
What is the equation to determine plasma osmolarity?
Plasma Osmolarity = 280 - 290 mOsm/L
Important Determinants:
-Sodium, Glucose, BUN
= 2 [Na] + Glucose/18 + BUN/2.8
What is the difference between a hypotonic and hypertonic solution relative to plasma osmolarity?
Hypotonic (255 mOsm/L) = solution osmolarity is less than plasma osmolarity – water enters and cell swells
Hypertonic (315 mOsm/L) = solution osmolarity is more than plasma osmolarity – water exits and cell shrinks
What IV fluids are hypotonic, isotonic, and hypertonic?
Hypotonic:
-NaCl 0.45% (154 mOsm/L)
-D5W (253 mOsm/L)
Isotonic:
-LR (273 mOsm/L)
-Plasmalyte A (294 mOsm/L)
-Albumin 5% (300 mOsm/L)
-NaCl 0.9% (308 mOsm/L)
Hypertonic:
-D5 NaCl 0.45% (405 mOsm/L)
-D5 LR (525 mOsm/L)
-D5 NaCl 0.9% (560 mOsm/L)
-NaCl 3% (1026 mOsm/L)
How does dextrose affect the tonicity of IV fluids?
Glucose contributes osmotically active molecules to the plasma
Glucose is metabolized to CO2 and water –> water = hypotonic
How do isotonic IV fluids distribute in the patient?
Isotonic solutions are very close to plasma –> these solutions expand the plasma volume and the ECV
-crystalloids tend to remain in the intravascular space for ~30 min before moving to the ECF
What complication can result when hypertonic saline is administered too quickly?
Central Pontine Myelinolysis
What are the advantages and disadvantages of colloids?
Advantages:
- Replacement ratio = 1:1
- Increases plasma volume (3-6 hrs)
- Smaller volume needed
- Less peripheral edema
- Albumin has anti-inflammatory properties
- Dextran 40 reduces blood viscosity (improves microcirculatory flow in vascular surgery)
Disadvantages:
- Albumin – binds Ca (hypocalcemia)
- FDA black box warning on synthetic colloids (risk of renal injury)
- Coagulopathy (Dextran > Hetastarch > Hextend)
What are the advantages and disadvantages of crystalloids?
Advantages:
-Replacement ratio = 3:1
-Expands the ECF
-Restores 3rd space loss
Disadvantages:
-limited ability to expand plasma volume – increases plasma volume 20-30 min (higher potential for peripheral edema)
-large volume of NaCl –> hyperchloremic metabolic acidosis
-dilutional effect on albumin (reduces capillary oncotic pressure)
-dilutional effect on coagulation factors
How does hyperkalemia affect the EKG? (list in order of appearance)
K+ 5.5 - 6.5 = Peaked T waves
K+ 6.5 - 7.5 = P wave flattening / PR prolongation
K+ 7.5 - 8.0 = QRS prolongation
K+ >8.5 = QRS –> sine wave –> VF
How do you treat hyperkalemia?
Cardiac membrane stabilization –> Calcium
Redistribution (shift K+ intracellularly –> Insulin/D50, Hyperventilation, Bicarbonate, Albuterol
Elimination –> Potassium wasting diuretics, Kayexalate, Dialysis
What are the signs/symptoms of hypocalcemia?
-Skeletal muscle cramps
-Neve irritability –> paresthesia and tetany
-Chvostek sign
-Trousseau sign
-Laryngospasm
-Mental status changes –> seizures
-Long QT interval
What are the signs/symptoms of hypercalcemia?
-Nausea
-Abdominal pain
-Hypertension
-Psychosis
-Mental status change –> seizures
-Short QT interval
How do you treat hypercalcemia?
0.9% NaCl
Loop Diuretic (Furosemide)
What are the signs/symptoms of hypermagnesemia?
5.8 - 10 mEq/L or 7 - 12 mg/dL = Loss deep tendon reflex
> 10 mEq/L or >12 mg/dL = Respiratory depression and Cardiac arrest
What is the treatment for hypermagnesemia?
Calcium chloride or Calcium gluconate
How does hypermagnesemia affect neuromuscular blockade?
Potentiates neuromuscular blockade
What are the cardiac, CNS, pulmonary, and electrolyte effects of acidosis?
Cardiac:
- increases P50 (right = release)
- increases SNS tone
- increases risk of dysrhythmias
- decrease contractility
CNS:
- increases cerebral blood flow and ICP
Pulmonary:
- increases pulmonary vascular resistance
Electrolyte:
- hyperkalemia
What are the cardiac, CNS, pulmonary, and electrolyte effects of alkalosis?
Cardiac:
- decreases P50 (left = love)
- decreases coronary blood flow
- increases risk of dysrhythmias
CNS:
- decreases cerebral blood flow and ICP
Pulmonary:
- decreases pulmonary vascular resistance
Electrolyte:
- hypokalemia
- decreased ionized calcium
What is the anion gap? What does it tell you?
Anion gap helps determine the cause of acidosis
Anion Gap = [Na+] - ([Cl-] + [HCO3-])
-normal = 8-12 mEq/L
-Accumulation of acid (AG >12) = gap acidosis
-Loss of bicarb or ECF dilution = non-gap acidosis
What are the possible causes of an anion gap acidosis?
(MUDPILES)
-Methanol
-Uremia
-Diabetic Ketoacidosis
-Paraldehyde
-Isoniazid
-Lactate (decreased DO2, sepsis, cyanide poisoning)
-Ethanol, ethylene glycol
-Salicylates (inhibits Krebs cycle)
What are the possible causes of a non-gap acidosis?
(HARDUP)
-Hypoaldosteronism
-Acetazolamide
-Renal Tubular Acidosis
-Diarrhea
-Ureterosigmoid Fistula
-Pancreatic Fistula
What is the etiology of metabolic alkalosis?
Addition of HCO3:
-sodium bicarb administration
-massive transfusion (liver converts preservatives to HCO3)
Loss of Nonvolatile Acid:
-loss of gastric fluid (most common)
-loss of acid in urine
-diuretics
-ECF depletion (increased Na reabsorption –> H and K excretion)
Increased Mineralocorticoid Activity:
-Cushing’s syndrome
-hyperaldosteronism
What are the 4 steps of hemostasis?
- Vascular Spasm
- Formation of the platelet plug (primary hemostasis)
- Coagulation and Formation of Fibrin (secondary hemostasis)
- Fibrinolysis when the clot is no longer needed
Where are platelets formed? Where are they metabolized?
Formed by megakaryocytes in the bone marrow
Cleared by macrophages in the reticuloendothelial system and the spleen
What is the normal value for platelets? What are the critical values?
Normal = 150,000 - 300,000
<50,000 = increases surgical bleeding risk
<20,000 = increases spontaneous bleeding risk
*monitors number of platelets, not the function
What are the 3 steps of platelet plug formation (Primary Hemostasis)?
- Adhesion
- Activation
- Aggregation
*platelet plug is formed in ~5 minutes
What are the 12 coagulation factors?
1 - Fibrinogen
2 - Prothrombin
3 - Tissue Factor
4 - Calcium Ions
5 - Labile Factor
7 - Stable Factor
8 - Antihemophilic Factor
9 - Christmas Factor
10 - Stuart-Power Factor
11 - Plasma Thromboplastin
12 - Hageman Factor
13 - Fibrin Stabilizing Factor
*all except factor 3 and 4 are synthesized in the liver
What activates the extrinsic coagulation pathway? What lab test measures it? What drug inhibits it?
Activated by vascular injury (tissue trauma liberates tissue factor from the subendothelium)
-measured by the PT and INR
-inhibited by warfarin
What activates the intrinsic coagulation pathway? What lab test measures it? What drug inhibits it?
Activated by blood injury or exposure to collagen
-measured by the PTT and ACT
-inhibited by heparin
What factors are in the extrinsic pathway, intrinsic pathway, and final common pathway of the coagulation cascade?
Extrinsic Pathway: Factors 3 and 7
-“…can be purchased for 3 cents”
Intrinsic Pathway: Factors 8, 9, 11, and 12
-“if you can’t buy the intrinsic pathway for $12, you can buy it for $11.98”
Final Common Pathway: Factors 1, 2, 5, 10, and 13
-“…can be purchased at the5 and dime (10) for 1 or 2 dollars on the 13th of the month
What is fibrinolysis? What enzyme causes it?
The breakdown of a clot once it is no longer needed
-Plasminogen is a proenzyme that is synthesized in the liver –> it is incorporated into the clot as it is being formed, but lays dormant until it is activated
-Plasmin is a proteolytic enzyme that degrades fibrin into fibrin degradation products
What are the 3 phases of the contemporary cell-based coagulation cascade?
Contemporary cell-based coagulation cascade attempts to explain how platelets, the extrinsic pathway, and the intrinsic pathway function in an interdependent manner
-the idea is that coagulation takes place on the surface of a cell that expresses tissue factor
Three Phases:
1. Initiation
2. Amplification
3. Propagation
What are the components of the TEG? What products are used to treat each component?
R Time: time to begin forming clot – 6-8 min – issue w/ coagulation factors – treat w/ FFP
K Time: time until clot has achieved fixed strength – 3-7 min – issue w/ fibrinogen – treat w/ Cryo
Alpha Angle: speed of fibrin accumulation – 50-60 degrees – issue w/ fibrinogen – treat w/ Cryo
Max Amplitude: highest vertical amplitude on the TEG (measures clot strength) – 50-60 mm – issue w/ platelets – treat w/ platelets +/- DDAVP
Amplitude at min after max amplitude (A60): height of vertical amplitude 60 min after the max amplitude – MA-5 – issue w/ excess fibrinolysis – treat w/ TXA, Aminocaproic acid
Identify the cause of the following TEGs
What is the mechanism of action of heparin?
Inhibits the intrinsic and final common pathways
-antithrombin III is a naturally occurring anticoagulant that circulates in the plasma – heparin binds to antithrombin and greatly accelerates its anticoagulant ability 1000-fold
-Heparin-AT complex neutralized thrombin and activated factors 9, 10, 11, and 12
How do you treat a patient with ATIII deficiency?
Treat with AT concentrate of FFP
-antithrombin deficiency is a common cause for failure to achieve anticoagulation despite an adequate heparin dose prior to cardiopulmonary bypass
Can a pregnant patient receive IV heparin?
Heparin does not cross the placenta and is safe in pregnancy
What is the normal ACT? What value should be achieved prior to transitioning to cardiopulmonary bypass?
Normal ACT = 90-120 seconds
ACT should be >400 seconds before going on cardiopulmonary bypass
ACT is measured before heparin administration, 3 min after it’s given, and every 30 min thereafter
What are the doses for heparin (for CPB) and protamine?
Heparin Dose = 300-400 U/kg (cardiac surgery dose)
Protamine Dose = 1 mg for every 100 U of heparin predicted to be in the circulation
How does protamine reverse heparin?
Heparin is a large, negatively charge, water-soluble compound
Protamine is a highly alkaline compound with a strong positive charge
Positive charge of protamine and negative charge of heparin create a neutralization reaction and stop heparin’s anticoagulant activity
What are the side effects of protamine?
-Hypotension (from histamine release – administer >5min)
-Pulmonary Hypertension (from TxA2 and serotonin release)
-Allergic Reaction (from previous sensitization to NPH insulin, fish allergy, vasectomy, multiple drug allergies)
What is the mechanism of action of warfarin?
Inhibits the enzyme Vitamin K epoxide reductase complex 1 (VKOR c1) – which is responsible for converting inactive Vit K to active Vit K
-indirectly blocks the manufacturing of the Vit K dependent factors (2, 7, 9, and 10 and protein C and S)
What are the antidotes for warfarin? When should each be used?
Vitamin K (10-20 mg PO, IM, or IV) – used to reverse for non-emergent, minor surgical procedures
-requires 4-8 hours to restore the concentration of Vit K dependent clotting factors in the blood
FFP (1-2 units), Recombinant Factor VIIa, or Prothrombin Complex Concentrate – emergent or high-risk procedures, such as intracranial procedures
What conditions can cause vitamin K deficiency?
Vit K is a fat-soluble vitamin that requires the presence of fat and bile for absorption – also manufactured by bacteria in the gut
Following impair fat absorption thus create Vit K deficiency:
-malabsorptive diseases
-impaired G flora
-decreased bile production
*deficiency of Vit K leads to coagulopathy
What is the risk associated with IV phytonadione?
IV admin is associated with life-threatening anaphylaxis
-best to avoid IV administration but if given by this route – rate should not exceed 1mg/min
Why do neonates receive vitamin K after birth?
Healthy intestinal flora is required for the gut to synthesize vitamin K
Neonates don’t have the intestinal flora that synthesizes vitamin K, so 0.5-1 mg IM after delivery is common
What are ADP receptor inhibitors? Give 4 examples.
How long must each be discontinued prior to surgery?
ADP receptor inhibitors prevent platelet aggregation and thrombus formation
-Ticagrelor: 1-2 days
-Prasugrel: 2-3 days
-Clopidogrel: 7 days
-Ticlopidine: 14 days
What are GIIb/IIIa receptor antagonists?
Give 3 examples. How long must each be discontinued prior to surgery?
Inhibit platelet aggregation and thrombus formation
-Abciximab: 3 days
-Eptifibatide: 1 day
-Tirofiban: 1 day
What drugs can be used to provide anticoagulation in a patient who is unable to receive heparin? How long must each be stopped prior to surgery?
Thrombin inhibitors
-Bivalirudin: 2-3 hours
-Argatroban: 4-6 hours
*hepartin should be stopped 6 hours prior to surgery
What is the mechanism of action for COX inhibitors? Which agents provide irreversible COX inhibition?
COX inhibitors prevent platelet aggregation by blocking cyclooxygenase 1 (COX-1) –> stops conversion of arachidonic acid to prostaglandins and ultimately thromboxane A2
-Aspirin is irreversible (lasts for the life of the platelet
-NSAIDs are reversible (duration is shorter than the life of the platelet)
What are antifibrinolytics? Give 2 examples
Antifibrinolytics stop the conversion of plasminogen to plasmin – Promote clot formation (reduces bleeding in cardiac and orthopedic surgery)
-Tranexamic Acid (TXA)
-Aminocaproic Acid
What are fibrinolytics? Give 5 examples
Facilitate the conversion of plasminogen to plasmin – breakdown clots (useful for myocardial infarction or embolic stroke)
-tPA
-Urokinase
-Streptokinase
-Reteplase
-Alteplase
Where is vWF synthesized? What is its function?
Synthesized by the vascular endothelium and megakaryocytes
Serves Two Functions:
-anchors the platelet to the vessel wall at the site of vascular injury (platelet adhesion) – binds to GP Ib receptor
-carries inactivated factor 8 in the plasma
What is Von Willebrand disease? What are the 3 types?
Most common inherited disorder of platelet function – platelet count is normal but do not function properly
Type 1: mild-moderate reduction in the amount of vWF produced
Type 2: vWF that is produced doesn’t work well
Type 3: severe reduction in the amount of vWF produced
How are the following lab results affected with Von Willebrand disease (PT/INR, PTT, platelet count, bleeding time, fibrinogen)?
PT/INR – no change
PTT – increased
Platelet Count – no change
Bleeding Time – increased
Fibrinogen – no change
What is the mechanism of action of desmopressin? What is the dose?
Synthetic analogue of antidiuretic hormone – stimulates the release of endogenous vWF and increases factor 8 activity
Patients with Type 1 disease respond best to desmopressin
Patients with Type 3 disease don’t respond to desmopressin because they do not produce vWF
Dose = 0.3 - 0.5 mcg/kg IV
Side Effect = hypotension w/ rapid admin
What are three other treatments (besides desmopressin) that can improve the coagulopathy of Von Willebrand disease?
-Cryoprecipitate: contains factors 8, 13, fibrinogen, and vWF (can be used for all types of disease)
-FFP: contains all clotting factors (can be used for all types of disease)
-Purified 8-vWF Concentrate: reduces risk of transfusion related infection (first line agent for the pt w/ type 3)
What is the pathophysiology of hemophilia A?
X-linked chromosomal disorder (more common in males) that causes factor 8 deficiency
-severe disease (factor 8 activity <1%) is associated with spontaneous bleeding into the joints, muscles, and vital organs
-patients often require orthopedic surgery
How are the following lab results affected in Hemophilia A (PT/INR, PTT, platelet count, bleeding time, fibrinogen)?
PT/INR – no change
PTT – increased
Platelet Count – no change
Bleeding Time – no change
Fibrinogen – no change
What is the treatment for hemophilia A?
-Factor 8 concentrate prior to surgery
-FFP and Cryo can also be used to replace factor 8 (increases risk of transfusion related disease transmission)
-Antifibrinolytics (TXA or Aminocaproic Acid) can be used to minimize bleeding during dental procedures
-A type and crossmatch is required for any surgical procedure
How is hemophilia B different from hemophilia A?
Hemophilia B is factor 9 deficiency
-labs and anesthetic management are similar to hemophilia A, but instead of factor 8 replacement, factor 9 concentrate is indicated
What is the role of recombinant factor 7 in the management of hemophilia A and B?
Sometimes pts w/ hemophilia A or B develop inhibitors that prevent exogenous factor 8 or 9 from achieving their therapeutic goals – Recombinant factor 7 is a “bypass” agent
-it skips over factor 8 or 9 in patients with inhibitors allowing the patient to form a clot
-Dose: 90-120 mcg/kg
*can increase risk of arterial thrombosis (MI and embolic stroke) as well as venous thrombosis (DVT or PE) –> risk/benefit ratio must be considered
What is the pathophysiology of disseminated intravascular coagulation (DIC)?
Characterized by disorganized clotting and fibrinolysis that lead to simultaneous occurrence of hemorrhage and systemic thrombosis
-generalized thrombin formation creates microvascular clots that impair tissue perfusion – results in tissue hypoxia and acidosis
-body attempts to break down these clots by activating its anticoagulant system – leads to widespread consumption of coagulation factors, fibrinogen, and platelets
What lab values are consistent with DIC? (PT/PTT, D-dimer, Platelets, Fibrinogen)
Increased PT/PTT
Increased D-dimer
Decreased Platelets
Decreased Fibrinogen
What 3 conditions are associated with a high risk of developing DIC?
- Sepsis (highest risk = gram-negative bacilli)
- Obstetric Complications (highest risk = preeclampsia placental abruption, and amniotic fluid embolism)
- Malignancy (highest risk = adenocarcinoma, leukemia, and lymphoma)
How do you manage a patient with DIC?
Definitive treatment is reversing the underlying cause
Supportive treatment includes:
-hypovolemia –> treat with IV fluids
-coagulopathy –> replace consumed blood components with FFP, platelets, and Cryo
-severe microvascular thrombosis –> IV heparin or LMWH
Compare and contrast type 1 and type 2 heparin-induced thrombocytopenia
HIT Type 1: Heparin induced platelet aggregation
- occurs after large heparin dose
- onset 1-4 days after heparin admin
- platelet count <100,000
- minimal morbidity
- treatment = resolves spontaneously even if heparin is continued
HIT Type 2: Antiplatelet antibodies (IgG) attack factor 4 immune complexes –> platelet aggregation
- occurs after any heparin dose
- onset 5-14 days after heparin admin
- platelet count <50,000
- hypercoagulable state causes high risk of amputation and death
- treatment = heparin must be discontinued – anticoagulate with direct thrombin inhibitor (Bivalirudin, Hirudin, Argatroban)
What is the pathophysiology and treatment of protein C and S deficiency?
Protein C produces an anticoagulant effect by inhibiting factor Va and VIIIa – creates feedback mechanism that prevents unnecessary clot formation (Protein S helps protein C do its job)
Deficiency can produce a hypercoagulable state, increasing risk of thrombosis
Treatment:
-thromboembolism is treated with heparin that is transitioned to warfarin
-pts may or may not require life-long anticoagulation w/ warfarin
What is the pathophysiology and treatment of factor 5 Leiden mutation?
Factor 5 Leiden causes a resistance to the anticoagulant effect of protein C
Treatment:
-only pts with thromboembolism require anticoagulation
-lifelong anticoagulation is unwarranted unless the pt experiences recurrent thrombotic events
What is the pathophysiology of sickle cell anemia?
Inherited disorder that affects erythrocytes – Amino acid substitution on the beta globulin chain alters RBC geometry
Affects RBC function:
-Deoxygenation of HgbS leads to sickling (conformational change that alters the erythrocyte geometry)
-in severe cases, sickling causes RBCs to clump together – causes mechanical obstruction of microvasculature in vital organs and joints (impairs tissue perfusion and causes intense pain)
-sickled cells are more prone to hemolysis and removal by the spleen (lifespan = 12-17 days)
What are the triggers that cause sickling of HgbS?
-Pain
-Hypothermia
-Hypoxemia
-Acidosis
-Dehydration
*anesthetic management focuses on avoiding there triggers
What is vaso-occlusive crisis?
Sickled cells –> impair tissue perfusion–> ischemic injury
- most common manifestation of sickle cell disease
Treatment: analgesics (oral or IV) and hydration
- hydroxyurea reduces the incidence and severity of vaso-occlusive crisis
What is the relationship between blood type, erythrocyte antigens, and plasma antibodies?
-Blood type is determined by specific glycoproteins present on the erythrocyte cell membrane
-These glycoproteins have an antigenic potential (wrong type has catastrophic consequences)
-Most clinically important antigens are the ABO and Rh systems
-If an antigen is expressed on the erythrocyte, then there will NOT be an antibody against that specific antigen in the plasma
-If an antigen is NOT expressed on the erythrocyte, then there WILL be an antibody against that specific antigen in the plasma
What blood type is the universal donor for erythrocytes? How about the universal acceptor?
Universal RBC Donor = O negative
Universal RBC Acceptor = AB positive
What blood type is the universal donor for FFP? How about the universal acceptor?
Universal FFP Donor = AB positive
Universal FFP Acceptor = O negative
What is the concern about an Rh-negative mother and pregnancy?
A person who is Rh-negative can be sensitized by exposure to Rh-positive blood during transfusion or pregnancy
-Rh-negative mother can be sensitized by her Rh-positive fetus –> transfer across the placenta
-mother receives Rhogam to prevent sensitization
-if the mother becomes sensitized and develops antibodies, a subsequent pregnancy with an Rh-positive fetus may result in erythroblastosis fetalis
What do each of the following blood tests test an how long does each test take?
Type
Screen
Crossmatch
Type:
- ABO and Rh-D antigens
- takes 5 min
- recipient blood is mixed with anti-A, anti-B, and anti Rh-D antibodies (0.2% chance of incompatibility reaction after this test - specific units not assigned to pt)
Screen:
- most clinically significant antibodies
- takes 45 min
- recipient plasma is mixed with commercially prepared O RBCs that contain known antigens (0.06% chance of incompatibility reaction after this test - specific units not assigned)
Crossmatch:
- compatibility between recipient plasma and the actual blood unit to be transfused
- takes 45 min
- simulates transfusion in a test tube (0.05% chance of incompatibility reaction after this test - specific units are assigned)
What is the next best option for a patient suffering from acute hemorrhage and there is not time to wait for crossmatched blood?
- Type-specific partially crossmatched blood
- Type-specific uncrossmatched blood
- Type O negative uncrossmatched blood (universal donor)
*listed most to least favorable options
Can type O positive blood ever be used for emergency transfusion?
If you don’t have time to obtain a type and crossmatch, type O negative is best for emergency transfusion, but…
Because 85% of the population is Rh-D positive, O positive can be used for emergency transfusion if the patient is NOT a woman of childbearing age and has NOT received a previous transfusion
What is the indication to transfuse packed RBCs?
RBCs are transfused to increase CaO2:
-hgb >10 (transfusion rarely required)
-hgb <6 (transfusion often required)
*decision to transfuse is guided by pt factors
What are the indications for FFP transfusion?
-Coagulopathy (PT or PTT >1.5x control)
-Warfarin reversal (acute need)
-Antithrombin deficiency
-Massive transfusion
-DIC
-C1 esterase deficiency (heredity angioedema)
*conditions that can be treated with factor concentrates often carry less infectious risk
What are the indications for platelet transfusion?
Thrombocytopenia (<50,000): invasive procedures, neuraxial blockade, or most surgeries
Thrombocytopenia (<100,000): eye and neurosurgery
Qualitative platelet defect
What is in cryoprecipitate? (4)
-Fibrinogen
-Factor 8
-Factor 13
-vWF
What are the indications for Cryo transfusion?
-Fibrinogen deficiency (<80-100 mg/dL)
-vWB disease
-Hemophilia
What is the dose for PRBC, FFP, Platelets, and Cryo?
-PRBCs = 1 unit increases Hgb by 1g/dL
-FFP = 5-8 mL/kg for warfarin reversal or 10-20 mL/kg for coagulopathy (increases factor concentration by 20-30%)
-Platelets = 1 pack per 10 kg/body weight
-Cryo = 5 bag pool increases fibrinogen by 50 mg/dL
What is the estimated blood volume in preterm neonates, full term neonates, infants, and adults?
Preterm Neonate: 90-100 mL/kg
Full Term Neonate: 80 -90 mL/kg
Infant: 80 mL/kg
Adult: 70 mL/kg
What is the formula for maximum allowable blood loss?
EBV x [(Startin Hbg - Target Hbg) / Starting Hbg)]
What four substances extend the shelf life of PRBCs? What is the function of each?
Citrate: anticoagulant that inhibits calcium (factor 4) - after transfusion of multiple units, citrate load can cause hypocalcemia
Phosphate: buffer that combats acidosis
Dextrose: primary substrate for glycolysis
Adenine: substrate that helps RBCs re-synthesize ATP – storage time to 35 days
*newer preservatives (adsol, nutricel, and optisol) extend storage time to 42 days
What does RBC storage lesion lead to?
-Decreased 2,3 DPG –> shifts oxyhemoglobin dissociation curve to the left (left=love) –> decreased O2 release
-Decreased ATP –> shift to anaerobic metabolism
-Decreased pH (increased lactic acid)
-Increased potassium (caution in neonates and renal failure)
-Impaired ability to change shape (important for capillary flow)
-Hemolysis
-Increased production of proinflammatory mediators
What is leukoreduction of blood? Why is it used and who does it benefit?
Leukoreduction removes WBCs from RBCs and platelets
-leukocytes are responsible for HLA alloimmunization, febrile nonhemolytic transfusion reactions, and CMV transmission – removing them reduces these risks
What is washing of blood? Why is it used and who does it benefit?
Washing the blood products with saline removes any remaining plasma (and antigens) in the donor RBCs – does not remove RBC antigens
Prevents anaphylaxis in IgA deficient patients
What is irradiation of blood? Why is it used and who does it benefit?
Irradiation exposes units to gamma radiation – disrupts WBC DNA in the donor leukocytes
Prevents graft-vs-host disease in immunocompromised patients
Populations who benefit include: leukemia, lymphoma, hematopoietic stem cell transplant, and DiGeorge syndrome
What is the most common infectious complication of RBC transfusion? How can this risk be reduced?
Cytomegalovirus (CMV)
-leukoreduction greatly reduces this risk (immunocompromised pts should receive leukoreduced blood)
What are the four most common infectious complications of RBC transfusion from most to least common?
-CMV (cytomegalovirus) – 1-3% of all transfusions
-Hepatitis B – 1 in 366,500
-Hepatitis C – 1 in 1,657,000
-HIV – 1 in 1,860,000
Why is bacterial contamination more common with platelets than with RBCs or FFP?
Platelets are stored at room temperature
*bacterial contamination can progress to sepsis
What are the signs and symptoms (observed under anesthesia and masked by anesthesia) of an acute hemolytic transfusion reaction?
Observed Under Anesthesia:
- hemoglobinuria (usually presenting sign)
- hypotension
- bleeding
Masked By Anesthesia:
- fever
- chills
- chest pain
- dyspnea
- nausea
- flushing
What is an acute hemolytic reaction? What are the complications?
Complement is activated in the recipient’s blood and plasma antibodies attack the antigens present on the donor blood cell
Complications:
-renal failure (acute tubular necrosis): free hgb in the form of acid hematin precipitates inside the renal tubules leading to mechanical obstruction
-DIC: erythrocyin is released from the RBC and it activates the intrinsic clotting cascade
-hemodynamic instability: free hemoglobin activates the kallikrein system – final product of this pathway is bradykinin (potent vasodilator)
*ABO incompatibility is most lethal
What is the treatment plan for an acute hemolytic reaction?
- Stop the transfusion
- Maintain urine output >75-100 mL/hr (IV fluids, mannitol 12.5-25g, or furosemide 20-40mg)
- Alkalinize the urine with Sodium Bicarb
- Send urine and plasma hemoglobin samples to blood bank
- Check platelets, PT, and fibrinogen
- Send unused blood to the blood bank to double-check cross match
- Support hemodynamics with IVF and pressors as needed
What is the pathophysiology of transfusion-related acute lung injury (TRALI)?
Caused by human leukocyte antigens (HLA) and neutrophil antibodies present in the donor plasma
Donor Antibodies –> Neutrophil activation in the lungs –> Endothelial injury –> Capillary leak –> Pulmonary edema –> Impaired gas exchange –> Hypoxemia –> Acidosis –> Death
*FFP and platelets contain the highest concentration of these antibodies
How does the source (donor group) of blood products affect the risk of TRALI?
The following donor groups impact the highest risk:
-multiparous women (highest risk)
-history of blood transfusion
-history of organ transplant
What are the diagnostic criteria for TRALI?
-Onset < 6 hours following transfusion
-Bilateral infiltrates on frontal CXR
-PaO2/FiO2 <300 mmHg or SpO2 <90% of RA
-Normal pulmonary artery occlusion pressure (no left atrial HTN or volume overload)
What physiologic disturbances result from massive transfusion?
-Alkalosis from citrate metabolism to bicarb in the liver
-Hypothermia from transfusion of cold blood
-Hyperglycemia from dextrose additive to stored blood
-Hypocalcemia from binding of calcium by citrate
-Hyperkalemia from admin of older blood
What is the lethal triad of trauma?
- Acidosis
- Hypothermia
- Coagulopathy
*problem begins with hemorrhage and hypoperfusion – ultimately impacts coagulation and acid-base balance
What is salvaged blood syndrome?
“Salvaged Blood Syndrome” = dilutional coagulopathy
-cell saver blood doesn’t return platelets and coagulation factors to the patient – large volume of salvaged blood returned to the patient has the possibility of dilutional coagulopathy
How is cell saver blood different from PRBCs?
Cell saver blood contains higher concentrations of 2,3-DPG and ATP, so CaO2 is greater and the cells are better able to maintain their biconcave shape (less sludging in the microcirculation)
What are the contraindications and controversial uses for intraop blood salvage?
Contraindications:
- sickle cell disease
- thalassemia
- topical drugs in a sterile field such as betadine, chlorhexidine, and topical antibiotics
- infected surgical site
- oncologic procedures
Controversial Uses:
- c-section due to the theoretical risk of anaphylactoid syndrome of pregnancy (amniotic fluid embolism)
*it is considered safe for transplant surgery
