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671A - Anesthesia I > Week 9 - Blood and Blood Component Therapy > Flashcards

Week 9 - Blood and Blood Component Therapy Flashcards

1
Q

What is the maximum allowable blood loss formula?

A

MABL = EBV x (initial Hct - lowest acceptable Hct) / initial Hct

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2
Q

Visual blood loss estimates for a fully soaked surgical sponge and a fully soaked laparotomy sponge?

A

10 mL, 100 - 150 mL

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3
Q

Rapid interventions of ________ and _________ point of care monitoring has become popular, however it doesn’t estimate the amount of blood loss.

A

Hct, Hgb

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4
Q

Physiological responses suggestive of anemia or intra operative hemorrhage?

A

Tachycardia, decreased blood pressure and eventually decreased oxygen saturation

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5
Q

What are various assessments monitoring vital organ perfusion?

A

Echocardiography, urine output, cerebral oximetry, ABG, and mixed venous oxygen saturation, near infrared spectroscopy (NIRS)

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6
Q

What should be monitored if anemia is suspected?

A

Hgb and Hct

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7
Q

How can coagulopathy be assessed?

A

Monitoring platlets, fibrinogen, thromboelastography (TEG), INR, and aPTT

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8
Q

What emerging technology can aid in discerning coagulation dynamics?

A

Ultrasound technique called sonic estimation of elasticity via resonance (SEER Sonorheometry)

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9
Q

What are some commonly practiced “transfusion triggers”?

A

Hgb less than 6 –> Almost always transfuse
Hgb 6 - 10 –> Transfusion based on specific patient factors
Hgb 10 or more –> “Never transfusing”

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10
Q

What are some specific patient factors aiding in your decision to transfuse blood product?

A

Consideration of cardiopulmonary reserve, experienced and expected blood loss, O2 consumption (reflected in indices such as arterial and mixed venous oxygen saturation) and the presence of atherosclerotic disease.

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11
Q

Withholding transfusions with Hgb as low as ______ g/dL is considered justifiable practice in patients with no cardiac, renal, or hematologic disorders

A

7

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12
Q

What is the purpose of the patient blood management strategy developed by AABB (American Association of Blood Banks)?

A

Optimize patient outcomes while helping guarantee blood components are available for those in need

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13
Q

What are the three strategies of patient blood management?

A
  1. Optimizing the patient own red blood cell mass
  2. Minimizing blood loss
  3. Treatment of anemia
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14
Q

What is the average blood volume of a premature infant?

A

90-105 mL/kg

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15
Q

What is the male average blood volume?

A

70 mL/kg

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16
Q

What is the female average blood volume?

A

65 mL/kg

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17
Q

What is the average blood volume of a term newborn infant?

A

80-90 mL/kg

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18
Q

Endogenous erythropoietin increases in responses of __________ and ___________

A

hypoxia, anemia

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19
Q

Erythropoietin production is blunted in ___________ __________

A

Critical illness

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20
Q

What are the two forms of oxygen in the human body?

A
  1. Dissolved O2 –> Physical form
  2. O2 combined with hemoglobin –> Chemical form (most important)
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21
Q

Minimal blood loss can be accomplished successfully with volume replacement of what fluids?

A

Crystalloids 1:3 (Give LR 1st choice, NS 2nd –> Due to risk of hyperchloremia) and colloids 1:1 or 1:2

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22
Q

If blood losses are hemorrhagic, generally replacement therapy should include __________ and ____________ ____________

A

blood, blood components

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23
Q

What is considered a safe Hgb threshold for blood replacement?

A

7 g/dL

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24
Q

What is the oxygen carrying content equation?

A

CaO2 = (SaO2 x Hgb x 1.34) + 0.003(PaO2)

CaO2 –> Oxygen carrying content

1.34 mL of O2 is bound to each gram of Hgb

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25
Q

What does the oxygen carrying content equation tell us about dissolved blood vs bound blood?

A

Only a fraction of O2 in blood is dissolved compared to bound O2

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26
Q

Why may blood loss formulas (MABL) not be accurate in determining estimated blood loss?

A

They consistently over estimate and under estimate blood loss

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27
Q

What traditional transfusion indicators have been abandoned due to causing unnecessary transfusions and reactions?

A

Hgb of 10 and Hct of 30%

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28
Q

What should transfusion determination be based upon?

A

Multiple factors –> This includes Hgb and Hct levels, as well as patients condition, vital organ perfusion, and anticipated blood loss during case

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29
Q

What does the AABB (American Association of Blood Banks) recommend as far as transfusion based decisions?

A

Evidence from multiple critical elements instead of one single factor

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30
Q

What does the ASA recommend clinicians doing in regard to bleeding risk?

A

Evaluate the patient throughout the entire perioperative period for bleeding

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31
Q

Erythropoietin is excreted by the ___________

A

kidneys

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32
Q

What alternative to blood replacement has shown a significant decrease in the need for allogenic blood transfusions across all surgical procedures?

A

Administration of erythropoietin preoperatively

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33
Q

What congenital or acquired diseases have shown increased complications with blood transfusions?

A

Sickle cell anemia, Factor VIII deficiency, liver disease, and idiopathic thrombocytopenia

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34
Q

Aspirin should be discontinued ____________ days prior to surgery

A

7-10

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35
Q

Warfarin should be discontinued _________ days prior to surgery

A

5

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36
Q

Certain procedures that anticipate significant blood loss may benefit from an _______________

A

antifibrinolytic (tranexamic acid) –> prevents the breakdown of clots by inhibiting plasminogen from turning into plasmin

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37
Q

What is an autologous transfusion?

A

A re infusion of the patients own blood or blood components that were salvaged during surgery or donated prior to

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38
Q

What are the three types of autologous donations?

A

Preoperative autologous donation, acute normovolemic hemodilution, and cell salvage (cell saver)

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39
Q

What is a preoperative autologous donation (PAD)?

A

Involves blood collection prior to surgery of the patients own blood –> Should be AT least 48-72 hours prior to allow for the patient to equilibrate

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40
Q

When can oral or intravenous iron be given?

A

During preoperative autologous donation to maintain proper erythropoiesis when patient has donated their blood.

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41
Q

What are contraindications to preoperative autologous donation (PAD)

A

Preexisting anemia, cyanotic heart disease, ischemic heart disease, aortic stenosis, or uncontrolled HTN

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42
Q

What are some complications of preoperative autologous donation (PAD)?

A

Bacterial contamination, increased costs, and 50% of collected blood is wasted because it is unused

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43
Q

What is acute normovolemic hemodilution?

A

Takes place in the OR –> patients blood in withdrawn here and replaced with crystalloids or colloids. Blood is given back toward the end of surgery or when hemostasis is achieved.

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44
Q

What is the working theory behind acute normovolemic hemodilution?

A

You dilute the blood so blood loss is minimized during surgery

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45
Q

What is the goal Hct level in acute normovolemic hemodilution?

A

20%

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46
Q

What is a potential complication in acute normovolemic hemodilution?

A

Hemodynamic instability due to a significant decrease in Hct

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47
Q

What are contraindications for acute normovolemic hemodilution?

A

Patients at risk for MI or those with significant organ damage that relies on stable Hct and Hgb

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48
Q

What is cell salvage?

A

The collection of the patients blood during surgery from suction and surgical drains –> This is filtered and washed and then re infused into the patient

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49
Q

What is an advantage to cell salvage?

A

Provides a supply of RBCs in proportion to the amount being lost.

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50
Q

What religious group may accept cell salvage therapy

A

Jehovah’s witnesses

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51
Q

Cell salvage can help reduce what 2 things?

A

Allogenic blood transfusions and postoperative anemia

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52
Q

Cell salvage should be used if blood loss of ____________ is anticipated

A

500 mL

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53
Q

What cell salvage filter should be used in cancer surgery?

A

leucodepletion filter

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54
Q

Trained personnel and equipment should be available ___________ a day in regard to cell salvage therapy

A

24 hours

55
Q

When is cell salvage contraindicated?

A

In patients with sepsis or some cancer surgeries

56
Q

What are some complications of cell salvage?

A

Electrolyte disturbances, dilutional coagulopathy, and DIC

57
Q

Using cell salvage can reduce the need of allogenic blood transfusions by __________

A

40%

58
Q

What is a direct donor transfusion?

A

Blood being donated from a family member or friend of the patient –> This can reduce the risk of transmission of diseases

59
Q

When should direct donor blood be collected?

A

At least 5 days prior to the patients procedure

60
Q

What are the two prerequisites prior to any blood transfusion?

A

ABO blood type and Rhesus antigen testing (usually antigen D)

61
Q

What antibodies are present in type O blood?

A

Anti-b and anti-a antibodies

62
Q

What antigens are present on type O blood?

A

NONE

63
Q

What does it mean if someone carries the Rhesus antigen?

A

They are + for whatever their blood type is –> A+, B+, AB+, or O+

64
Q

How is blood type determined?

A

By the presence or absence of antigens on the RBC

Present –> A, B, or AB
Absent –> O

65
Q

Where can the Rh antigen be found of the RBC?

A

Transmembrane protein that can be found on the surface of the RBC

66
Q

What Rh antigen is the most common?

A

Antigen D, this is also immunogenic

67
Q

What antibodies would you expect in a patient with type A+ blood?

A

Anti-B antibodies

68
Q

What antibodies would you suspect in a patient with type AB- blood?

A

None

69
Q

What does a type and screen test for?

A

Determines ABO type, presence of Rh D antigen, and other commonly known antibodies

70
Q

What does a crossmatch test?

A

Tests the patients blood against the prospective donor’s blood to determine if an adverse reaction occurs. “trial transfusion”

71
Q

What blood type is considered the universal donor?

A

O -

72
Q

What blood type is considered the universal recipient?

A

AB +

73
Q

In an emergency transfusion, what blood should be given?

A

O + –> People of childbearing age and have never received a O + blood transfusion in the past
O - –> When you are unaware of the patients transfusion history OR to a female of childbearing age

74
Q

If a patient is receiving type O blood in an emergency transfusion, when can they be switched back to their primary ABO blood type?

A

All 3 of these must occur
- When inventory permits
- When bleeding has slowed or stopped
- MOST IMPORTANTLY a recent crossmatch indicates compatibility with a sample of the patients blood

75
Q

What accounts for 50% of deaths after trauma?

A

Hemorrhage, within the first 24 hours of injury

76
Q

What three things determine a massive transfusion?

A
  • 10 units of PRBC’s in 24 hours
  • 5 units of RBC’s in 4 hours
  • Loss of one blood volume
77
Q

What has improved mortality in patients suffering from traumatic hemmorhage?

A

Early and rapid delivery of blood products and with a primary goal of treating acute coagulopathy.

78
Q

What blood product maintains tissue oxygenation?

A

PRBCs

79
Q

What blood product addresses coagulation issues?

A

FFP, platelets, and cryoprecipitate

80
Q

What is the plasma to RBC ratio for replacing depleted blood volume in massive transfusion protocols?

A

1:1 or 1:2

81
Q

You should transfuse at least 1 unit of platelets for every ________ units of RBC’s when following massive transfusion protocols

A

6

82
Q

More recent studies have lead massive transfusion protocols to infuse what three things to aid in clot formation?

A
  1. Calcium chloride (factor 4)
  2. Tranexamic acid (prevents clots from being dissolved via plasmin)
  3. Cryoprecipitate
83
Q

What is the benefit to administering parts of blood (RBCs, FFP, platelets, cryo) opposed to whole blood?

A

Allows for targeting specific patient needs

84
Q

What blood product should be given for urgent reversal of anticoagulation?

A

FFP –> Contains ALL clotting factors

85
Q

What is an indication to transfuse cryoprecipitate?

A

Hypofibrionogenemia or consumptive coagulopathy

86
Q

Why would you want to transfuse PRBCs?

A

To improve hemoglobin concentrations and oxygen carrying capacity

87
Q

How long are RBCs good for if stored if a refrigerator properly?

A

42 days –> 300 mL total volume with a Hct of 65%

88
Q

How much you expect Hbg and Hct to change when giving 1 unit of PRBCs?

A

1 unit = 1 g/dL increase in Hgb and a 2-3% increase in Hct

89
Q

What blood product is generally administered at 1 mL for every 2 mL of blood loss in adults?

A

PRBCs –> 600 mL blood loss = 1 unit of PRBCs (300mL)

90
Q

Pediatric patients experiencing blood loss should receive PRBC at an amount of __________ mL per kg and infants at __________ mL per kg

A

10-15, 15 –> Infants have larger blood volumes per kg than adults

91
Q

What are platelets essential for? When should they be transfused?

A

Hemostasis, transfused for platelet dysfunction ot thrombocytopenia

92
Q

What are alloantibodies? What if a patient has to receive a platelet transfusion but they have developed alloantibodies?

A

Alloantibodies are immune antibodies that are only produced following exposure to foreign red blood cell antigens
The patient will need single donor apheresis platelets, this comes at an increased expense –> compared to the normal method which it is separated from whole blood and collected from 6-10 donors

93
Q

After transfusing 1 unit of platelets, how would you suspect the patients platelet level to change?

A

Increase by 5-10,000

94
Q

Is ABO matching needed for transfusing platelets?

A

No, but is preferred because incompatibility can lead to shortened survival or plts and a small degree of hemolysis

95
Q

At what platelet count should platelets be transfused?

A

10,000 or less –> Who are stable and not bleeding to prevent spontaneous bleeding (20,000 per Reed’s slides)
50,000 or less –> For patients actively bleeding

96
Q

How long are platelets good for?

A

24 hours if open at room temp with continuous agitation
5 days if closed at room temp with continuous agitation

97
Q

How long are frozen RBC’s good for?

A

10 years at -80C

98
Q

What does FFP contain?

A

ALL CLOTTING FACTORS

99
Q

What is the most commonly used plasma product?

A

FFP

100
Q

How long can FFP be stored for?

A

1 year at -8 to -30 C if frozen within 8 hours

101
Q

What happens if FFP is not transfused within 24 hours of being thawed?

A

Factors V and VIII begin to decline

102
Q

What amount of FFP should be used for urgent warfarin reversal?

A

5-8 mL/kg

103
Q

When 10 - 20 mL per kg of FFP is transfused, how will coagulation levels change?

A

Increase by 20 - 30%

104
Q

What are the 4 Variables in the ABC score assessment for MTP?

A

*Pulse< 120bpm
*SBP< 90mmHg
*FAST- Focused Assessment with Sonography in Trauma
*Penetrating Torso Injury

105
Q

What does cryoprecipitate contain?

A

100 units of factor VIII, 200 mg of fibrinogen, fibronectin, and von Willebrand factor

106
Q

How is cryoprecipitate collected?

A

Thawing FFP to 4 C and collecting the precipitate via centrifuge

107
Q

When should cryoprecipitate be administered?
3 indications

A

Only patients actively bleeding with von Willebrand disease, fibrinogen levels less than 80-100 mg per dL, and prophylactically in patients with congenital fibrinogen deficiencies or von Willebrand disease who are unresponsive to desmopressin (DDAVP)

108
Q

What changes occur during blood stroage?

A

Blood undergoes structural and functional changes over time –> ATP and 2,3-diphosphoglycerate decrease while potassium levels increase. Acidosis and oxidative damage …

109
Q

Using RBCs after _____________ of collection, patients experienced reduction in short term and long term survival

A

2 weeks

110
Q

What is added to stored blood to prevent clotting?

A

citrate phosphatase dextrose (CPD) –> Can cause hypocalcemia

111
Q

What is the suggested platelet count prior to most surgical procedures?

A

At least 50,000

112
Q

What platelet count should a patient have prior to an endoscopy?

A

At least 30,000

113
Q

What are the most common reactions after receiving blood, although rare?

A

Fever and allergic reactions

114
Q

Acute vs delayed blood transfusion reactions?

A

Acute –> Generally more severe and occur within 24 hours of transfusion
Delayed –> Occurs days, months, and even years after transfusion

115
Q

What is the most susceptible blood product to bacterial contamination?

A

Platelets

116
Q

Blood product contamination increases in likely hood with ________________

A

Increased length of time blood is stored

117
Q

When administering blood in the OR, what can be masked by general anesthesia?

A

Acute hemolytic reactions –> unexplained hypotension, hemoglobinuria, or a hemorrhagic episode shortly after the start of the transfusion

118
Q

What is a hemolytic blood transfusion reaction?

A

The patients antibodies destroy the donors RBCs

119
Q

What are the presenting symptoms of an acute hemolytic reaction?

A

Pain at infusion site, fever, chills, back pain, substernal pain, altered LOC, dyspnea, hypotension, hemoglobinuria, tendency to bleed

120
Q

Acute hemolytic reactions are rare, but can lead to what?

A

Shock or DIC

121
Q

What should be done if patient experiences an acute hemolytic reaction?

A

Stop transfusion and provide hemodynamic support and fluids management with NS –> Severe reactions may need FFP, cryo, and platelets to counteract coagulopathies

122
Q

What is a delayed hemolytic reaction?

A

Much more common blood transfusion reaction occurring with a mild symptoms –> jaundice, decreased Hgb levels, and hemoglobinuria

123
Q

What patient population is at increased risk for developing delayed hemolytic reactions?

A

Obstetric patients and those who have received transfusions in the past.

124
Q

What is TRALI?

A

Transfusion related acute lung injury –> Occurs when alloreactive plasma antibodies within blood products lead to clumping and activation of leukocytes –> This causes acute lung injury and non cardiogenic pulmonary edema.

125
Q

What are symptoms of TRALI?

A

New acute lung injury within 6 hours of the transfusion –> Hypoxemia, ARD, increased peak airways, hypotension, and fever

126
Q

What is TACO?

A

Transfusion associated circulatory overload –> Leading cause of death in transfusion complications since 2016!
Pulmonary edema occurs due to large volumes of transfused products over a short period of time.

127
Q

What are some symptoms of TACO?

A

Respiratory distress or HTN within 6-12 hours after completing a transfusion
Other symptoms include hypoxemia, tachycardia, widened pulse pressure, JVD, rales and wheezing in the lungs.

128
Q

What is the primary treatment for TACO?

A

Supplemental O2 and fluid mobilization via diuretic therapy, as well as ventilatory support

129
Q

Symptoms of an IgE related reaction

A

Allergic reaction –> usually minor and limited to urticaria and erythema –> Treated with diphenhydramine

130
Q

The patient will have a more severe allergic blood transfusion reaction if _______ deficient

A

IgA

131
Q

When would an IgA deficient patient develop a severe blood transfusion reaction?

A

Upon second exposure to IgA containing blood products –> First exposure would cause patient to develop IgE antibodies to IgA

132
Q

What type of blood should be given to patients who have experienced an anaphylactic reaction in the past?

A

Washed blood, which removes IgA

133
Q

In a severe, IgA mediated reaction to a blood transfusion, what symptoms would you expect the patient to present with?

A

Anaphylaxis –> bronchospasm, dyspnea, and hypotension –> Can occur with a little as a few mL of blood

671A - Anesthesia I (22 decks)

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