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Flashcards in topic 8 Deck (87)
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1
Q

Avg #of units required:

Car Accident

A

50 units of blood

2
Q

Avg #of units required:

Heart Surgery

A

6 units of blood

6 units of platelets

3
Q

Avg #of units required:

Organ Transplant

A

40 units of blood
30 units of platelets
20 bags of Cryo
25 units FFP

4
Q

Avg #of units required:

Bone Marrow Transplant

A

120 units of platelets

20 units of blood

5
Q

Avg #of units required:

Burn

A

20 units of platelets

6
Q

% of open heart patients that require transfusions

A

30-70%

Leads to 2-4 donor exposures

7
Q

Percentage of all RBC units transfused in US occur during CABG procedures.

A

10%

8
Q

Blood usage in US is significantly ________ than other Western countries

A

higher

9
Q

Blood is a

A

liquid transplant

10
Q

Blood transfusions cause

A

changes in the immune system

11
Q

new transfusion=

A

new donor

12
Q

Blood transfusions lead to complications such as

A

Post op infections
Ventilator-acquired pneumonia
Central line sepsis
Increased LOS, mortality rates.

13
Q

Transfusion risks- infections

A

Bacterial
Hepatitis
HIV

14
Q

Transfusion risks non-infectious:

Febrile Fever=

A
  • Fever, chills
  • Pt antibodies are reacting with white cell antigens or white cell fragments in the transfused blood products.
  • OR- due to cytokines which accumulate during storage.
  • Most common with platelet transfusions
15
Q

Transfusion risks non-infectious:

Uticarial (Allergic) Reactions=

A

1%
Urticaria, itching , flushing
Caused by foreign proteins

16
Q

Transfusion risks non-infectious:

Anaphylactic Reactions

A

Hypotension, tachycardia, cardiac arrhythmia, shock, cardiac arrest

  • caused by patients who have IgA deficiency who have anti-IgA antibodies.
  • Require special washed/ tested blood products
17
Q

Transfusion risks non-infectious:

Acute Hemolytic Reactions

A
  • Caused by transfusion of ABO incompatible blood

- Chills, fever, pain, hypotension, dark urine, uncontrolled bleeding due to DIC

18
Q

Transfusion risks non-infectious:

Hyopthermia

A

Caused by transfusion of too many cold blood products

19
Q

Transfusion risks non-infectious:

Volume…

A

overload

20
Q

Transfusion risks non-infectious:

Citrate Toxicity

A
  • Metabolized by liver
  • Rapid transfusion of large quantity of blood products
  • Binds calcium and magnesium – depleting stores
  • Myocardial depression
  • Coagulopathy
21
Q

Transfusion risks non-infectious:

Potassium Effects

A
  • Stored RBC leak K+
  • Irradiation increased the rate of leak
  • Cardiac effects
22
Q

Transfusion Related Acute Lung Injury

◦Symptoms

A

Similar to ARDS

-Hypotension, Fever, Dyspnea, Tachycardia

23
Q

Transfusion Related Acute Lung Injury (TRALI) =

A

Non-Cardiogenic pulmonary edema with diffuse bilateral pulmonary infiltrates on CXR
◦Occurs within 6 hours of tx- Most cases present w/in 1-2 hours
◦All blood products are culprits
◦Occurs 1/2000 transfusions

24
Q

TRALI is attributed to

A

HLA Antibodies
Granulocyte antibodies
Biologically active mediators in the blood.

25
Q

TRALI treatment

A

Ventilator support for ~96 hours

26
Q

TRALI mortality

A

5-10%

27
Q

Clinically, transfusions are associated with

A

Longer hospital stays
Longer time to extubation
Morbidity
Mortality

28
Q

9 techniques to minimize blood usage

A
  1. Autologous transfusion
  2. Pre-bypass autologous donation
  3. Intraoperative Cell Saver use
  4. Shed mediastinal blood recovery
  5. Accept lower hematocrit
  6. Retrograde Autologous Priming
  7. Hemoconcentration
  8. Plasma/Platelet Pheresis
  9. Mini-circuits
29
Q

Bloodless medicine=

A

MULTIMODALITY and MULTIDISCIPLINARY approach to patient care without the use of allogenic blood.
-AKA: Transfusion-Free Medicine

30
Q

Blood conservation=

A

Global concept aimed at reducing patient exposure to allogenic blood products. Does not exclude use

31
Q

Denton Cooley (Early 1960’s)=

A

Published article in the American Journal of Cardiology (1964) titled Open heart surgery in the Jehovah’s Witness”

  • Described his techniques for treating these patients
  • 1977 – reported experience with 500 JW patients
32
Q

World War 1=

A

Blood Anticoagulation

  • Allowed for transport of blood to the wounded
  • PROBLEM: Storage
33
Q

World War 2=

A

Storage problem overcome with the advent of blood banks

34
Q

1953=

A

Use of blood alternatives

  • Switched from plasma to Dextran (volume expander)
  • Sugar substrate
  • Due to incidence of hepatitis transmittal
35
Q

1985=

A

Started looking into “blood substitutes”

Searched for oxygen carrier

36
Q

Introduction of cell savers

A

Surgeon Gerald Klebanoff (Vietnam Vet) introduced the first cell saver in a military hospital

37
Q

Recombinant Factor VIIa

A
  • Hemopheliacs

- Israeli army discovered potential to stop life threatening hemorrhage

38
Q

Currently, there are more than ___ organized bloodless programs in the US

A

100
There is a huge demand
-Patients are asking for it

39
Q

Pre-op history: Age

A

tolerance of anemia is age dependent
Elderly don’t tolerate
As age increases, risk of transfusion increases

40
Q

Pre-op history: Gender

A
  • women are more likely than men to get transfused

- Lower hct and prone to blood loss with menses

41
Q

Pre-op history: Height/weight

A
  • required to do calculations

- Small patients and obese patients are at risk for transfusion

42
Q

Pre-op history: race/ethnicity

A

Anemia and Coagulation disorders are associated with certain races

43
Q

Ask about patient-related obstacles to transfusion-free therapy:

A
◦Anemia
◦Hemostatic disturbances
◦Medical conditions increasing perioperative blood loss
◦Obstacles to surgical hemostasis
◦Factors decreasing anemia tolerance
44
Q

Pre-op lab work

A

Hgb
PT/INR / PTT
Platelet Count and Platelet Function Tests

45
Q

Pre-op treat any:

A
  • coagulopathies

- anemia: Optimize Hgb prior to surgery

46
Q

Pre-op treat polycythemia

A
  • Risk of hemorrhage during surgery (hyperviscosity)

- Plebotomy

47
Q

Pre-op avoid pharmacological coagulopathies

A

Drugs (not anticoagulants) than have increased bleeding risk

-NSAIDs, PCN, NTG, High dose Vitamin C, St. John’s Wort, Ginger, Garlic, etc.

48
Q

Anesthesiologist is a good resource to help detect any

A

obstacles in blood management

49
Q

Anesthesia helps to

A
  • correct any coagulopathies/anemia preop.
  • Help position the patient to decrease blood loss
  • Provide controlled hypotension
50
Q

Keeping the patient

A

Optimizes clotting

51
Q

Anesthesia Timing of fluid administration

A
  • Restrict until surgical hemostasis is achieved

- Intravascular pressure is not too high

52
Q

Autologous Donation=

A

Donation where the donor and recipient are identical

  • Patient donates blood to be used on themselves during surgery.
  • Avoids use/ risks of donor blood
53
Q

Auto donation Requires a hematocrit of

A

33%

54
Q

Auto donation contraindications:

A
Recent MI
CHF
Aortic Stenosis
Transient Ischemic Attacks
Hypertension
Unstable Angina
Bacteremia
55
Q

Auto Donation:

Donation of whole blood can be split

A
  • Allows not only donation of RBC, but also FFP

- Requires special order from physician

56
Q

Auto Donation:

Plateletpheresis and Plasmapheresis

A

Allows the donation of platelets and plasma

57
Q

Prebypass autologous normovolemic hemodiultion=

A
  • Used to remove blood from the patient pre-bypass for transfusion later in the case.
  • Removed volume is replaced with crystalloid
58
Q

Prebypass autologous normovolemic hemodiultion Spares platelets from bypass and requires a hct of

A

35%

59
Q

Prebypass autologous normovolemic hemodiultion: remove about

A
500-1000mL (1-3 units)
◦Depends on starting hct
◦Depends on age of patient
◦Depends on BSA
◦Depends on coexisting conditions
60
Q

Prebypass autologous normovolemic hemodiultion: Blood is placed in a bag with

A

anticoagulant

◦Usually CPD

61
Q

Prebypass autologous normovolemic hemodiultion: Reinfused after

A

protamine is administered

62
Q

Prebypass autologous normovolemic hemodiultion: contraindications

A
◦COPD
◦CHF
◦CAD
◦Unstable Angina
◦Renal Insufficiency
◦Severe Aortic Stenosis
◦Coagulopathy
63
Q

Dry Venous Line=

A
  • Requires the use of VAVD
  • Venous line is emptied prior to connection to the venous cannula
  • Volume is removed to a bag and discarded or sequestered
  • Eliminates about 400-1000mL
64
Q

Dry Venous Line cautions=

A
  • Only works if patient has adequate volume pre-op

- If patient is dry, will need the volume anyways

65
Q

Mini Circuit=

A

AKA: Miniaturized Extracorporeal Circuits
Decreases foreign surface area
Decreases prime volume
Decreases blood-air contact

66
Q

Mini Circuits attempt to:

A
  • Decrease hemodilution
  • Decrees inflammatory response
  • Decrease volume shifts
67
Q

Mini Circuit setup

A

Closed A-V Loop with centrifugal pump, membrane oxygenator, coated tubing
◦No venous reservoir
◦No cardiotomy
◦Often no heat exchanger or arterial line filter
◦Centrifugal pump provides kinetic assisted venous drainage and blood flow

68
Q

Mini Circuit prime volume

A

500mL

◦Can be decreased with RAPing

69
Q

Mini Circuits are mainly used for

A

CABGs

◦Some valves have been done

70
Q

Mini Circuits- 2 types=

A

Totally Integrated Devices

Combination of components

71
Q

Mini Circuit: Totally Integrated Devices

A

Include air handling and elimination systems, centrifugal pump and membrane oxygenator.

  • CorX (Cardiovention)
  • Cobe Synergy
72
Q

Mini Circuit: Combination of components

A

MECC System (Jostra)
MCPB
DeltaStream ERP (Medos)
Resting Heart System (Medtronic)

73
Q

Mini Circuit benefits

A
  • Less inflammatory reaction
  • Less activation of coagulation and fibrinolysis
  • Less hemodilution
  • Less use of autologous blood
  • Marginally improved renal and neurological function
74
Q

Mini Circuit: variables impacting outcomes

A
steroids
Aprotinin
degree of heparinization
type of tubing coating
patient population
75
Q

Mini Circuit Concerns

A
  • Air handling
  • Requires surgeon to take care to avoid air entrapment around the cannula
  • More microemboli with MECCs compared to normal circuits
  • No reservoir = no way to handle excess volume
  • No immediate volume infusion
  • No heat exchanger (on most)
  • Use of separate cell saver (Delay in processing, loss of factors/platelets)
  • Increased cost
  • Adaptability when surgical complications/ need requires normal ECC
76
Q

Things you can do instead of using mini circuits

A
  • Cut lines short
  • Get as close to the table as possible
  • Elevate the reservoir: Use VAVD
  • Put modular pump heads near outlet/inlet of oxygenator
  • Dry venous line: Requires VAVD
  • Go on with low prime volume
77
Q

Ultrafiltration/hemoconcentors=

A

Filtration of water across a semipermeable membrane via hydrostatic pressure gradient

  • Water crosses the membrane which creates a solute concentration gradient
  • Solutes have a higher concentration in blood so they move to the water side which has a lower solute concentration
78
Q

Ultrafiltration/hemoconcentors removes

A

water and electrolytes

79
Q

Ultrafiltration/hemoconcentors: Z-BUFing

A

you need to make sure to add sodium bicarb to the normal saline you’re Z-BUFing with to avoid acidosis

80
Q

Modified Ultrafiltration (MUF)=

A
  • Withdrawing blood from the patient via the arterial line (post bypass)
  • Running the blood through a hemoconcentrator
  • Pumping the blood back into the patient via the venous line
81
Q

Modified Ultrafiltration (MUF) is primarily used in

A

pediatrics

82
Q

Modified Ultrafiltration (MUF): Can use the cardioplegia circuit

A

Make sure to flush out the cardioplegia solution with blood
◦Already have a roller pump, bubble trap, heat/exchanger, line pressure monitor, already connected to the arterial line.
◦Risk of air entrapment around the arterial cannula: Don’t transfuse up the arterial cannula once started MUF
◦Pump flow rate less than MUF flow rate.

83
Q

Cell saving=

A
  • Use heparinized saline or CPD as an anticoagulant
  • Cells are separated from the fluid by a centrifuge
  • RBC fall to the bottom, Plasma on top
  • RBC washed with 3x bowl volume (min)
  • Put in a reinfusion bag for administration
84
Q

Cell saving removes

A
Fat
air
tissue debris
potassium
hormones
bioactivators
85
Q

Cell saving limitations

A
◦Delay in processing
◦Loss of plasma proteins
◦Loss of coagulation factors and platelets
◦Expense
◦Operator attention and time
86
Q

Reinfusion of shed blood

A
  • Blood collected from the mediastinum and pleural cavities post op can be reinfused
  • Doesn’t clot due to defibrination
  • Increased level of free Hgb
  • Contains activated products
87
Q

Cardiopat=

A
  • Shed blood can be collected and processed
  • Uses a dynamic disk to process.
  • Processes a variable volume of blood
  • Consistently delivers washed RBCs w/ hct of 70-80%
  • Processes up to 2 liters per hour or as little as 5 mL of RBCs