blood Flashcards
(43 cards)
The most appropriate order of blood products transfused sequentially through the
same blood administration set is:
A) RBC - plasma - plts
B) RBC - plts - plasma
C) Plasma - RBC - plts
D) Plts- RBC -plasma
D) Plts- RBC -plasma
according to Lifeblood guidelines, platelets MUST be given before RBC if in the same line, as red cell debris will trap platelets; platelets and plasma can be sequential through the same set; as platelets take a long time to transfuse, it makes sense to first transfuse plasma (fast), then platelets, then red cells
A medication that would be acceptable to a patient who refuses all products derived
from human plasma is:
a) Prothrombinex
b) Activated factor 7
c) Fibrinogen concentrate
d) Albumin
e) anti-d
Factor 7 - Recombinant, made from baby hamster kidney cells
Albumin - Alburex® 5 AU (Human Albumin 50 g/L) is an Australian manufactured albumin product
Fib con - Lyophilised precipitate. manufactired from cryoprecipitate.
PCC - Prothrombinex-VF® is a lyophilised concentrate of human coagulation factors containing factors II, IX and X and a small amount of factor VII.
Red cross lifeblood.
Correct answer is rVIIa
NP Once a unit of fresh packed red blood cells has been removed from controlled refrigeration the transfusion should be completed within
a) 2.5 hours
b) 3 hours
c) 3.5 hours
d) 4 hours
REPEAT
4 hours
As per Lifeblood
Start the transfusion as soon as possible after removing the blood component from approved temperature-controlled storage. Transfusion of each pack should be completed prior to the labelled expiry or within four hours, whichever is sooner.
Redcross: “Transfusion of each pack should be completed prior to the labelled expiry or within four hours, whichever is sooner. “
Shelf life of platelets: 5 days (Stored at 20-24 degrees, must be agitated gently and continuously)
FFP: Once FFP is thawed, must use within 24 hours.
Albumin administration: At RCH we allow the product to be administered within 6 hours of piercing the bottle. (from RCH.org)
Cryoprecipitate
Thawed cryoprecipitate should be maintained at 20°C to 24°C until transfused.
Once thawed, should be used within six hours if it is a closed single unit, or within four hours if it is an open system or units have been pooled.
The correct blood collection tube for a mast cell tryptase test is a:
a. Potassium EDTA
b. serum separating tube
c. sodium citrate
d. sodium oxalate something
REPEAT
b. serum separating tube (gold top tube or red)
Potassium EDTA (purple)
-> FBC
sodium citrate (blue)
-> clotting screen/Rotem
sodium oxalate (green)
-> heavy metals (lead copper zinc)
20.2 If group A Rh-ve fresh frozen plasma is not available for use in an A Rh-ve patient, of the following your next best choice should be
a. A+
b. B-
c. AB+
d. O+
e. O-
a. A+
Group A Plasma component preference
1st choice: A
2nd Choice: AB
3rd Choice: B
[a] If the patient is a female of childbearing potential, O RhD negative red cells should be used until the patient’s blood group is established.
[b] Group A platelets with the A2 subgroup don’t express significant amounts of A antigen and are therefore preferable to other group A platelets when transfusing group O and B recipients.
[c] Apheresis platelets that have a low titre anti-A/B or pooled platelets pose a lower risk of haemolysis when transfusing ABO incompatible components.
[d] Plasma components that have low titre anti-A/B pose a lower risk of haemolysis when transfusing ABO incompatible components.
[e] Group A plasma may be used as per local institutional policies.
If no A, use AB Rh + cryo (Ie; no anti A or anti B)
Cryo incompatible can be given, but large volumes are high risk for DIC
https://litfl.com/cryoprecipitate/
21.2 You have been asked to provide general anaesthesia for a complex thoracic endovascular aortic aneurysm repair. After the placement of a lumbar drain the recommended safe time before the administration of intravenous heparin is
a) 1 hour
b) 4 hours
c) 6 hours
d) 12 hours
1 hour
ASRA: 1 hour
Although the occurrence of a bloody or difficult neuraxial needle placement may increase risk, there are no data to support mandatory cancellation of a case. Direct communication with the surgeon and a specific risk-benefit decision about proceeding in each case are warranted.
Currently, insufficient data and experience are available to determine if the risk of neuraxial haematoma is increased when combining neuraxial techniques with the full anticoagulation of cardiac surgery. We suggest postoperative monitoring of neurologic function and selection of neuraxial solutions that minimise sensory and motor block to facilitate detection of new/progressive neurodeficits.
NYSORA:
Administration of intravenous heparin intraoperatively should be delayed for at least 1 hour after epidural placement; a delay before administration of subcutaneous heparin is not required. In cases of full heparinization for CPB, additional precautions include delaying surgery for 24 hours in the event of a traumatic tap, tightly controlling the heparin effect and reversal, and removing catheters when normal coagulation is restored.
22.2 The medication most strongly associated with an acute primary hypotensive reaction following transfusion of blood products is
a. aspirin
b. celecoxib
c. hydralazine
d. metoprolol
e. labetalol
f. perindopril
f. perindopril
Hypotensive transfusion reactions, which account for almost 3% of all transfusion reactions, are associated with patients treated with angiotensin-converting enzyme inhibitors. The current hypothesis suggests that they are caused by bradykinin-induced vasodilation in the absence of allergic, hemolytic, or septic mechanisms. The hypotension observed frequently is unresponsive to conventional therapy with catecholamines. The suggested intraoperative management includes cessation of transfusion and washing red blood cells before blood replacement.
Hypotensive reactions to transfusion may not always be recognized. To prevent these reactions, clinicians have several options: they may discontinue the ACE inhibitor (elective transfusion), not use a leukoreduction filter (if the patient has no absolute requirement for leukoreduced blood components), use washed cellular components, or use components that have undergone leukoreduction at the collection facility or the hospital blood bank before transfusion (since bradykinin is degraded during storage).
22.1 A patient in atrial fibrillation with a CHA2DS2-VASc score of 2 has presented for elective hip surgery. Warfarin had been ceased for four days preoperatively and on the day before surgery the international normalized ratio (INR) was 2.1. The best course of action at this point is to
a) Postpone surgery
b) Vitamin K 3mg IV
c) Prothrombinex 25IU/kg
d) Cell saver intraop
e) Proceed with surgery
Give 3mg of Vitamin K and re-check on day of surgery proceed if INR <1.5 on DOS
21.2 In a patient with anaemia of chronic disease, of the following the most likely to be elevated is
a. MCV
b. transferrin saturation
c. Increased soluble Transferrin Receptor
d. Ferritin
e. Total iron binding capacity
d. Ferritin
ANZCA blue book:
ACD caused primarily by inflammation
Mechanism:
1. Iron
- Inflammation reduces Iron availabilty as a protective mechanism whereby Iron is sequestered and stored in macrophages to limit availability to microbial pathogens
- Hepcidin expression is increased, this prevents the release of Iron by reticuloendothelial system resulting in “functional iron deficiency” with reduced tissue availability of iron, despite apparently normal total body iron stores. (hence increased Ferritin)
- Response to erythropoietin
- mechanism not clear suspect blunting of response to erythropoietin - Therapeutic agents
chemotherapies that impair bone marrow response to erythropoiesis
65% of patients with lung and gynae cancer treated with platinum based drug develop anaemia
RCPA advice on interpretation of Soluble Transferrin Receptor:
Soluble transferrin receptor levels in plasma are elevated if there is increased iron demand due to Iron deficiency, increased erythropoiesis (eg, Haemolysis) or dyserythropoiesis (eg, Megaloblastic anaemia), regardless of other, coexistent states.
Thus, it can be used to demonstrate iron deficiency in patients who also have an acute phase response and it can distinguish Iron deficiency from the Anaemia of chronic disease.
Patients with an acute phase response have reduced plasma iron and transferrin with elevation of Ferritin, making these usual indicators unreliable.
A previously healthy 22-year-old man is involved in an altercation and sustains a ruptured spleen. During splenectomy he is transfused with packed red blood cells. One hour into the transfusion his SpO2 rapidly decreases, his ventilator pressures
increase, frothy sputum appears in the endotracheal tube and he is febrile. The likely cause is:
a) TRALI
b) TACO
AT
a) TRALI
Both TACO and TRALI are characterised by:
- hypoxia
- acute dyspnoea
- diffuse bilateral infiltrates
However, presence of fever is more in keeping with TRALI.
Reference:
Distinguishing between transfusion related acute lung injury and transfusion associated circulatory overload Robert C. Skeatea and Ted Eastlund
Kate A bleeding patient has ROTEM results including: [table attached]. The most
appropriate treatment is:
a) Fibrinolysis
LINDON
20.2 If group A Rh-ve fresh frozen plasma is not available for use in an A Rh-ve patient, of the following your next best choice should be
a. A+
b. B-
c. AB+
d. O+
e. O-
a. A+
Group A Plasma component preference
1st choice: A
2nd Choice: AB
3rd Choice: B
[a] If the patient is a female of childbearing potential, O RhD negative red cells should be used until the patient’s blood group is established.
[b] Group A platelets with the A2 subgroup don’t express significant amounts of A antigen and are therefore preferable to other group A platelets when transfusing group O and B recipients.
[c] Apheresis platelets that have a low titre anti-A/B or pooled platelets pose a lower risk of haemolysis when transfusing ABO incompatible components.
[d] Plasma components that have low titre anti-A/B pose a lower risk of haemolysis when transfusing ABO incompatible components.
[e] Group A plasma may be used as per local institutional policies.
If no A, use AB Rh + cryo (Ie; no anti A or anti B)
Cryo incompatible can be given, but large volumes are high risk for DIC
https://litfl.com/cryoprecipitate/
22.1 A normal sized six-year-old girl has a haemoglobin of 70 g/L following surgery. The volume of packed red blood cells that you would plan to infuse to raise her haemoglobin to 80 g/L is
a. 80ml
b. 100ml
c. 120ml
d. 180ml
e. 200ml
b. 100ml
Paediatric weight estimation:
Luscombe: Weight (kg) = (age x 3) + 7
RCH: Weight (kg) = (age + 4) x 2
Formula for calculating transfusion volume (mL)
Children <20 kg:
PRBC (mL) = wt (kg) x Hb (g/L) rise (desired Hb – actual Hb) x 0.5 (transfusion factor)
Children >20 kg: 1 unit PRBC
Example:
6 + 4 x 2 = 20kg
20kg x 10g/l x 0.5 = 100ml
22.1 In comparison with fresh frozen plasma, cryoprecipitate contains an increased concentration of factor
a. II
b. VII
c. XI
d. XIII
d. XIII
But Fibrinogen (I) is the most significant factor that
20.2 The composition of Plasma-Lyte 148 (in mmol/l) includes
a Na 140 Mg 1.0 K 5.0 acetate 27 lactate 0
b Na 140 Mg 1.5 K 5.0 acetate 0 lactate 27
c Na 140 Mg 1.0 K 4.0 acetate 24 lactate 0
d Na 140 Mg 1.0 K 4.0 acetate 0 lactate 24
e Na 140 Mg 1.5 K 5.0 acetate 27 lactate 0
e Na 140 Mg 1.5 K 5.0 acetate 27 lactate 0
20.1 What is the level below which we need to replace fibrinogen in a pregnant patient with a PPH
A. <1 g/L
B. <1.5 g/L
C. <2 g/L
D. <2.5 g/L
E. <3 g/L
<2g/L
21.2 Cryoprecipitate contains all of the following EXCEPT
a) Factor I
b) Factor VII
c) Factor VIII
d) VWF
e) Fibronectin
b) Factor VII
Redcross:
Cryoprecipitate contains most of the following found in fresh frozen plasma:
1. factor VIII
2. fibrinogen
3. factor XIII
4. von Willebrand factor
5. fibronectin
Prothrombinex-VF® is a lyophilised concentrate of human coagulation factors it contains:
Factors:
II
IX
X
small amount of factor VII.
Also contains:
plasma proteins (human)
Antithrombin III (human)
Heparin sodium (porcine)
Sodium
Phosphate
Citrate
Chloride
23.1 Cryoprecipitate contains coagulation factors
A. 2, 8, 13, von willebrands
B. 1, 7, 13 , von willebrands.
C. 1, 8, 13, von willebrands.
D. 2, 7, 13, von willebrands.
C.
Cryoprecipitate contains Factor VIII, XIII, fibrinogen (factor I), fibronectin, vWF
https://www.lifeblood.com.au/health-professionals/products/blood-components/cryoprecipitate
22.1 When fresh frozen plasma is administered to treat hypofibrinogenaemia in a bleeding patient, the volume required to achieve an increase in plasma fibrinogen concentration of one gram per litre is
A. 5 ml/kg
B. 10 ml/kg
C. 20 ml/kg
D. 30 ml/kg
E. 50 ml/kg
D. 30 ml/kg
Identification and Management of Obstetric Hemorrhage
Anesthesiology Clinics - Obstetric Anesthesia (2017)
https://www.anesthesiology.theclinics.com/article/S1932-2275(16)30074-X/fulltext
Although FFP, cryoprecipitate, and fibrinogen concentrates can all be used to increase fibrinogen levels, the optimal strategy for managing hypofibrinogenemia in obstetric hemorrhage is unclear. The relatively low concentration of fibrinogen in FFP limits its usefulness in the treatment of significant hypofibrinogenemia. To increase fibrinogen plasma level by 1 g/L, 30 mL/kg of FFP is necessary, increasing the risk of pulmonary edema and other hypervolemic complications. Cryoprecipitate, which is a concentrated source of fibrinogen, factor VIII, fibronectin, von Willebrand factor (vWF), and factor XIII, will increase fibrinogen levels by ~0.7 to 1 g/L for every 100 mL given. Although cryoprecipitate is associated with a lower transfusion volume, the standard “dose” (10 U) is typically prepared by pooling concentrates from multiple donors. Given the risk of infectious disease transmission and/or an immunologic reaction from exposure to multiple donors, several countries preferentially use purified, pasteurized fibrinogen concentrate for the treatment of congenital and/ or acquired hypofibrinogenemia. Fibrinogen concentrates are also prepared from large donor pools, but subsequent processing removes or inactivates potentially contaminating viruses, antibodies, and antigens. Studies comparing cryoprecipitate and fibrinogen concentrates utilization in hemorrhage resuscitation suggest fibrinogen concentrates are associated with lower blood loss, decreased RBC transfusion, and greater increases in plasma fibrinogen levels. Although the most appropriate method of fibrinogen replacement is somewhat controversial, the critical role of fibrinogen in reversing the coagulopathy accompanying obstetric hemorrhage is clear. As such, close monitoring and replacement of fibrinogen are crucial in the management of the bleeding parturient.
22.2 Normal (0.9%) saline has the physical properties of
a. Na 140, 280 mOsm/L
b. Na 148, 296 mOsm/L
c. Na 150, 300 mOsm/L
d. Na 154, 308 mOsm/L
D Na 154, 308 mOsm/L
21.1 The composition of blood returned to the patient from intraoperative cell salvage shows
A. No evidence of haemolysis
B. Normal 2,3 DPG
C. Nil evidence of bone cement or some embolism type
D. Normal levels of coagulation factors
B. Normal 2,3 DPG
higher Hct-60%
No immunimodulation
require reinfusion within 6hrs
pause with sement, caution metal fragments
20.2 Of the following, the agent that causes the LEAST prolongation of the Thrombin Clotting Time (or Thrombin Time) is
a) Heparin
b) LMWH
c) Bivalirudin
d) Warfarin
e) Dabigatran
d) Warfarin
Warfarin – no effect on thrombin time
Heparin - causes considerable prolongation of TT.
LMWH, fondaparinux or direct factor Xa inhibitors have no effect on TT as the predominantly inhibit factor Xa.
-> However LMWH in very high concentration can affect TT.
Dabigatran, Bivalirudin and other direct thrombin inhibitors prolong TT considerably.
The thrombin time (TT), also known as the thrombin clotting time (TCT) is a blood test that measures the time it takes for a clot to form in the plasma of a blood sample containing anticoagulant, after an excess of thrombin has been added. Warfarin prevents thrombin synthesis but does not inhibit it, therefore no effect on TT.
21.2 A bleeding patient has ROTEM results including (results displayed) . The most appropriate treatment is
a) Cryoprecipitate
b) FFP
c) Platelets
d) TXA
e) Protamine
e) Protamine
The interpretation of this graph is not especially laborious. The cardinal abnormality is the massively prolonged CT and CF of the INTEM graph, which suggests that something has killed the intrinsic pathway of the clotting cascade. The CT returns to normal in the HEPTEM graph, which is essentially just an INTEM test with adde heparinase. The presence of heparinase seems to have reversed all of the coagulopathy - the CFT, alpha-angle and MCF have all returned to normal. Therefore, this patient has no coagulation problems other than the heparin.
https://derangedphysiology.com/main/required-reading/haematology-and-oncology/Chapter 1.2.0.1/intepretation-abnormal-rotem-data
