Blood Conservation- Exam 1 Flashcards Preview

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Flashcards in Blood Conservation- Exam 1 Deck (75):
1

Blood Transfusion Complications (General)

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

2

2 Types of Transfusion Risks

Infectious
Non-infectious

3

Types of Infectious Transfusion Risks

Bacterial
HIV
Hepatitis

4

Types of Non-Infectious Transfusion Risks

Febrile Rxns
Urticarial (Allergic) Rxns
Anaphylactic Rxns
Acute Hemolytic Rxns
Volume Overload
Hypothermia
Citrate Toxicity
Potassium Effects

5

Febrile Reactions

Fever, chills
Antibodies reacting w. white cell antigens or white cell fragments in transfused blood products or due to cytokines which accumulate during storage
Most common with platelet transfusions

6

What non-infectious reaction is most common with platelet transfusions?

Febrile Reactions

7

Urticarial (Allergic) Reactions

1%
urticaria, itching, flushing
caused by foreign proteins

8

Anaphylactic Reactions

Hypotension, tachycardia, cardiac arrythmia, shock, cardiac arrest
caused by patients who have IgA deficiency who have anti-IgA antibodies (require specially washed/tested blood products)

9

Acute Hemolytic Reactions

Caused by transfusions of ABO incompatible blood
Chills, fever, pain, hypotension, dark urine (plasma free hgb) uncontrolled bleeding due to DIC

10

Volume Overload

Not on bypass; big concern in ICU; no where for volume to go

On bypass- can tx a lot of rxns and can prevent volume overload

11

Citrate Toxicity

Metabolized by liver
Rapid transfusion of large quantiity of blood products
Binds calcium and magnesium- depleting stores
Myocardial depression
Coagulopathy

12

Potassium Effects

Stored RBC leak K+
Irradiation increased the rate of leak
Cardiac effects (must give slowly or they could go into cardiac arrest)

13

TRALI

transfusion related acute lung injury

14

TRALI Symptoms

Similar to ARDS
Hypotension, fever, dyspnea, tachycardia

15

What is TRALI?

Non-cardiogenic pulmonary edema with diffuse bilateral pulmonary infiltrates on CXR

16

How fast can TRALI occur?

Occurs within 6 hours of tx
Most cases present within 1-2 hours

17

What are the culprits for causing TRALI?

All blood products

18

How common is TRALI?

1/2000 transfusions

19

TRALI Pathophysiology

Unclear.
Attributed to HLA Antibodies, Granulocyte antibodies and biologically active mediators in the blood

20

What is the Tx for TRALI?

Ventilator support for ~96 hours

21

What ii TRALI mortality?

5-10%

22

Clinically, transfusions are associated with....

Longer hospital stays
Longer time to extubation
Mobidity
Mortality

23

What are some techniques to minimize our impact on blood usage?

Autologous transfusion
Pre-bypass autologous donation
Intraoperative cell saver use
Shed mediastinal blood recovery
Accept lower HCT
RAP
Hemoconcentration
Plasma/Platelet Pheresis
Mini-circuits

24

Bloodless Medicine

Transfusion-free medicine
Multimodality and Multidisciplinary approach to patient care without the use of allogenic blood.

25

Blood Conservation

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

26

Jehovah's Witness booklet related to bloodless medicine

Blood, Medicine, and the law of God (1961)
-Transfusion rxns
-Transfusion related syphilis, malaria, hepatitis

27

Which doctor took JW tranfusion requests to heart?

Denton Cooley (1960's)

28

What is Cooley's 1964 publication

Open Heart Surgery in the JW; described techniques for treating these patients

1977- reported experience with 500 JW patients

29

How did the military contribute to blood management?

Did surgery on wounded soldiers before transfusions were even available

confronted with blood loss but not way to replace the blood; stopped bleeding promptly and effectively

30

WWI and Blood Management

Blood Anticoagulation
Allowed for transport of blood to the wounded
Problem: Storage!

31

WWII and Blood Management

Storage problem overcome with the advent of blood banks

32

What blood management development occurred in 1953?

Use of blood alternatives
Switched from plasma to Dextran (volume expander) deue to incidence of hepatitis transmittal

33

Dextran

Sugar substrate, used outside US instead of plasma in 1953

34

What blood management develoment occured in 1985?

Started looking into blood subsitutes; military role
Searched for oxygen carrier

35

Who introduced the first cell saver in a military hospital?

Surgeon Gerald Klebanoff (Vietnam Vet)

36

What is significant about Recombinant Factor VIIa?

Hemopheliacs
Israeli army discovered potential to stop life threatening hemorrhage (used aprotinin before)

37

How many organized bloodless programs are in the US?

More than 100

38

What is the major variable related to percent transfusions?

Institution physicians (not patients!)

39

What should be obtained in a focused patient Hx pre-op?

Age
Gender
Weight/Height
Race/ethnicity/background/religion

40

Why is age important in a focused hx?

Tolerance of anemia is age dependent
As age increased, risk of transfusion increases

41

Why is gender important in focused hx?

Women more likely than men to get transfused
(lower hct; prone to blood loss with menses)

42

What size patients are at risk for transfusion?

Small patients
Obese patients

43

What patient-related obstacles should be asked about in pre-op?

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

44

What lab work should be done pre-op?

Hgb
PT/INR/PTT
Platelet count and platelet function tests

45

Drugs that have increased bleeding risk

NSAIDs, PCN, NTG, HIgh doses of Vitamin C, St. John's Wort, Ginger, Garlic, etc.

46

What temperatures optimize clotting?

Warm

47

How long before surgery would autologous donation have to be done?

At least 2 weeks prior

48

Auto-Donation requires what HCT?

33%

49

Contraindications for Autologous Donation

Recent MI
CHF
Aortic Stenosis
Transient Ischemic Attacks
HTN
Unstable Angina
Bacteremia

50

What allows the donation of platelets and plasma?

Plateletpheresis and Plasmapheresis

51

Prebypass Autologous Normovolemic Hemodilution

Used to remove blood from the patient pre-bypass for transfusion later in the case (spares platelets)

Removed volume replaced with crystalloid

52

Prebypass Autologous Normovolemic Hemodilution HCT requirement

AT least 35%

53

How much fluid is removed in prebypass autologous normovolemic hemodilution?

500-1000mL (1-3 units)
-Depends on starting HCT, age, BSA, existing conditions

54

When is blood reinfused during PANH?

After protamine is administered

55

Contraindications for PANH?

COPD
CHF
CAD
Unstable Angina
Renal insufficiency
Severe aortic stenosis
Coagulopathy

56

How much prime do you remove in RAP?

200-600mL of prime

57

Dry Venous Line Technique

Venous line emptied prior to connection to venous cannula
Requires VAVD
Volume removed to a big and discarded or sequestered

58

How much fluid does the dry venous line technique remove?

400-1000 mL

59

Mini-Circuit Advantages

Decreased foreign surface area (less inflammatory)
Decreases prime volume (less hemodilution)
Decreases blood-air contact

60

What does a mini circuit lack?

Venous reservoir
Cardiotomy
Often no heat exchange or art line filter

61

What is mini circuit prime volume?

500 mL; can be decreased with RAP- ing

62

What procedures use mini circuits usually?

Mostly CABGs
Some valves have been done

63

2 types of Mini-circuits

Totally Integrated Devices
Combination of Components

64

Totally Integrated Devices (Mini circuit)

Include air handling and eliminiation systems, centrifugal pump and membrane oxygantor

ex. CorX (Cardiovention) and Cobe Synergy

65

Combination of Components

MECC System (jostra)
MCPB
Deltra Stream ERP(medos)
Resting Heart System (Medtronic)

66

What variables affect the outcomes in mini circuits?

Steroids
Aprotinin
Degree of heparinization
Type of tubing coating
Patient population

67

ERC

Electric Remove Clamp

68

APC

Air Purge Control

69

Ultrafiltration/Hemoconcentration

Filtration of water across a semipermeable membrane via hydrostatic pressure gradient

Water crosses membrane which creates a solute concentration gradient

Solute from blood (high concentration) to water (low concentration)

70

What must you add if you're Z-BUFing?

Add sodium bicarb to the normal saline you're Z BUFing with to avoid acidosis

71

MUF

Modified Ultrafiltration
Withdrawing blood from the patient via the arterial line (post bypass); run blood through hemoconcentrator, pump blood back to patient via venous line

72

What does a cell saver remove?

Fat, air, tissue debris, potassium, hormones, bioactivators, etc.

73

Cell Saver Limitations

Delay in processing
Loss of plasma proteins
Loss of coag factors and plts
Expense
Operator attention and time

74

Cardiopat

Shed blood collected and processed
Uses dynamic disk to process- processes variable volume of blood
Consistently delivers washed RBCs w/ hct of 70-80%
Processes up to 2 L/hr or as little as 5mL of RBCs

75

What HCT can you tolerate if you are healthy and have good LV function?

20-25%