Chapter 16 Transfusion Therapy in Selected Patients

Question 1

What is a massive transfusion?

Answer 1

Replacing total blood volume in 24hrs

Question 2

What symptoms are present with hypovolemia?

Answer 2

Symptoms of hypovolemia: hypotension, cooling of extremities, oliguria, acidosis, increased respiration

Question 3

What are the priorities to correct during a massitive transfusion?

Answer 3

1. Correct hypovolemia with crystalloids. Normal saline or Ringer’s Lactate to prevent shock
2. Optimize the oxygen-carrying capacity
3. Maintain hemostasis: platelets and coagulation factors
4. Correct or avoid metabolic disturbances
5. Maintain intravascular volume with colloids (ie. Albumin)

Question 4

What are the complications in a massive transfusion that can occur?

Answer 4

1. Microvascular hemorrhage due to either a) dilution of coag. factors & platelets
   b) hypotension
   c) consumption of coag. factors
   d) consumption of platelets
2. Citrate toxicity due to decrease in ionized calcium from anticoagulants in blood products.
3. Hypothermia due to rapid infusion of blood products.

Question 5

What is done to counteract microvascular hemorrhage caused by a massive transfusion?

Answer 5

Platelets
Fresh Frozen Plasma
or
Control hypotension

Question 6

What is done to correct citrate toxicity?

Answer 6

Slower infusion or calcium replacement if severe.

Question 7

What is done to counteract hypothermia from a massive transfusion?

Answer 7

Use of high-flow blood warmers.

Question 8

What happens in cardiac surgery that puts them at risk for bleeding? How does the Dr. typically counteract that?

Answer 8

Patient’s blood circulates through an oxygenating pump outside the patient’s body. Results in decrease in platelet number and function, decrease in coagulation factors, hypothermia, increase in residual heparin.

Usually put on warfarin following surgery.

Question 9

What are risk factors for bleeding during cardiac surgery?

Answer 9

1. Time on pump
2. Patient’s age
3. Previous cardiac surgery
4. Surgical procedure: valve replacement, CABG or both.
5. Preoperative medications: aspirin and anticoagulant.
6. Heparin effects.
7. Decreased platelet function from hypothermia.

Question 10

What causes physiologic anemia in infants receiving a transfusion?

Answer 10

Changing from fetal Hgb to adult Hgb, can cause physiologic anemia of infancy. More of a concern in low weight, pre-mature babies

Question 11

Besides physiologic anemia, what other issues does the Dr. need to be aware of with neonates when giving them a transfusion?

Answer 11

1. Iatrogenic blood loss in hospitals
2. Decreased response in production of erythropoietin
3. Low tolerance to hypothermia
4. Greater risk of cytomegalovirus infection
5. Decreased ability to metabolize citrate and potassium
6. Decreased ability to restore 2,3-DPG in older units

Question 12

What is type of blood should be given and how should it be given to neonates for a transfusion?

Answer 12

1. Try to give blood less than 7 days old. Always give CMV negative units. Irradiate and wash red cells first.
2. Give small amounts of blood as slow as possible through a blood warmer or can administer with a syringe.

Question 13

What is the type of bleeding risk to the patient getting a liver transplant?

Answer 13

Liver
Transplantation is associated with massive hemorrhage due to hypocoagulability

Question 14

How does giving erythropoietin help the person receiving a kidney transplant?

Answer 14

Kidney - Erythropoietin has reduced need for transfusion

See slide 8 for a table of avg blood components transfused during transplant surgery.

Question 15

What actions are taken to enhance graft survival?

Answer 15

Graft survival is enhanced with;
1. HLA-matched donor–recipient combinations,
2. Leuko-reduction,
3. Live donor for kidney transplant,
4. ABO compatibility for vascularized grafts such as livers, kidneys and heart (not as important for bone, heart valves, skin or cornea).

Question 16

What is Hematopoietic Progenitor Cell (HPC) Transplantation used for?

Answer 16

1. Hematopoietic cells contain stem cells and progenitor cells
2. Used for aplastic anemia, thalassemia, sickle cell disease, acute leukemia, lymphomas, multiple myeloma, PNH, multiple sclerosis, etc.

Question 17

What are the different types of HPC transplants are there?

Answer 17

Transplants can be:
1. Allogeneic
2. Syngeneic*
3. Autologous

*Means genetically identical or sufficiently identical & immunologically compatible to donate for transplant purposes.

Question 18

What are sources for HPC transplants from the donor’s body?

Answer 18

Sources:
1. Bone marrow
2. Peripheral blood stem cells (apheresis)
3. Umbilical cord blood

Question 19

How does the quality of the HLA match in a HPC transplant matter?

Answer 19

HLA matched - closer the better.

Question 20

What are the purposes of therapeutic apheresis?

Answer 20

Therapeutic apheresis removes abnormal cells, plasma, or plasma constituents to:
1. Supply an essential substance that is absent
2. Reduce the quantity of a particular antibody
3. Modify mediators of inflammation
4. Clear immune complexes
5. Replace cellular elements

See slide 12 for details on indications for therapeutic apheresis.

Question 21

What are the risks that chemotherapy brings to a patient?

Answer 21

1. Chemotherapy can result in a decrease of platelets, leukocytes, hemoglobin, and hematocrit.
2. Side effects include bleeding, anemia, and infection.

Question 22

What alternatives are there for chemotherapy patients instead of transfusion?

Answer 22

Alternatives to transfusion include:
1. Erythropoietin
2. Colony-stimulating factors (CSFs)
3. DDAVP (desmopressin)

See slide 14 for details on alternatives to transfusion.

Question 23

What can result in transfusion needs in patients that have chronic renal disease?

Answer 23

Patients that undergo dialysis will have many hematologic complications that require attention.
1. Elevated urea levels (uremia) leads to altered rbc shapes and often are removed by the spleen.
2. The equipment used for dialysis can also harm the patient’s red cells, leaving them anemic.
3. These individuals are not able to produce erythropoietin since they have kidney damage

Question 24

What are the similar symptoms between Hemolytic uremic syndrome (HUS) and Thrombocytopenic Purpura (TTP)?

Answer 24

1. Thrombocytopenia
2. Microangiopathic hemolytic anemia
3. Renal dysfunction
4. Central nervous system involvement

Question 25

What kind of transfusion therapy may HUS and TTP patients need?

Answer 25

Treatment 1. Therapeutic plasma exchange daily for 1 to 2 weeks 2. Platelet transfusions are contraindicated (i.e. should not be used).

Question 26

For sickle cell anemia why might a transfusion be necessary?

Answer 26

Transfusion may be necessary to: 1. Treat acute anemia 2. Prevent stroke or recurrent pain episodes

Question 27

What is a common occurrence with those with sickle cell disease?

Answer 27

1. About 25% to 30% of patients with sickle cell disease will develop alloantibodies 2. Some patients are phenotypically matched to prevent alloimmunization (D, C, E, K)

Question 28

What is a common complication of repeated transfusions in sickle cell disease and also thalassemia?

Answer 28

Iron overload is a complication of repeated transfusions in sickle cell disease and also thalassemia

Question 29

What causes drug induced hemolytic anemia?

Answer 29

1. Drug adsorbs on RBC membrane 2. Drug–antibody complex adsorbs on RBC membrane 3. Drug causes autoantibody to be produced

Question 30

What are two characteristics of hemostatic disorders? Symptoms. Common disorders.

Answer 30

Hemostatic disorders are characterized as: 1. One or more coagulation proteins are decreased or missing 2. Protein has normal production but abnormal structure

Question 31

How are most hemostatic disorder treated?

Answer 31

Most are treated with factor concentrates or DDAVP

Question 32

What are two symptoms of hemostatic disorders? Give some names of common hemostatic disorders.

Answer 32

Symptoms include prolonged bleeding, bleeding in joints, and subcutaneous bleeding Common disorders include von Willebrand’s disease, hemophilia A, and hemophilia B

Question 33

What are some alternatives to transfusion?

Answer 33

1. Growth factors 2. Blood derivatives 3. Volume expanders

Question 34

What do growth factors do?

Answer 34

Stimulate bone marrow to produce RBCs, white blood cells, and platelets

Question 35

What are blood derivatives?

Answer 35

Blood derivatives 1. Factor VIIa, VIII, or IX 2. Antithrombin: inhibits coagulation 3. Protein C: inhibits coagulation