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ACVECC Top 100(?) Papers > Coagulation/Transfusion > Flashcards

Coagulation/Transfusion Flashcards

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1
Q

According to Cooper et al. (2017), does transfusing fresh RBCs (<7 days) improve survival compared to standard-issue RBCs in critically ill adults?

A

No. The TRANSFUSE trial found no significant difference in 90-day mortality between patients receiving fresh RBCs and those receiving standard-issue RBCs.

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2
Q

What was the median storage age difference between RBC units in the TRANSFUSE trial by Cooper et al. (2017)?

A

The median storage age was 11 days for standard-issue and 6 days for fresh RBCs.

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3
Q

According to Holst et al. (2014), what hemoglobin threshold was shown to be safe for transfusion in septic shock patients?

A

A lower transfusion threshold of 7 g/dL was non-inferior to a higher threshold of 9 g/dL in terms of 90-day mortality in septic shock patients.

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4
Q

What is a key clinical implication of the TRISS trial (Holst et al., 2014) for veterinary ECC?

A

Restrictive transfusion strategies may be safe in septic patients, avoiding unnecessary transfusions and reducing transfusion-associated complications.

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5
Q

According to the CURATIVE Consensus (2019), what are the 4 primary indications for antithrombotic use in veterinary ECC?

A

1) Thromboprophylaxis, 2) Treatment of arterial thrombosis, 3) Treatment of venous thrombosis, 4) Management of DIC.

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6
Q

What is the CURATIVE Domain 1 focused on?

A

Venous thromboembolism prophylaxis – including risk assessment, stratification, and LMWH/UFH protocols.

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7
Q

What key tool is recommended by CURATIVE for identifying patients at risk of thrombosis?

A

A risk assessment model (RAM) based on underlying disease, inflammation, immobility, and coagulopathy.

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8
Q

In CURATIVE Domain 3, what is the preferred antiplatelet agent for arterial thromboembolic disease in cats?

A

Clopidogrel is the preferred first-line agent due to evidence of efficacy and relatively low bleeding risk.

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9
Q

According to Ueda et al. (2021), how does a P2RY1 gene polymorphism affect clopidogrel response in cats with HCM?

A

Cats with a specific P2RY1 SNP had reduced platelet inhibition, suggesting genetic resistance to clopidogrel.

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10
Q

What is the mechanistic basis for clopidogrel resistance in cats with P2RY1 mutations (Ueda et al., 2021)?

A

The P2RY1 receptor is involved in ADP-mediated platelet activation; mutations may reduce receptor binding or signaling, diminishing drug efficacy.

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11
Q

According to Goggs et al. (2018), what 4 scoring systems were evaluated for outcome prediction in canine DIC?

A

1) JAAM, 2) ISTH, 3) TSCH, 4) Modified Veterinary Scoring System (VSS).

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12
Q

What was the best-performing scoring system for predicting death in dogs with overt DIC, according to Goggs et al. (2018)?

A

The JAAM DIC score had the highest area under the curve (AUC) and best overall predictive value for non-survival.

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13
Q

What are hallmark lab findings in overt DIC in dogs per Goggs et al. (2018)?

A

Prolonged PT/aPTT, thrombocytopenia, elevated D-dimers, hypofibrinogenemia, and evidence of organ dysfunction.

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14
Q

According to Boyd et al. (2021), how do IV fluids alter coagulation function in critically ill animals?

A

IV fluids can cause hemodilution, endothelial glycocalyx damage, and altered platelet/endothelial interaction, impairing coagulation.

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15
Q

Which types of fluids have the greatest impact on coagulopathy per Boyd et al. (2021)?

A

Synthetic colloids (e.g., HES) have the greatest negative impact due to platelet dysfunction and impaired clot firmness.

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16
Q

What is a pathophysiologic consequence of crystalloid over-resuscitation on coagulation, per Boyd et al. (2021)?

A

Crystalloid overload leads to dilutional coagulopathy, hyperchloremic acidosis, and shear-stress–induced endothelial dysfunction.

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17
Q

According to the CURATIVE Consensus, how does one balance thrombotic and bleeding risk in ECC patients?

A

Use a structured risk-benefit analysis, including disease state, platelet count, clotting times, active bleeding, and comorbidities.

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18
Q

What is the CURATIVE guideline recommendation for thromboprophylaxis in dogs with IMHA?

A

Low molecular weight heparin (LMWH) or clopidogrel should be considered early due to the high risk of thrombosis.

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19
Q

Define: input sensor in the context of coagulation physiology.

A

An input sensor detects vascular injury (e.g., via exposure of subendothelial tissue factor or collagen) and initiates clotting.

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20
Q

Define: controller algorithm in the coagulation cascade.

A

The controller algorithm is the coordinated activation of coagulation factors and platelets that amplify and regulate thrombin generation.

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21
Q

Define: actuator in hemostasis.

A

The actuator is the fibrin clot formation and cross-linking that physically halts blood loss.

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22
Q

What is the function of a feedback loop in coagulation?

A

Positive feedback (e.g., thrombin activating FV, FVIII) amplifies clot formation, while negative feedback (e.g., antithrombin, protein C) limits coagulation.

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23
Q

What is the “target setpoint” in coagulation system regulation?

A

The balance between clot formation and fibrinolysis that maintains hemostasis without spontaneous thrombosis or bleeding.

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24
Q

Which domains of the CURATIVE guidelines address bleeding disorders vs. thrombosis?

A

Domain 4 and 5 focus on bleeding risk and management of coagulopathies, while Domains 1–3 address thrombosis and antithrombotics.

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25
How should platelet count influence antithrombotic therapy per CURATIVE?
Antithrombotic agents should be used with caution if platelets <30,000/μL, unless thrombosis is life-threatening.
26
What anticoagulant is preferred in patients with renal dysfunction according to CURATIVE?
Unfractionated heparin (UFH) is preferred due to its shorter half-life and reversibility compared to LMWH.
27
What are common complications of RBC transfusion in critical illness?
Febrile non-hemolytic reactions, TRALI, TACO, hemolysis, alloimmunization, and transfusion-transmitted infections.
28
What component of transfused blood contributes to immunomodulation and prothrombotic risk?
Microparticles, free hemoglobin, pro-inflammatory cytokines, and aged erythrocyte byproducts in stored blood.
29
What coagulation test is most sensitive to dilutional coagulopathy?
Thromboelastography (TEG) or ROTEM can detect changes in clot strength and fibrinolysis earlier than PT/aPTT.
30
Which CURATIVE recommendation addresses cats with arterial thromboembolism and CHF?
Dual therapy with clopidogrel ± LMWH is advised, especially in cats with recurrent ATE or high-risk HCM.
31
What is the CURATIVE Domain 2 focused on?
Therapeutic management of venous thrombosis, including anticoagulant selection, duration, and monitoring.
32
What antithrombotic agents are preferred in the treatment of venous thrombosis per CURATIVE Domain 2?
LMWH (e.g., enoxaparin), UFH, and direct oral anticoagulants (DOACs) like rivaroxaban are recommended based on case context.
33
What is the recommended initial treatment protocol for suspected PTE in dogs per CURATIVE?
LMWH at treatment dose (e.g., enoxaparin 1 mg/kg SC q8h or 1.5 mg/kg SC q12h) with close monitoring, +/- clopidogrel if platelet activation suspected.
34
What is CURATIVE Domain 4 focused on?
Assessment and management of bleeding risk, including hemorrhagic diatheses and guidance on transfusion thresholds.
35
What are common causes of bleeding in ECC patients per CURATIVE Domain 4?
Thrombocytopenia, platelet dysfunction, coagulopathy (DIC, liver disease), fibrinolysis, trauma, anticoagulants.
36
What lab markers guide bleeding risk assessment?
Platelet count, PT/aPTT, BMBT, TEG/ROTEM, fibrinogen concentration, and clinical bleeding signs.
37
What is CURATIVE Domain 5 focused on?
Monitoring of anticoagulant therapy, especially unfractionated heparin (UFH) and LMWH using aPTT, anti-Xa, or TEG/ROTEM.
38
What is the target aPTT ratio for UFH monitoring per CURATIVE Domain 5?
Target aPTT = 1.5–2.5× baseline for therapeutic anticoagulation.
39
How is LMWH monitored, and what test is preferred?
Anti-factor Xa activity, ideally 0.5–1.0 IU/mL (peak, 4h post-dose) for treatment; 0.2–0.4 IU/mL for prophylaxis.
40
What is the role of thromboelastography (TEG) in monitoring coagulation?
TEG evaluates whole blood viscoelastic properties, providing data on clot initiation (R), kinetics (K), strength (MA), and fibrinolysis (LY30).
41
Define: hypercoagulable pattern on TEG.
Short R/K, high alpha angle, high MA — indicates excessive clot formation and strength (e.g., IMHA, neoplasia, PTE).
42
Define: fibrinolytic shutdown vs hyperfibrinolysis on TEG.
- Shutdown: low LY30 (<0.8%) despite hypercoagulable state. - Hyperfibrinolysis: high LY30 (>7.5%) with rapid clot breakdown.
43
What is the mechanism of action of tissue plasminogen activator (tPA)?
tPA converts plasminogen to plasmin, promoting fibrin degradation and resolving clots.
44
What are common storage lesions in transfused RBCs?
Decreased 2,3-DPG, ATP, increased free Hb, microparticles, potassium, oxidative damage, reduced deformability.
45
Compare TACO and TRALI in transfusion reactions.
- TACO: Volume overload, responds to diuretics, high BNP, pulmonary edema. - TRALI: Immune-mediated, no volume overload, neutrophil activation, pulmonary infiltrates, normal BNP.
46
According to TRACS Part 1, how are transfusion reactions defined?
A transfusion reaction (TR) is any adverse event temporally associated with a blood transfusion, whether or not it is proven to be directly caused by the transfusion.
47
How does TRACS categorize transfusion reactions?
TRs are categorized as: immune vs. non-immune, acute (<24h) vs. delayed (>24h), and infectious vs. non-infectious.
48
What are the major immune-mediated transfusion reactions described in TRACS Part 1?
- Acute hemolytic transfusion reaction (AHTR) - Febrile non-hemolytic reaction (FNHTR) - Allergic reactions - Delayed hemolytic reaction (DHTR)
49
What is the pathophysiology of an acute hemolytic transfusion reaction (AHTR) according to TRACS Part 2?
AHTRs result from preformed alloantibodies binding to donor RBCs, activating complement, and causing intravascular hemolysis, cytokine storm, and shock.
50
What are the clinical signs of an AHTR in dogs or cats?
Fever, vomiting, hemoglobinemia, hemoglobinuria, hypotension, tachycardia, collapse, and sometimes death.
51
What is the mechanism of febrile non-hemolytic transfusion reactions (FNHTR)?
FNHTRs result from recipient antibodies reacting with donor leukocytes or platelets, or from cytokines accumulated during storage.
52
What is the key pathophysiologic difference between FNHTR and AHTR?
FNHTR does not involve RBC destruction, whereas AHTR causes acute hemolysis due to alloantibody-mediated complement activation.
53
What is the likely mechanism behind allergic transfusion reactions (TRACS Part 2)?
Allergic reactions result from IgE or mast cell–mediated hypersensitivity to donor plasma proteins.
54
According to TRACS Part 2, what causes non-immune hemolytic reactions?
- Improper storage or warming - Mechanical trauma (small gauge needles, pressure bags) - Hypo-osmolar fluids (e.g., LRS) - Rapid infusion through narrow catheters
55
What defines transfusion-related acute lung injury (TRALI) in veterinary patients?
Non-cardiogenic pulmonary edema within 6 hours of transfusion, associated with donor leukocyte antibodies, neutrophil activation, and endothelial damage.
56
How does TRALI differ from TACO in terms of pathophysiology?
- TRALI = immune-mediated neutrophil activation and capillary leakage. - TACO = volume overload and increased hydrostatic pressure.
57
What diagnostic criteria are recommended in TRACS Part 3 to identify a transfusion reaction?
Baseline vitals, serial monitoring, PCV/TS, plasma color, urinalysis, blood smear, Coombs test, TEG/ROTEM if coagulopathy suspected.
58
What are the key steps in managing a suspected transfusion reaction according to TRACS Part 3?
1) Stop the transfusion, 2) Assess vitals, 3) Supportive care (fluids, O2, antihistamines, corticosteroids), 4) Report and classify reaction.
59
What drug therapy is typically used for mild allergic transfusion reactions?
Diphenhydramine (1–2 mg/kg IM or IV) may be given, and transfusion resumed cautiously if no worsening.
60
What is the AVHTM's stance on steroid use for transfusion reactions?
Steroid use is controversial; may be considered in moderate-severe allergic or inflammatory reactions, but no strong evidence supports routine use.
61
According to TRACS, what clinical signs suggest TACO over TRALI?
- Increased BNP, jugular venous distension, hypertension, positive fluid balance, and response to diuretics suggest TACO.
62
What are the recommended monitoring intervals during transfusion per TRACS?
Baseline → every 15 min for first 30 min, then q30–60 min, and post-transfusion assessment.
63
What is the purpose of a transfusion reaction report per TRACS Part 3?
To standardize data collection, allow institutional review, improve donor-recipient safety, and support future veterinary transfusion research.
64
Define: “input sensor” in the transfusion context.
The input sensor detects transfused antigenic material (e.g., foreign RBCs, leukocytes, proteins) triggering the recipient's immune system.
65
Define: “controller algorithm” in transfusion immunity.
The controller is the immune system’s programmed response—e.g., B-cell activation, complement cascade, mast cell degranulation.
66
Define: “actuator” in the setting of a transfusion reaction.
The actuator is the physiologic effector — e.g., hemolysis, cytokine release, histamine-mediated vasodilation, or pulmonary edema.
67
What is the “setpoint” in transfusion physiology?
The homeostatic immune tolerance toward self or minor antigens — altered by previous sensitization (e.g., prior transfusion, pregnancy).
68
What type of transfusion reaction is most common in dogs?
Febrile non-hemolytic transfusion reactions (FNHTRs) are most common in dogs.
69
What is a delayed hemolytic transfusion reaction (DHTR) and when does it occur?
Occurs >24 hours post-transfusion, often days later, due to secondary immune response to donor RBC antigens, resulting in extravascular hemolysis.
70
What type of crossmatch is most useful in preventing hemolytic reactions?
An antiglobulin-enhanced crossmatch (Coombs-based) may detect incomplete antibodies and reduce AHTR risk.
71
According to TRACS, what is a “febrile reaction” defined as?
A rise in temperature >1°C (1.8°F) during or within 4 hours of transfusion without another identifiable cause.
72
What is the most effective way to prevent AHTRs in dogs and cats?
ABO and DEA 1 typing + crossmatching, especially in previously transfused patients or breeds with naturally occurring alloantibodies (e.g., cats).
73
What feline blood types are most relevant to transfusion safety?
Type A, Type B, and Type AB. Most domestic cats in the US are Type A, but some purebreds (e.g., Devon Rex, British Shorthair) may be Type B.
74
Do cats have naturally occurring alloantibodies against other blood types?
Yes. Unlike dogs, cats possess strong, naturally occurring alloantibodies, which can cause severe hemolytic reactions on first mismatched transfusion.
75
What is the consequence of giving Type A blood to a Type B cat?
A severe, often fatal acute hemolytic transfusion reaction, due to strong anti-A IgM alloantibodies causing rapid complement-mediated intravascular hemolysis.
76
What is the consequence of giving Type B blood to a Type A cat?
A mild delayed hemolytic reaction, due to weaker anti-B IgG antibodies, causing extravascular hemolysis over time.
77
What type of transfusion reaction is most common in cats, according to TRACS?
Hemolytic transfusion reactions (HTRs) are most common in cats due to blood type incompatibility or prior sensitization.
78
What pre-transfusion testing is always required in cats?
AB blood typing and crossmatching, even before a first transfusion, due to the high risk of naturally occurring alloantibodies.
79
When is crossmatching recommended in cats?
Crossmatching is recommended before all transfusions, especially in cats that have been previously transfused or are >4 days post-transfusion.
80
What is a Mik antigen and why is it clinically relevant in cats?
Mik is a non-AB RBC antigen that can cause alloimmune reactions in typed and crossmatched cats; some cats lacking Mik may react to Mik+ donor blood.
81
What are the clinical signs of acute hemolytic transfusion reactions in cats?
Hypotension, tachycardia, vomiting, collapse, hypothermia, pigmenturia, and death can occur rapidly during or shortly after transfusion.
82
What is the recommended transfusion rate for cats during the first 15 minutes?
0.25–0.5 mL/kg over 15 minutes, to monitor for adverse reactions before increasing to maintenance rate.
83
What physical exam findings during transfusion may suggest a reaction in cats?
Sudden bradycardia or tachycardia, hypotension, vomiting, facial pruritus, respiratory changes, pigmenturia, or mental status change.
84
Why are febrile non-hemolytic reactions less commonly reported in cats than dogs?
Cats may mask early signs (e.g., fever, malaise) or not mount robust febrile responses; reactions may go unnoticed without close monitoring.
85
What volume overload risks are cats particularly prone to during transfusion?
Due to their small blood volume and poor cardiac reserve, cats are at high risk for TACO (transfusion-associated circulatory overload).
86
How is TACO best prevented in feline transfusion patients?
- Careful rate control (≤5 mL/kg/hr), - Use of infusion pumps, - Pre-transfusion echocardiography or NT-proBNP in high-risk cats, - Diuretics in some cases.
87
What transfusion volume is typically used in cats?
10–22 mL/kg is a standard dose of packed RBCs, adjusted based on PCV target and clinical signs.
88
How does TRACS recommend distinguishing allergic vs hemolytic reactions in cats?
Allergic: facial pruritus, urticaria, vomiting without pigmenturia or hypotension. Hemolytic: hemoglobinemia/uria, collapse, fever, hypotension, +/- DIC.
89
What is the feline transfusion protocol if an allergic reaction occurs?
Stop transfusion, administer diphenhydramine (1–2 mg/kg IM or IV), monitor for signs of worsening. Consider restarting at lower rate if mild.
90
What is the feline transfusion protocol if a hemolytic reaction occurs?
Stop transfusion permanently, initiate supportive care (IV fluids, oxygen, corticosteroids, +/- pressors), and submit reaction report.
91
What diagnostics are useful post-reaction in cats?
PCV/TS, plasma color, urinalysis, bilirubin, blood smear, Coombs test, and possibly TEG if coagulopathy suspected.
92
Should feline donors be screened for infectious disease?
Yes — screen for FeLV, FIV, hemoplasmas (Mycoplasma haemofelis), Bartonella, and other region-specific pathogens.

ACVECC Top 100(?) Papers (11 decks)

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