Transfusion Therapy

Question 1

When to do serological crossmatch?

Answer 1

• patient has no previous blood type on record
• mixes RBCs from donor with plasma of recipient EDTA tube
• immediate spin
• extended

Question 2

when to do electronic crossmatch?

Answer 2

• utilized when 2 determinations of recipient blood type match
• must be validated at each site and annually thereafter

Question 3

all incompatible crossmatches must be resolved before transfusion except which scenarios?

Answer 3

• neonatal crossmatch
• emergency release (pre-packaged)
• massive transfusion
• signed physician order for uncrossmatched blood

Question 4

explain why no neonate crossmatch to resolve incompatibilities

Answer 4

• neonates don’t have fully functioning immune systems until 4 months old
• no crossmatch required for maternal plasma unless she has an Ab

Question 5

neonate units tend to be what?

Answer 5

• O neg
• CMV neg
• sickle cell neg
• less than 7 days old
• irradiated
• aliquoted (calc based on baby weight)

Question 6

neonate transfusion risks

Answer 6

• graft v host disease from immunocompetent lymphocytes
• viral transmission
• volume overload
• toxicity

Question 7

describe emergency release blood

Answer 7

• type and screen has not been performed on recipient
• type and screen performed when pt sample arrives and new blood can be set up
• patient may not be ID’d
• good practice is to set up replacement emergency packages as soon as one is taken

Question 8

required practice for massive transfusion

Answer 8

set up replacement massive transfusion packages as soon as one is taken
requires signed physician order

Question 9

describe massive transfusion protocol

Answer 9

• 10 RBCs in 24 hr
• 5 RBCs in 1 hr
• serological crossmatch of additional units not needed
• must balance fluids replaced in body. Consider: toxicity, overload, coagulation
• may be emergency release

Question 10

massive transfusion package ratios

Answer 10

4 RBC: 4 plasma: 1 plt: 1 cryo pool

Question 11

massive transfusion patient risks

Answer 11

• coagulopathy: monitor at bedside or in lab
• hypocalcemia: from excess citrate, give calcium
• acid-base imbalance: monitor Na and Cl in chem, acidosis = shock
• hypothermia: lots of cold blood infused rapidly -> cardiac arrhythmia

Question 12

chemistry labs in hypothermia

Answer 12

• citrate/lactate metabolism decrease
• potassium increase
• hemoglobin/oxygen affinity increase

Question 13

presurgery regulations

Answer 13

• method of blood collection ensure positive pt ID
• use serum or plasma samples < 3 days old if recipient has been pregnant or transfused within past 3 months
• procedures show incompatibility btwn donor RBC and pt serum/plasma
• use method that shows agglutination, coating, and hemolytic Ab
• protocols expedite transfusion in life-threatening emergencies and records of that + signed physician form kept

Question 14

how can patient qualify for crossmatch extension beyond 72 hr, in surgery context?

Answer 14

• no transfusions or pregnancies within 3 months
• no allo-Ab present

Question 15

scheduled surgery stuff to do

Answer 15

• pre-work: type and screen
• have product on hand
• have staff on hand

Question 16

heart surgery

Answer 16

• bypass reduces plts in circulation, so longer surgery needs more transfusion
• potential blood loss ~1000 ml pre-setup 2 RBC:1 plt
• sensitive to potassium in system, so recommend long dated blood products

Question 17

liver surgery

Answer 17

• patient usually experiencing severe coagulopathy -> may consider plasma exchange before surgery
• potential blood loss great so pre-set up 4 RBCs: 4 plasma: 2 plt: 2 cryo, prep for massive protocol
• intraoperative cell salvage should be considered

Question 18

kidney surgery

Answer 18

• endstage renal disease associated with severe anemia -> may have been supported by transfusion pre-surgery
  -pt may have difficulty clearing anticoags or other meds -> avoid EPO
• potential blood loss < 1000 ml -> keep transfusions to supportive levels, RBCs may be only product needed

Question 19

orthopedic/spinal surgery

Answer 19

• most pt have fully functioning organs
• many studies show transfusion during hospital stays lead to worse outcomes
• potential blood loss <1000 ml -> keep transfusions to supportive levels, RBCs may be only product needed

Question 20

pre-surgery transfusion tools

Answer 20

• selected cell panel
• pre-order expected inventory
• positive pt ID

Question 21

blood loss prevention techniques if dealing with Jehovah’s witnesses

Answer 21

• least invasive surgical procedures
• micro-sampling for blood draw
• premed with vitamins and supplements to increase O2 carrying capacity
• hemodilution (plasma expanders)

Question 22

lab practices if dealing with Jehovah’s witnesses

Answer 22

• verify that pt declines all blood transfusion interventions
• Hgb and plts will be monitored but not acted upon
• do not collect blood bank sample

Question 23

oncology transfusion risks

Answer 23

• graft v host disease from transfusion of immunocompetent lymphocytes
• viral transmission
• volume overload
• allergic reaction
• suppression of erythropoiesis
• refractoriness

Question 24

oncology pt treatment

Answer 24

irradiated cellular components

Question 25

serological difficulties with oncology pt

Answer 25

- reverse type discrepancy - warm autoimmune hemolytic anemia (WAIHA) - drug interactions

Question 26

general difficulties with oncology pt

Answer 26

- tumor removal risky bc could be very vascularized - chemo destroys cellular components -> need chronic transfusions - immune response consumes coag factors - lack of immune response risks infection - AABB rec transfusion triggers -> Hgb ~ 8 g/dl and plt ~10,000

Question 27

urgent warfarin reversal transfusion decisions

Answer 27

- pt mentally compromised - rec plasma for intracranial hemorrhage - Vitamin K or PCC (prothrombin complex concentrates) if pt not at risk from volume loss

Question 28

traumatic brain injury transfusion decisions

Answer 28

- keep brain tissue oxygenated, requires higher transfusion threshold - risk of stroke in coagulopathy

Question 29

TTP transfusion decisions

Answer 29

recommend plasma exchange instead of plt infusion

Question 30

pregnancy transfusion decisions

Answer 30

avoid transfusions if possible

Question 31

AIDS transfusion decisions

Answer 31

- may have chronic anemia, increased plt Ab, leukopenia - irradiated components recommended

Question 32

sickle cell disease therapy transfusions

Answer 32

- goal: reduce intravascular sickling by dilution effect - chronic transfusion to maintain sickle Hgb at 50% - maintain hct level so require plasma too - allo-Ab formation likely so **phenotype match at least for Rh and Kell**

Question 33

thalassemia transfusion decisions

Answer 33

- super transfusion -> maintain Hgb at 9 g/dl -> less splenomegaly, better child growth - might suppress pt hematopoiesis - allo-Ab formation likely so **phenotype match at least for Rh and Kell**

Question 34

bone marrow transplant transfusion decisions

Answer 34

- pre-transplant: prevent alloimmunization by sparing transfusion regimen - transplant: need irradiated leukoreduced products (usually RBC and plt, use HLA-matched plt if refractory - post-transplant: temporary or permanent chimerism -> serological difficulties 2+ years

Question 35

immunocompromised pt risks

Answer 35

- graft v host disease - bacterial sepsis - TACO - toxicity - alloimmunization with 2+ transfusions

Question 36

immunocompromised pt treatment

Answer 36

irradiated leukoreduced components, may be HLA or phenotype matched

Question 37

immunocompromised pt serological issues

Answer 37

ABO discrepancy

Question 38

immunocompromised pt list

Answer 38

- neonates - AIDS - oncology - transplant - getting transfusion from fam member

Question 39

how to work on pt cases

Answer 39

- health history - diagnosis - transfusion history - Ab screen results