Blood

Front 1

Complications of blood transfusions (immune)

Back 1

• Haemolytic
o ABO incompatibility
o Rh incompatibility
o Other red cell antigen
• TRALI (transfusion related lung injury)
• Allergic reactions
o Mild
o Anaphylaxis
• GVHD
• SIRs
o Cytokine storm
o Need 2 or more of:
• Temp <36 or >39
• RR>20 or PaCO2 <32mmHg
• HR >90
• WCC <4 or >12
• Transfusion related immune modulation
o ↑risk of post-op bacterial infections
o ↑risk of cancer recurrence

Front 2

Complications of blood transfusions (non-immune)

Back 2

• circulatory overload
• Fe overload
• electrolyte disturbance
o hypo/hyperkalaemia
o hypocalcaemia
• acidosis
• hypothermia
• coagulopathy
o dilution of coagulation factors and platelets if just transfuse RBC
• infective
o viral: Hep B/C, HIV
o bacterial
o other eg malaria

Front 3

TRALI

Back 3

• leading cause of transfusion related morbidity and mortality
• occurs within 6/24 of transfusion
• criteria for diagnosis
o ALI
o Acute onset
o Hypoxaemia
• PaO2/Fi <300
• SpO2 <90%
o Bilateral opacities on CXR
o No evidence of L heart failure
o Within 6/24 of transfusion
• Management
o Supportive
o Typically recover within 3/7
• Pathophysiology
o Immune
• Antibody mediated mechanism in most cases
• Prevention
o Exclude donors involved with TRALI
o Highest risk from multiparous females

Front 4

Warfarin reversal (emergency surgery)

Back 4

Emergency surgery
-WH
-vit K 1-5mg
- prothrombinex 25-50unit and FFP 300ml OR FFP 10-15mls/kg
- cant just give prothrombinex as low in factor 7

Front 5

causes of DIC

Back 5

• Main causes
o Sepsis
o Malignancy
o Obstetric disorder eg pre-eclampsia, FDIU, placental abruption
o ABO incompatible transfusion

Front 6

Thrombolysis contraindictions

Back 6

Absolute: (6)
- surgery <3 weeks
- haemorrhagic stroke
- any stroke within 2/12
-intracranial neoplasm
-active bleed in past 1/12
-aortic dissection

Relative: (9)
-non-compressible lesion
- CVA >2/12 but <12/12
-pregnancy
- allergy
-active peptic ulcer disease
- severe hypertension on presentation (>180/110)
-surgery/trauma within 1/12
- CPR >10mins
-bleeding diathesis
-

Front 7

BART (blood conservation using antifibrinolytics in a randomized trial) NEJM 2008

Back 7

-prospective double blind multicentre RCT
- aprotonin is superior to TXA and aminocaporic acid to decrease massive post-op bleeding in high risk cardiac surgical patients
- 3 groups (aprotonin, TXA, aminocaproic acid)
- early termination due gto higher risk of death in aprotonin group (NNH of 50)
- subgroup analysis showed likely due to increased cardiac deaths
-aprotonin no longer licensed for use in Australia

Front 8

CRASH-2

Back 8

-randomised double blinded placebo controlled multi centre trial
- large
intervention was 1g tranexamic acid followed by 1g over 8/24
- all cause mortality was significantly reduced with tranexamic acid
-mortality due to bleeding was reduced
-no significant difference for thrombo-occlusive events
-no significant difference for blood products received

Front 9

TRICC (transfusion requirement in critical care) NEJM 1999

Back 9

- summary: in resuscitated, euvolumic patients there is no statistical difference in 30/7 mortality in patients receiving restrictive transfusion regime (aim Hb 70-90, transfused when <70) vs liberal transfusion regime (aim Hb 100-120, transfuse when Hb <100)
-patients with IHD benefit from more liberal transfusion regime
-younger patients (<55yo) and patients who were less unwell (APACHE) had a significantly lower 30/7 mortality with a restrictive regime
-multicentre RCT in ICU patients

Front 10

Sickle cell disease

Back 10

- caused by inheriting HbS, may be HbSS (homo) or HbSA (hetero). Endemic in Africa, Middle East, India, Mediterranean
-pathophysiology: due to vaso-occlusion from sickled cells leading to haemolysis and tissue infarction
- causes of sickling
dehydration, hypoxia, hypercarbia, acidosis, infection, hypothermia. Risk is proportion to [HbS], therefore hetero less likely

Clinical features:
CVS: dilated cardiomyopathy, coronary artery disease
Resp: pulm HTN from chronic small thrombosis +/- RHF
Renal: CRI
CNS: TIA common
GIT: functional asplenism due to splenic infarction, hyperbilirubinaemia, gallstones
Immune: anaemic, decreased immune function predisposing to infection
Pain

Ix:
-bloods: Hb (usually 6-9), reticulocytes increased

Mx:
- aim to avoid sickling (keep warm, well hydrated, not hypercarbic or hypoxic) early antibiotics, avoid prolonged fasting
- early GS as may have antibodies due to multiple previous transfusions
- use of hydroxyurea increases amount of HbF
- folic acid prevets deficiency due to chronic erythropoiesis
- can use tourniquet, just need meticulous exsanguination of limb prior to application

Front 11

porphyrias

Back 11

- enzyme defect in the haem synthesis pathway leading to build up of substrates
- acute or non-acute, only acute can degenerate into crisis
- crisis can be precipitated by drugs, infection, stress, ETOH, menustration, dehydration
- symptoms: variable, pain, CN and peripheral nerve palsy, coma, mental state disturbance

anaesthetic aims
- avoid trigger drugs, check up to date formulary
- avoid prolonged fasting
- pre-med for anxiety