Transfusion and coagulation_2024 (1).pptx

Blood transfusion and coagulation manageme nt Greta Mitzova- Vladinov, DNP,CRNA Associate Professor of Clinical UM SONHS  The students will be able to: State the goals of transfusion therapy Determine indications for transfusion...

Blood transfusion and coagulation manageme nt Greta Mitzova- Vladinov, DNP,CRNA Associate Professor of Clinical UM SONHS  The students will be able to: State the goals of transfusion therapy Determine indications for transfusion therapy Objectiv State the current recommendations for transfusion of blood and blood es products List the most common complications associated with transfusion of blood and blood products Correctly determine different blood products utilization in clinical situations. Understand use and interpretations of TEG for coagulation management  Normal Hemostatic Mechanisms von Willebrand factor (vWF) tissue factor (TF) antithrombin (AT) activated protein C (APC) tissue factor pathway inhibitor Hemmings, 2013 (TFPI) tissue plasminogen activator (tPA)  Patient blood Why blood transfusion? management: “the - to increase oxygen- Goals of appropriate use of carrying capacity and blood and blood intravascular volume. components with a goal transfusi of minimizing their use.” on In hemorrhaging patient the goals should be to restore intravascular volume, cardiac output, and organ perfusion to normal levels  1988 NIH consensus: Healthy patients with Hb >10 g/dL rarely require perioperative blood transfusions, Patients with acute anemia < 7 g/dL frequently require blood transfusions. Indication The ultimate determination of the s for Hgb or Hct value at which blood should be given is a clinical judgment transfusi based on:  cardiovascular status, ons  age,  anticipated additional blood loss,  arterial oxygenation,  SVO2,  CO,  intravascular blood volume. Decisions for additional blood transfusions based on:  Overall condition of the patient  Anticipated blood loss  Actual blood loss  Amount of intravenous fluids given overall  Hgb concentration Liberal vs. restrictive blood transfusion strategy is based on the Hgb value:  Restrictive - Hgb < 7 to 8 g/dL  Liberal – Hgb > 9 to 10 g/dL Separation of whole blood for component therapy Hemmings, 2013 PRBC PRBC – Hct 50%-70%, compatible with D50.4%NS, D5NS, 0.9% NS, and Normosol-R with a pH of 7.4. Recommendations for transfusion: Blood loss > 20% of blood volume Hgb level < 8 g/dL Hgb level < 9 to 10 g/dL with major disease (e.g., emphysema, ischemic heart disease) Hgb level < 10 g/dL with autologous blood Hgb level < 11 to 12 g/dL if ventilator dependent Platelet concentrates Pooled concentrates from 4 to 6 whole-blood donations or as apheresis concentrates obtained from one donor.. 1U Plt concentrate increases to 7000 to 10,000 platelets/mm3 at 1 hour after transfusion to the 70-kg adult. Indications for transfusion: Rarely prophylactically for ITP Preop for surgical and OB patients if plts < 50 × 109/L Microvascular bleeding or known plt dysfunction Fresh Frozen Plasma Contains all the plasma proteins, factors V and VIII Should be compatible with recipients’ ABO types, Rh not needed Usual dose is 5 to 8 mL/kg, up to 10 to 30 mL/kg ASA guidelines for administration: 1. Replacement of inherited single coagulation factor deficiencies for which no virus-safe products exists 2. Replacement of multiple coagulation factor deficiencies with associated bleeding, DIC 3. As a component of plasma exchange in patients with ITP4. Reversal of warfarin anticoagulation 5. Prevention of dilutional coagulopathy in patients with major Cryoprecipi tate Contains concentrated factors VIII:C (i.e., procoagulant activity), factor VIII:vWF (i.e., von Willebrand factor), fibrinogen, factor XIII, and fibronectin Give as rapid infusion via filter within 6 hrs of thawing. Each unit contains 150 to 250 mg of fibrinogen; 5 to 10 units are thawed and pooled before infusion. Indications for use: Bleeding due to acquired hypofibrinogenemia ( 75 ml/hr Transfusion reactions- Transfusion-Related Acute Lung Injury (TRALI) Leading cause of transfusion-related mortality Manifested as non-cardiogenic pulmonary edema Symptoms: Fever, dyspnea, fluid in the endotracheal tube, and severe hypoxia 1-2 hrs after transfusion Risk factors: higher interleukin-8 (IL- 8) levels, liver surgery, ETOH abuse, shock, higher peak airway pressures while being mechanically ventilated, smoking, and positive fluid-balance. Tx: stop transfusion, ICU support Transfusion reactions Nonhemolytic reactions Febrile reactions – most common, need direct antiglobulin test to r/o hemolytic reaction Allergic reactions Anaphylactoid – foreign protein in the transfused blood Anaphylactic - transfusion of IgA to patients who are IgA deficient and have formed anti- IgA  Other risks of blood transfusions Infectious Non-infectious HIV – 1:1,500,00 Transfusion-associated Hep B – 1:200,000 circulatory overload (TACO) Hypotension Hep C – 1:1,000,000 Cytomegalovirus Graft-versus-host Bacteria – 1:1,000 Transfusion-related immunomodulation (TRIM) Transfusion-related AKI Evaluation and management of perioperative coagulopathy Prevention and management of surgical bleeding Algorithms and use of TEG  Patient factors Insult from cardiopulmonary bypass The Fibrinolysis Platelet dysfunction bleeding Clotting factors cardiac Hypothermia patient – Causes Kaplan’s Cardiac Anesthesia, Ch. 35 Preventi on of bleeding in the cardiac patient Kaplan’s Cardiac Anesthesia, Ch. 35 Useful drugs to reduce bleeding during cardiac surgery Protamine Tranexamic acid or epsilon aminocarpoic acid Recombinant factor VIIa (aprotinin) Desmopressin  PROTAMINE AND REVERSAL OF ANTICOAGULATION Protamine binds heparin and inactivates it 1 mg protamine neutralizes 100 units of heparin. Usual protocols: 1. Protamine dose based on the total amount of heparin given for the procedure 2. Use of calculated circulating heparin concentrations (Hepcon HMS) Severe hypotension may result 3. Anaphylactoid reaction (NPH Insulin use, vasectomy, fish allergy) 4. Decreased SVR with rapid administration 5. RV failure d/t severe pulmonary vasoconstriction protamine should be stored in unique packaging or in a separate, nearby location to prevent inadvertent inappropriate or premature administration Antifibrinolytics: Tranexamic acid (TXA) for cardiac surgery Routinely used in cardiac surgery – more favorable profile compared to EACA, which is associated with higher rate of renal dysfunction Administered loading does 1gm before incision (10mg/kg), followed by 1mg/kg/hr Administration before CPB – lower blood loss, chest tube drainage decreased by 30% postop, blood transfusion 5 days postop decreased from 41% to 22% Higher than 2gm doses increase risk of seizures Antifibrinolytics: Tranexamic acid (TXA) for noncardiac surgery Used for treatment and/or prevention of excessive blood loss during and after major surgeries 1gm before incision and 1gm at end of surgery effective in decreasing major bleeding (9.1% with TXA vs 11.7% placibo) Lower risk of dead and hemorrhage in C/Section (postpartum) and trauma patients Cardiovascular risks vs benefits need to be evaluated on individual basis  Desmopressin Analog of vasopressin, provides more potent and longer-lasting antidiuretic activity than vasopressin, with little vasoconstriction Releases coagulation system mediators from vascular endothelium - Factor VIII & vWF Dose is 0.3 µg/kg, IV, SC and intranasal Metabolism in liver and kidney, urinary excretion, plasma half-life of 2.5 to 4 hours Rapid IV administration decreases BP and SVR possibly by prostacyclin release or stimulation of extrarenal vasopressin V2 receptors. The antidiuretic action of the drug poses no problem in the absence of excessive free water administration. Specific hemostatic benefit include uremia, cirrhosis, aspirin therapy, and surgery of various types Managem ent of the bleeding cardiac patient Kaplan’s Cardiac Anesthesia, Ch. 35  Algorithm of the evaluation and initial therapy of a patient with suspected perioperati ve coagulopat hy  Diagnosis and Treatment of a Hemorrhagic Diathesis after Blood Tests: platelet count, PTT, and plasma fibrinogen Transfusions level, TEG If PTT is >1.5 times normal and other tests are normal, the bleeding is due to very low levels of factors V and VIII – Tx with FFP or cryo Dilutional thrombocytopenia in association with DIC, and hypoperfusion is the most likely cause of bleeding from blood transfusion – Tx with Plt concentrates. Low plasma fibrinogen level