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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5565_Библиотеки_им_академика_М_И_Перельмана.pdf
88 PRACTICAL SELF-ASSESSMENT FOR TRANSFUSION MEDICINE PROFESSIONALS
________________________________ _______________________________
夝
Question 2: Published experimental data support which of the following state-
ments?
A. Otherwise healthy patients who are hypovolemic due to acute hemorrhage
should receive RBC transfusion.
B. Cardiac output decreases dramatically when hemoglobin levels fall below 7 g/
dL in healthy patients.
C. Most patients benefit from a more liberal RBC transfusion threshold, such as
hemoglobin ~ 10 g/dL.
D. A platelet count of 50,000/L is a more reasonable transfusion threshold than
20,000/L in afebrile, non-bleeding patients who do not have an underlying
coagulopathy.
E. A platelet count of 5000 to 10,000/L is a safe transfusion threshold for acute
leukemic patients.
B. All the other answers are incorrect. The laboratory values at which transfusion
should be initiated (transfusion thresholds) continue to be debated. Most experts
agree that the decision to transfuse RBCs should be made on the basis of individual
patient needs rather than laboratory values. The TRICC trial showed that cardiac
patients may benefit from a more restrictive transfusion threshold (between 7 g/dL
and 9 g/dL hemoglobin).
________________________________ _______________________________
夝
Question 3: Which statement about the transfusion of factor concentrates or FFP is
true?
A. Prophylactic FFP transfusions for patients scheduled for invasive procedures
are generally indicated when the PT or PTT are 15 times their mid-normal val-
ues or greater.
B. If the PT and PTT are prolonged, FFP should be given the night before surgery.
C. Pooled factor concentrates have a lower risk of viral transmission compared to
FFP.
D. FFP should be used to reverse the effects of warfarin. Vitamin K should be the
second choice when FFP is not effective.
E. The initial dose of FFP should be approximately 1.0 mL/kg. PT and/or PTT
should be measured 15 minutes after infusion.
C. Factor concentrates actually carry less risk than FFP because they are virus-inacti-
vated, which substantially decreases the risk of transmission of select viral agents
(those that have a lipid envelope, which does not include parvovirus or hepatitis A).
Several large studies have shown that there is very poor correlation between mildly
to moderately prolonged PT/PTT and risk of bleeding. Transfusion with FFP should
INDICATIONS FOR TRANSFUSION 89
be optimally timed to be immediately before a proposed procedure because several
of the factors, such as Factor VII have very short (several hours) half-lives. If possible,
alternatives to FFP (vitamin K, specific factor concentrates) should be utilized if clin-
ically appropriate before using FFP. FFP dosing usually starts with 10 mL/kg of
patient body weight with assessment of PT/PTT within 15 to 30 minutes following
transfusion.
________________________________ ________________________________
夝
Question 4: Which of the following is NOT considered to be an indication for FFP?
A. Patient with petechial bleeding, but a normal PT/PTT.
B. Massive transfusion.
C. Warfarin reversal when vitamin K fails.
D. Replacement of coagulation factors during therapeutic plasma exchange.
E. Bleeding patient with a documented factor deficiency and no available factor
concentrate.
A. Petechial bleeding is more indicative of a platelet deficiency (or direct damage to
vasculature). Platelets are a better choice in this setting.
________________________________ ________________________________
夝
Question 5: Which of the following statements about Cryoprecipitated AHF is true?
A. It is ineffective in a patient who is also hypofibrinogenemic (fibrinogen <80-
100 mg/dL).
B. Each unit of Cryoprecipitated AHF contains 15 to 25 mg of fibrinogen in
approximately 10 mL of plasma.
C. Cryoprecipitate can be used to treat patients with all types of vWF disease.
D. One unit of Cryoprecipitated AHF contains twice as much fibrinogen as one
unit of FFP.
E. In a patient in whom volume overload is a likely concern, it is better to give
FFP than Cryoprecipitated AHF to replace fibrinogen levels.
C. Cryoprecipitate can be given to all types of vWD patients, even those with Type
IIb for whom desmopressin is contraindicated or Type III where desmopressin is
ineffective. Each unit of Cryoprecipitated AHF contains at least 150 mg of fibrinogen
suspended in a volume of 5 mL to 15 mL. FFP has twice as much fibrinogen in a vol-
ume 20 times greater.
90 PRACTICAL SELF-ASSESSMENT FOR TRANSFUSION MEDICINE PROFESSIONALS
________________________________ _______________________________
夝
Question 6: Which of the following outcomes is effectively accomplished by leuko-
cyte reduction of blood components?
A. Decreases the incidence of febrile nonhemolytic transfusion reactions.
B. Helps prevent transfusion-associated graft-vs-host disease.
C. Decreases the incidence of transfusion-associated acute lung injury.
D. Eliminates the risk of CMV transmission.
E. Reverses the effects of platelet refractoriness.
A. Leukocyte reduction can reduce (but not eliminate) the risk of CMV transmission
and reduce the incidence of HLA alloimmunization and the subsequent platelet
refractoriness that may ensue. TRALI is believed to be caused by the passive transfer
of donor antibodies directed again recipient antigens. For that reason leukocyte
reduction does not play a role in reducing the incidence of TRALI.
________________________________ _______________________________
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Question 7: When is the best time to perform leukocyte reduction?
A. At the bedside, just before the transfusion.
B. At the bedside, during the transfusion.
C. In the blood bank, just before issuing the unit.
D. In the blood donor center, before storage.
E. It makes no difference when it occurs; the incidence of adverse effects will be
the same regardless.
D. Cytokines are released from leukocytes occurs during storage, and cytokines are
believed to play an important role in these transfusion reactions. So performing leu-
kocyte reduction is most effective when done before storage. In some countries,
such as Canada, universal leukocyte reduction is mandated. Although not manda-
tory in the United States the majority of the cellular blood components are filtered.
Filtration before storage removes leukocytes before they are able to elaborate cyto-
kines and may therefore be more effective in preventing febrile nonhemolytic trans-
fusion reactions.
________________________________ _______________________________
夝
Question 8: Which of the following statements about transfusion-associated graft-
vs-host disease (TA-GVHD) is true?
A. The GVHD that may occur in marrow transplant recipients is much more fatal
than TA-GVHD.
INDICATIONS FOR TRANSFUSION 91
B. TA-GVHD is caused by engraftment of viable donor lymphocytes.
C. Recipients who receive non-HLA-matched blood components are at increased
risk compared to those receiving HLA-matched blood components.
D. Elderly patients are at increased risk for TA-GVHD compared to the general
population.
E. Leukocyte-reduced blood components are an acceptable substitute for irradi-
ated products.
B. Transfusion-associated graft-vs-host disease is associated with a higher mortality
than the graft-vs-host disease seen with marrow transplant recipients. There is an
increased risk associated with HLA-matched donations, transfusions to profoundly
immunosuppressed individuals, and transfusions to premature infants. Leukocyte-
reduced components are not a substitute for components where leukocytes have
been inactivated (through irradiation) because viable engraftable leukocytes are still
present (although in reduced numbers).
________________________________ ________________________________
夝
SUGGESTED READING
General
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National Blood Resource Education Program expert panel. Transfusion alert: Indica-
tions for the use of red blood cells, platelets, and fresh frozen plasma. Washington,
DC: National Institutes of Health; August 1993. NIH Publication 93-2974a.
Red Cells
Audet AM, Goodnough LT. Practice strategies for elective red blood cell transfusion.
Ann Intern Med 1992;116:404-6.
Carson JL, Duff A, Berlin JA, et al. Perioperative blood transfusion and postoperative
mortality. JAMA 1998;279:199-205.
Carson JL, Grossman BJ, Kleinman S, et al for the Clinical Transfusion Medicine
Committee of the AABB. Red blood cell transfusion: A clinical practice guideline
from the AABB. Ann Intern Med [March 26, 2012 ePub ahead of print.]
Carson JL, Terrin ML, Novek H, et al. Liberal or restrictive transfusion in high-risk
patients after hip surgery. N Engl J Med 2011;365:2453-62.
Consensus conference. Perioperative red cell transfusion. JAMA 1988;260:2700-3.
92 PRACTICAL SELF-ASSESSMENT FOR TRANSFUSION MEDICINE PROFESSIONALS
DeFoe GR, Ross CS, Olmstead EM, et al. Lowest hematocrit on bypass and adverse
outcomes associated with coronary artery bypass grafting. Ann Thorac Surg 2001;
71:769-76.
Ely EW, Bernard GR. Transfusions in critically ill patients. N Engl J Med 1999;340:
467-8.
Goodnough LT, Brecher ME, Kanter MH, AuBuchon JP. Transfusion medicine: First
of two parts—blood transfusion. N Engl J Med 1999;340:438-47.
Hébert PC. Transfusion Requirements in Critical Care: The TRICC trial—a focus on
the sub-group analysis. Vox Sang 2002;83(Suppl 1):387-96.
Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled
clinical trial of transfusion requirements in critical care. N Engl J Med 1999;340:
409-17.
Hébert PC, Wells G, Tweeddale M, et al. Does transfusion practice affect mortality
in critically ill patients? Am J Respir Care Med 1997;155:1618-23.
Hébert PC, Yetsir E, Martin C, et al. Is a low transfusion threshold safe in critically ill
patients with cardiovascular diseases? Crit Care Med 2001;29:227-34.
Simon TL, Alverson DC, AuBuchon J, et al, for the Red Cell Administration Practice
Guidelines Development Task Force of the College of American Pathologists. Prac-
tice parameter for the use of red cell transfusions. Arch Pathol Lab Med 1998;122:
130-8.
Thurer RL. Evaluating transfusion triggers. JAMA 1998;279:238-9.
Weiskopf RB, Viele MK, Feiner J, et al. Human cardiovascular and metabolic
response to acute, severe isovolemic anemia. JAMA 1998;279:217-21.
Welch HG, Meehan KR, Goodnough LT. Prudent strategies for elective red blood
cell transfusion. Ann Intern Med 1992;116:393-402.
Wu W-C, Rathore SS, Wang Y, et al. Blood transfusion in elderly patients with acute
myocardial infarction. N Engl J Med 2001;345:1230-6.
Platelets
Beutler E. Platelet transfusions: The 20,000/L trigger. Blood 1993;81:1411-13.
Consensus conference. Platelet transfusion therapy. JAMA 1987;257:1777-80.
Gaydos LA, Freireich EJ, Mantel N. The quantitative relation between platelet count
and hemorrhage in patients with acute leukaemia. N Engl J Med 1962;266:905-9.
Gil-Fernandez JJ, Alegre A, Fernandez-Villata MJ, et al. Clinical results of a stringent
policy on prophylactic platelet transfusion: Non-randomized comparative analysis
in 190 bone marrow transplant patients from a single institution. Bone Marrow
Transplant 1996;18:931-5.
INDICATIONS FOR TRANSFUSION 93
Gmur J, Burger J, Schanz U, et al. Safety of stringent prophylactic platelet transfusion
policy for patients with acute leukaemia. Lancet 1991;338:1223-6.
Hanson SR, Slichter SJ. Platelet kinetics in patients with bone marrow hypoplasia:
Evidence for a fixed platelet requirement. Blood 1985;66(5):1105-9.
Heckman KD, Weiner GJ, Davis CS, et al. Randomized study of prophylactic plate-
let transfusion threshold during induction therapy for acute leukemia: 10,000/L
versus 20,000/L. J Clin Oncol 1997;15:1143-9.
Kruskall MS. The perils of platelet transfusions. N Engl J Med 1997;337:1914-15.
Patrono C, Garcia Rodriguez L, Landolfi R, Baigent C. Drug therapy: Low-dose aspi-
rin for the prevention of atherothrombosis. N Engl J Med 2004;353(22):2373-83.
Rebulla P, Finazzi G, Marangoni F, et al, for the Gruppo Italiano Malattie Emato-
logiche Maligne dell’Adulto. The threshold for prophylactic platelet transfusions in
adults with acute myeloid leukemia. N Engl J Med 1997;337:1870-5.
Wandt H, Frank M, Ehninger G, et al. Safety and cost effectiveness of a 10 × 10
9
/L
trigger for prophylactic platelet transfusions compared with the traditional 20 × 10
9
/
L trigger: A prospective comparative trial in 105 patients with acute myeloid leuke-
mia. Blood 1998;91:3601-6.
Fresh Frozen Plasma
Abdel-Wahab OI, Healy B, Dzik WH. Effect of fresh-frozen plasma on prothrombin
time and bleeding in patients with mild coagulation abnormalities. Transfusion
2006;46:1279-85.
Burns ER, Goldberg SN, Wenz B. Paradoxical effect of multiple mild coagulation
factor deficiencies on the prothrombin time and activated partial thromboplastin
time. Am J Clin Pathol 1993;100:94-8.
Ciavarella D, Reed RL, Counts TL, et al. Clotting factor levels and the risk of diffuse
microvascular bleeding in the massively transfused patient. Br J Haematol 1987;67:
365-8.
Consensus conference. Fresh-frozen plasma: Indications and risks. JAMA 1985;253:
551-3.
Counts RB, Haisch C, Simon TL, et al. Hemostasis in massively transfused trauma
patients. Ann Surg 1979;190:91-9.
Ewe K. Bleeding after liver biopsy does not correlate with indices of peripheral coag-
ulation. Digest Dis Sci 1981;26:388-93.
Fresh-Frozen Plasma, Cryoprecipitate, and Platelets Administration Practice Guide-
lines Development Task Force of the College of American Pathologists. Practice
parameter for the use of fresh-frozen plasma, cryoprecipitate, and platelets. JAMA
1994;271:777-81.
94 PRACTICAL SELF-ASSESSMENT FOR TRANSFUSION MEDICINE PROFESSIONALS
Holland LL, Foster TM, Marlar RA, Brooks JP. Fresh frozen plasma is ineffective for
correcting minimally elevated international normalized ratios. Transfusion 2005;45:
1234-5.
Makris M, Greaves M, Phillips WS, et al. Emergency oral anticoagulant reversal: The
relative efficacy of infusions of fresh frozen plasma and clotting factor concentrate
on correction of the coagulopathy. Thromb Haemost 1997;77:477-80.
McGill DB. Predicting hemorrhage after liver biopsy. Digest Dis Sci 1981;26:385-7.
McVay PA, Toy PTCY. Lack of increased bleeding after paracentesis and thoracente-
sis in patients with mild coagulation abnormalities. Transfusion 1991;31:164-71.
Roback JD, Caldwell S, Carson JL, et al. Evidence-based practice guidelines for
plasma transfusion. Transfusion 2010;50:1227-39.
Rustad H, Myhre E. Surgery during anticoagulant treatment. Acta Med Scand 1963;
173:115-19.
Segal JB, Dzik WH, for the Transfusion Medicine/Hemostasis Clinical Trials Net-
work. Paucity of studies to support that abnormal coagulation test results predict
bleeding in the setting of invasive procedures: An evidence-based review. Transfu-
sion 2005;45:1413-25.
Stanworth SJ, Brunskill SJ, Hyde CJ, et al. Is fresh frozen plasma clinically effective?
A systematic review of randomized controlled trials. Br J Haematol 2004;126:139-52.
Triulzi DJ. The art of plasma transfusion therapy. Transfusion 2006;46:1268-70.
Wallis JP, Dzik W. Is fresh frozen plasma overtransfused in the United States? Trans-
fusion 2004;44:1674-5.
Granulocyte Transfusions
Dale DC, Liles WC, Llewellyn C, et al. Neutrophil transfusions: Kinetics and func-
tions of neutrophils mobilized with granulocyte-colony-stimulating factor and dexa-
methasone. Transfusion 1998;38:713-21.
Huestis DW, Glasser L. The neutrophil in transfusion medicine. Transfusion 1993;
34:630-46.
Jendiroba DB, Lichtiger B, Anaissie E, et al. Evaluation of three mobilization meth-
ods for the collection of granulocytes. Transfusion 1998;38:722-8.
Price TH. Granulocyte transfusion: It’s time for an answer. Transfusion 2006;46:1-5.
Strauss RG. Granulocyte transfusion therapy. Hematol/Oncol Clin North Am 1994;
8:1159-66.
Strauss RG. Therapeutic granulocyte transfusions in 1993. Blood 1993;81:1675-8.
INDICATIONS FOR TRANSFUSION 95
Irradiation
Anderson KM. Broadening the spectrum of patient groups at risk for transfusion-
associated GVHD: Implications for universal irradiation of cellular blood compo-
nents. Transfusion 2003;43:1652-4.
Luban NLC. Transfusion-associated graft-versus-host disease in the neonate—
expanding the spectrum of disease. Transfusion 1996;36:101-3.
Ohto H, Anderson KC. Post-transfusion graft-versus-host disease in Japanese new-
borns. Transfusion 1996;36:117-23.
Przepiorka D, LeParc GF, Stovall MA, et al. Use of irradiated blood components:
Practice parameter. Am J Clin Pathol 1996;106:6-11.
Leukocyte Reduction
Blajchman MA. Immunomodulatory effects of allogeneic blood transfusions: Clini-
cal manifestations and mechanisms. Vox Sang 1998;74(Suppl 2):315-19.
Blajchman MA. Transfusion-associated immunomodulation and universal white cell
reduction: Are we putting the cart before the horse? Transfusion 1999;39:665-70.
Bowden RA, Slichter SJ, Sayers M, et al. A comparison of filtered leukocyte-reduced
and cytomegalovirus (CMV) seronegative blood products for the prevention of trans-
fusion-associated CMV infection after marrow transplant. Blood 1995;86:3598-603.
The Trial to Reduce Alloimmunization to Platelets Study Group. Leukocyte reduc-
tion and ultraviolet B irradiation of platelets to prevent alloimmunization and refrac-
toriness to platelet transfusions. N Engl J Med 1997;337:1861-9.
Vamvakas EC. Is white blood cell reduction equivalent to antibody screening in pre-
venting transmission of cytomegalovirus by transfusion? A review of the literature
and meta-analysis. Transfus Med Rev 2005;19:181-99.
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immunomodulation: Fact or fiction? Blood 2001;97:1180-95.
In: Leonard G, Licata M.
Practical Self-Assessment for Transfusion Medicine Professionals
Bethesda, MD: AABB Press, 2012
9
Autologous Blood
QUESTIONS
Question 1: Which of the following statements is true about a preoperative autolo-
gous blood donation program?
A. Contributes substantially to the community blood supply.
B. Results in intraoperative blood recovery, sometimes called “cell salvage.”
C. Eliminates the risk of febrile and allergic transfusion reactions.
D. Eliminates the risk of transfusion-transmitted infectious agents.
E. Allows for the transfusion of whole blood, which contains platelets and coagu-
lation factors in addition to red cells, in lieu of allogeneic RBC units.
________________________________ ________________________________
夝
Question 2: Which of the following patients might consider participating in autolo-
gous donation?
A. A patient with a hemoglobin level of 10.5 g/dL or hematocrit of 31%.
B. A patient scheduled for surgery in 2 days.
C. A patient with an open, ulcerated skin lesion on his forehead.
D. A G2P1 female who says she “bled a lot” during her first spontaneous vaginal
delivery.
E. A patient scheduled for orthopedic surgery who has no history of cardiac dis-
ease or seizure disorder.
________________________________ ________________________________
夝
Question 3: Which statement about preoperative autologous blood donation is true?
A. About one-tenth of all preoperatively collected units are wasted.
B. The maximum age limit is 65 years of age.
C. Preoperative autologous donation is also a cost-savings option.
98 PRACTICAL SELF-ASSESSMENT FOR TRANSFUSION MEDICINE PROFESSIONALS
D. Recombinant human erythropoietin is licensed for use in the preoperative
period to increase the red cell mass in the collected autologous unit(s).
E. The maximum surgical blood order schedule, a document prepared jointly by
the transfusion service and surgeons, can serve as a guide for determining patient
eligibility and the number of units of autologous blood that could be donated.
________________________________ _______________________________
夝
Question 4: Which bacterium can proliferate during storage (even at 4 C) and is the
most commonly isolated bacterium in RBC units?
A. Agrobacterium radiobacter.
B. Yersinia enterocolitica.
C. Flavomonas species.
D. Escherichia coli.
E. Staphylococcus epidermidis.
________________________________ _______________________________
夝
Question 5: A patient qualifies for autologous donation of several units of blood.
Which of the following statements regarding the typical procedure used by most
physicians is true?
A. The patient will most likely donate blood at 2-week intervals.
B. Collection should begin as close to surgery as possible, preferably no more
than 4 weeks before surgery.
C. The maximum amount of blood that can be drawn at each donation cannot
exceed 1 unit.
D. The physician may prescribe daily oral iron supplements throughout the dona-
tion period.
E. The last donation should be on admission to the hospital.
________________________________ _______________________________
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Question 6: Rates of adverse reactions in patients donating autologous blood are the
same as the rates for allogeneic blood donors. Which of the following signs/symp-
toms is helpful in differentiating a vasovagal response from a hypovolemic reaction
(secondary to acute loss of intravascular volume from the donation)?
A. A decrease in blood pressure.
B. A decrease in heart rate.
C. A decrease in oxygen saturation.
D. Postural dizziness.
E. Pallor.