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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5565_Библиотеки_им_академика_М_И_Перельмана.pdf
110 PRACTICAL SELF-ASSESSMENT FOR TRANSFUSION MEDICINE PROFESSIONALS
A. Response rates in recipients of allogeneic marrow transplants are lower than
the response rates in recipients of autologous marrow transplants.
B. Studies have shown that rhEPO-treated patients are able to donate significantly
more autologous blood than non-rhEPO-treated patients.
C. One potential role for rhEPO is in accelerating postoperative recovery of
hemoglobin/hematocrit levels, particularly in severely anemic patients.
D. rhEPO may be of benefit in anemic Jehovah’s Witness patients, but for religious
reasons, the patients should be told if the rhEPO is stabilized in human albu-
min.
E. All of the above statements are TRUE.
________________________________ _______________________________
夝
Question 4: Which of the following statements about blood substitutes is true?
A. Hemoglobin-based oxygen carriers (HBOCs) have very short half-lives and
require very high fractional inspired oxygen levels.
B. Perfluorocarbons must be modified in some way to prevent extravasation.
C. Crosslinking and polymerization of HBOCs increase renal filtration and
decrease their half-life in the body.
D. Limited shelf-life makes blood substitutes less than ideal for emergency situa-
tions.
E. Blood substitutes could potentially be beneficial in the setting of acute normo-
volemic hemodilution.
________________________________ _______________________________
夝
Question 5: Which of the following statements about the potential use of blood sub-
stitutes in sickle cell anemia patients is true?
A. Recombinant hemoglobin solutions have a higher viscosity than albumin or
normal human hemoglobin and thus can increase the whole blood viscosity.
B. Recombinant hemoglobin solutions replicate red cell membrane antigens that
are found on endogenous red cells.
C. Recombinant hemoglobin solutions could help improve blood flow and raise
hemoglobin concentration during acute sickle cell crises.
D. Recombinant hemoglobin solutions, due to their extended half-life in vivo
compared to RBCs, can obviate the need for RBC transfusions in sickle cell
patients.
E. Recombinant hemoglobin solutions should never be used instead of RBCs for
“pump-priming” in patients undergoing cardiopulmonary bypass surgery.
________________________________ _______________________________
夝
ERYTHROPOIETIN, BLOOD SUBSTITUTES, AND ENZYMATICALLY CONVERTED RED CELLS 111
ANSWERS
Question 1: Which of the following statements about erythropoietin (EPO) is true?
A. The main source of EPO in fetal life is the marrow.
B. The plasma EPO level rises linearly as hemoglobin levels decrease below nor-
mal levels ~15 g/dL.
C. Recombinant EPO eliminates the need for supplemental iron.
D. Recombinant EPO takes 3-4 days to elicit a response, so it has no use in the
acute treatment of anemia due to acute hemorrhage.
E. Recombinant EPO facilitates the movement of red cells through plastic tubing.
D. Erythropoietin is produced in the fetal liver, eventually shifting to the kidneys as
in adults. EPO levels are related to hemoglobin concentration, but will usually stay
within the reference range until the hemoglobin level decreases below 10.5 g/dL.
The use of recombinant EPO requires adequate iron stores and often the administra-
tion of EPO is performed along with iron supplementation.
________________________________ ________________________________
夝
Question 2: Which patient population is LEAST likely to respond to recombinant
EPO?
A. Anemic patients with end-stage renal disease undergoing dialysis 3 times per
week.
B. Anemic patients with anemia of chronic disease secondary to a chronic inflam-
matory condition.
C. Anemic patients with myelodysplastic syndrome.
D. Anemic patients with multiple myeloma.
E. Anemic patients with HIV whose endogenous EPO level is below 500 IU/L.
C. Anemic patients with myelodysplastic syndrome have very poor response rates
(<20%) to EPO. Anemic patients with multiple myeloma respond well to EPO (>75-
85%), as do the anemic patients described in Choices A, B, and E.
________________________________ ________________________________
夝
Question 3: Which statement regarding the use of rhEPO in the treatment of anemia
is NOT true?
A. Response rates in recipients of allogeneic marrow transplants are lower than
the response rates in recipients of autologous marrow transplants.
B. Studies have shown that rhEPO-treated patients are able to donate significantly
more autologous blood than non-rhEPO-treated patients.
112 PRACTICAL SELF-ASSESSMENT FOR TRANSFUSION MEDICINE PROFESSIONALS
C. One potential role for rhEPO is in accelerating postoperative recovery of
hemoglobin/hematocrit levels, particularly in severely anemic patients.
D. rhEPO may be of benefit in anemic Jehovah’s Witness patients, but for religious
reasons, the patients should be told if the rhEPO is stabilized in human albu-
min.
E. All of the above statements are TRUE.
A. This is false because it is reversed. Perhaps the reason why the recipients of allo-
geneic marrow respond better to rhEPO therapy is because they are more likely to
have very low endogenous EPO levels.
________________________________ _______________________________
夝
Question 4: Which of the following statements about blood substitutes is true?
A. Hemoglobin-based oxygen carriers (HBOCs) have very short half-lives and
require very high fractional inspired oxygen levels.
B. Perfluorocarbons must be modified in some way to prevent extravasation.
C. Crosslinking and polymerization of HBOCs increase renal filtration and
decrease their half-life in the body.
D. Limited shelf-life makes blood substitutes less than ideal for emergency situa-
tions.
E. Blood substitutes could potentially be beneficial in the setting of acute normo-
volemic hemodilution.
E. HBOCs have a very long shelf life compared to RBCs (up to 1 year) and are often
modified with a macromolecule to prevent extravasation, which may prevent some
of the toxicity associated with HBOCs. The modifications elongate the half-life of
HBOCs by decreasing renal filtration. PFCs are not prone to extravasation and toxic-
ity as HBOCs are. Because of their long half-lives, PFCs and HBOCs are of greatest
potential in emergency situations.
________________________________ _______________________________
夝
Question 5: Which of the following statements about the potential use of blood sub-
stitutes in sickle cell anemia patients is true?
A. Recombinant hemoglobin solutions have a higher viscosity than albumin or
normal human hemoglobin and thus can increase the whole blood viscosity.
B. Recombinant hemoglobin solutions replicate red cell membrane antigens that
are found on endogenous red cells.
C. Recombinant hemoglobin solutions could help improve blood flow and raise
hemoglobin concentration during acute sickle cell crises.
ERYTHROPOIETIN, BLOOD SUBSTITUTES, AND ENZYMATICALLY CONVERTED RED CELLS 113
D. Recombinant hemoglobin solutions, due to their extended half-life in vivo
compared to RBCs, can obviate the need for RBC transfusions in sickle cell
patients.
E. Recombinant hemoglobin solutions should never be used instead of RBCs for
“pump-priming” in patients undergoing cardiopulmonary bypass surgery.
C. In sickle cell patients one of the biggest concerns is the decreased blood flow. As
a result, any blood substitute that could potentially decrease viscosity would be of
benefit, especially in the setting of an acute sickle cell crisis. The recombinant
hemoglobin systems thus far developed have a lower viscosity than albumin or nor-
mal human hemoglobin. Despite their usefulness in the acute setting, recombinant
hemoglobin blood substitutes have a short half-life and should not be used in isola-
tion, but rather as an adjunctive therapy to accompany RBC transfusion. Use of
recombinant hemoglobin as an oxygen carrier may help patients with less overall
blood volume tolerate the extracorporeal volume required in a pump or apheresis
device. Recombinant hemoglobin would therefore be useful to prime the pump in
children undergoing procedures that require apheresis or bypass.
________________________________ ________________________________
夝
SUGGESTED READING
Erythropoietin
Atabek U, Alvarez R, Pello MJ, et al. Erythropoietin accelerates hematocrit recovery
in post-surgical anemia. Am Surg 1995;61:74-7.
AuBuchon JP. Minimizing donor exposure in hemotherapy. Arch Pathol Lab Med
1994;118:380-91.
Bennett CL, Luminari S, Nissenson AR, et al. Pure red cell aplasia and epoetin ther-
apy. N Engl J Med 2004;351:1403-8.
Bohlius J, Weingart O, Trelle S, Engert A. Cancer-related anemia and recombinant
erythropoietin—an updated overview. Nat Clin Pract Oncol 2006;3:152-64.
Boogaerts M, Mittleman M, Vaupel P. Beyond anaemia management: Evolving role
of erythropoietin therapy in neurological disorders, multiple myeloma and tumor
hypoxia models. Oncology 2005;69(Suppl 2):22-30.
Drueke TB, Locatelli F, Clyne N, et al for the CREATE Investigators. Normalization
of hemoglobin level in patients with chronic kidney disease and anemia. N Engl J
Med 2006;355:2071-84.
Engert A. Recombinant human erythropoietin in oncology: Current status and fur-
ther developments. Ann Oncol 2005;16:1584-95.
114 PRACTICAL SELF-ASSESSMENT FOR TRANSFUSION MEDICINE PROFESSIONALS
Goodnough LT. Clinical application of recombinant erythropoietin in the periopera-
tive period. Hematol/Oncol Clin North Am 1994;8:1011-20.
Remuzzi G, Inglefinger JR. Correction of anemia: Payoffs and problems. N Engl J
Med 2006;355:2144-6.
Singh AK, Szczech L, Tang KL, et al for the CHOIR Investigators. Correction of ane-
mia with epoetin alfa in chronic kidney disease. N Engl J Med 2006;355:2085-98.
Blood Substitutes
Agrawal YP, Freedman M, Szczepiorkowski ZM. Long-term transfusion of polymer-
ized bovine hemoglobin in a Jehovah’s Witness following chemotherapy for
myeloid leukemia: A case report. Transfusion 2005;45:1735-8.
Gonzalez P, Hackney AC, Jones S, et al. A phase I/II study of polymerized bovine
hemoglobin in adult patients with sickle cell disease not in crisis at the time of
study. J Invest Med 1997;45:258-64.
Goodnough LT, Monk TG, Brecher ME. Acute normovolemic hemodilution should
replace the preoperative donation of autologous blood as a method of autologous-
blood procurement. Transfusion 1998;38:473-6.
Gould SA, Moore EA, Hoyt DB, et al. The first randomized trial of human polymer-
ized hemoglobin as a blood substitute in acute trauma and emergent surgery. J Am
Coll Surg 1998;187:113-22.
Gould SA, Moore EA, Hoyt DB, et al. The life-sustaining capacity of human polym-
erized hemoglobin when red cells might be unavailable. J Am Coll Surg 2002;195:
445-55.
Gould SA, Moore EA, Moore FA, et al. Clinical utility of human polymerized hemo-
globin as a blood substitute after acute trauma and urgent surgery. J Trauma
1997;43:325-32.
Gould SA, Rosen AL, Sehgal LR, et al. Fluosol-DA as a red-cell substitute in acute
anemia. N Engl J Med 1986;314:1653-6.
Greenburg AG. Clinical implications of blood substitutes. Artif Organs 1998;22:47-
9.
Habler OP, Kleen MS, Hutter JW, et al. Effects of hyperoxic ventilation on hemodilu-
tion-induced changes in anesthetized dogs. Transfusion 1998;38:135-44.
Habler OP, Kleen MS, Hutter JW, et al. Hemodilution and intravenous perflubron
emulsion as an alternative to blood transfusion: Effects on tissue oxygenation during
profound hemodilution in anesthetized dogs. Transfusion 1998;38:145-55.
Hess JR. Update on alternative oxygen carriers. Vox Sang 2004;87(Suppl 2):S132-5.
ERYTHROPOIETIN, BLOOD SUBSTITUTES, AND ENZYMATICALLY CONVERTED RED CELLS 115
Jahr JS. A novel blood substitute: Use of HBOC-201 (Hemopure [R]) to decrease the
need for RBC: Results of a pivotal trial in orthopedic surgery (abstract). Crit Care
Med 2001;29(Suppl A):A168.
Kasper SM, Grune F, Walter M, et al. The effects of increased doses of bovine hemo-
globin on hemodynamics and oxygen transport in patients undergoing preoperative
hemodilution for elective abdominal aortic surgery. Anesth Analg 1998;87:284-91.
LaMuraglia GM, O’Hara PJ, Baker WH, et al. The reduction of the allogeneic trans-
fusion requirement in aortic surgery with a hemoglobin-based solution. J Vasc Surg
2000;31:299-308.
Levy JH, Goodnough LT, Greilich PE, et al. Polymerized bovine hemoglobin solu-
tion as a replacement for allogeneic red cell transfusion after cardiac surgery:
Results of a randomized, double-blind trial. J Thorac Cardiovasc Surg 2002;124:35-
42.
Mullon J, Giacoppe G, Claggett C, et al. Transfusions of polymerized bovine hemo-
globin in a patient with severe autoimmune hemolytic anemia. N Engl J Med 2000;
342:1638-43.
Scott MG, Kucik DF, Goodnough LT, Monk TG. Blood substitutes: Evolution and
future applications. Clin Chem 1997;43:1724-31.
Song DA, Wilson DF, Pastuszko A, et al. Comparison of the efficacy of blood and
polyethylene glycol-hemoglobin in recovery of newborn piglets from hemorrhagic
hypotension: Effect on blood pressure, cortical oxygen, and extracellular dopamine
in the brain. Transfusion 1995;35:552-8.
Stetter MN, Baerlocher GM, Meiselman HJ, Reinhart WH. The influence of recombi-
nant hemoglobin solution on blood rheology. Transfusion 1997;37:1149-55.
Thyes C, Spahn DR. Current status of artificial O
2
carriers. Anesthesiol Clin North
America 2005;23:373-89.
Von Dobschuetz E, Hutter J, Hoffmann T, Messmer K. Recombinant human hemo-
globin with reduced nitric oxide-scavenging capacity restores effectively pancreatic
microcirculatory disorders in hemorrhagic shock. Anesthesiology 2004;100:1484-
90.
Wahr JA, Trouwborst A, Spence RK, et al. A pilot study of the effects of perflubron
emulsion, AF 0104, on mixed venous oxygen tension in anesthetized surgical
patients. Anesth Analg 1996;82:103-7.
Enzymatically Converted Red Cells and PEGylated Red Cells
Garratty G. Progress in modulating the RBC membrane to produce transfusable uni-
versal/stealth donor RBCs. Transfus Med Rev 2004;18:245-56.
116 PRACTICAL SELF-ASSESSMENT FOR TRANSFUSION MEDICINE PROFESSIONALS
Kruskall MS, AuBuchon JP. Making Landsteiner’s discovery superfluous: Safety and
economic implications of a universal group O red blood cell supply. Transfus Sci
1997;14:613-20.
Kruskall MS, AuBuchon JP, Anthony KY, et al. Transfusion to blood group A and O
patients of group B RBCs that have been enzymatically converted to group O. Trans-
fusion 2000;40:1290-8.
Lenny LL, Hurst R, Goldstein J, Galbraith RA. Transfusions to group O subjects of 2
units of red cells enzymatically converted from group B to group O. Transfusion
1994;34:189-91.
Lenny LL, Hurst R, Zhu A, et al. Multiple-unit and second transfusions of red cells
enzymatically converted from group B to group O: Report on the end of phase 1 tri-
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Lubin DM. Universal RBCs. Transfusion 2000;40:1285-9.
In: Leonard G, Licata M.
Practical Self-Assessment for Transfusion Medicine Professionals
Bethesda, MD: AABB Press, 2012
11
Special Transfusion Situations
QUESTIONS
Question 1: Which statement about hemolytic disease of the fetus and newborn
(HDFN) is true?
A. It generally occurs during the first trimester.
B. If severe, it results in extramedullary hematopoiesis.
C. It may result in hypoxia-induced damage to the brain and spinal column.
D. The fetus is at risk for developing kernicterus secondary to hyperbilirubinemia
and low levels of glucuronyl transferases.
E. The neonate is at risk for developing hydrops fetalis secondary to anemia.
________________________________ ________________________________
夝
Question 2:
Which statement is true about the antigens/antibodies that cause HDFN?
A. The two most significant antigens associated with HDFN are the D antigen and
the ABO antigens.
B. An Rh-negative mother will rarely have an Rh-positive fetus.
C. A K-negative mother will likely have a K-positive fetus.
D. RhIG is a monoclonal anti-D IgM antibody preparation given subcutaneously.
E. RhIG dose should be doubled for a woman who has already been sensitized to
D antigen.
________________________________ ________________________________
夝
Question 3: Which statement is NOT true about the administration of RhIG to Rh-
negative females?
A. It should be given at 28 weeks’ gestation to Rh-negative, antibody-negative,
pregnant females who may be carrying Rh-positive fetuses.
B. It may or may not be given again within 72 hours of delivery depending on the
Rh type of the neonate’s cord blood.
118 PRACTICAL SELF-ASSESSMENT FOR TRANSFUSION MEDICINE PROFESSIONALS
C. A 300-g dose (one vial) is enough to prevent immunization of 15 mL of fetal
red cells.
D. RhIG can be given beyond the 72-hour period after delivery, but the efficacy is
uncertain.
E. If the fetus is Rh-positive, fetal rosette testing should be performed immediately
to accurately quantify the amount of fetomaternal hemorrhage.
________________________________ _______________________________
夝
Question 4:
Which statement about antigen/antibodies that can cause HDFN is true?
A. Pregnant females with group AB blood are most at risk for HDFN.
B. HDFN due to ABO antibodies is usually severe because the A and B antigens
are strongly expressed at birth.
C. Approximately 95% of cases of HDFN are due to antibodies to antigens other
than Rh antigens.
D. When given to the mother within 72 hours after delivery, RhIG can protect
against sensitization to Kell antigens on fetal red cells.
E. After D and ABO antibodies, the next most important causes of HDFN are anti-
K and anti-c.
________________________________ _______________________________
夝
Question 5: A G1P0 mother at 10 weeks is at her first obstetric visit with a brand
new family practitioner. The mother’s type and screen results reveal that she is O
negative. In the appropriate management of this patient, what should be the practi-
tioner’s next step?
A. Administer RhIG at 28 weeks.
B. Perform another antibody screen at 28 weeks.
C. Ensure she was tested for the presence of weak D.
D. Measure amniotic fluid bilirubin levels.
E. Consult a pathologist for clinical advice.
________________________________ _______________________________
夝
Question 6: If a clinically significant antibody is detected at any stage during the
testing of an obstetric patient, what should be the very next step?
A. Titer the antibody.
B. Perform amniocentesis to determine bilirubin level.
C. Perform PUBS to determine bilirubin level.
D. Perform intrauterine transfusion.
E. Perform molecular studies on amniocytes.
SPECIAL TRANSFUSION SITUATIONS 119
________________________________ ________________________________
夝
Question 7: An obstetric patient has a high or rising antibody titer. The decision is
made to perform fetal middle cerebral artery (MCA) Doppler flow studies to detect
fetal anemia. Which of the following statements about this procedure is true?
A. Decreased flow rates indicate the presence of anemia.
B. The value obtained for the MCA is plotted on a Liley curve.
C. The MCA is a noninvasive technique.
D. The sensitivity is less than 85%.
E. MCA Doppler flow studies should be preceded by percutaneous umbilical
blood sampling.
________________________________ ________________________________
夝
Question 8: Which statement about intrauterine transfusion is NOT true?
A. O-negative blood is always given.
B. The transfused RBCs should not contain any antibodies directed against fetal
red cell antigens.
C. The transfused RBCs should be irradiated.
D. The transfused RBCs must be compatible with any maternal antibodies.
E. The transfused RBCs should be concentrated to a hematocrit of 85-90% by
removal of plasma.
________________________________ ________________________________
夝
Question 9: Which of the following antigens is the most common specificity for
neonatal/fetal alloimmune thrombocytopenia (NAIT/FAIT)?
A. HPA-1a.
B. HPA-1b.
C. HPA-1c.
D. HPA-2.
E. HPA-47.
________________________________ ________________________________
夝
Question 10: What is the most appropriate manner to manage a pregnant woman
with a history of a previous conception affected by NAIT/FAIT?
A. RhIG 300 μg, one dose.
B. IVIG alone, but only in emergent situations.
C. IVIG, with or without corticosteroids.