a. Packed RBC i. Indication: severe or symptomatic anemia, acute blood loss, ii. Prepared from whole blood by sedimentation or centrifugation.
b.
c.
d.
e.
f.
One unit contains 250-350 mL.
iii. Can be stored up to 35 days depending on processing iv. Is a less danger of fluid overload and are preferred choice since they are more component specific Frozen RBC i. Indication: autotransfusion, stockpiling or rare donors for pts. w/ alloantibodies ii. Are prepared from RBC using glycerl for protection and frozen. Can be stored for 10 yrs. iii. Must be used w/I 24 hrs of thawing Platelets i. Indication: bleeding caused by thrombocytopenia; but not for ITP, heparin induced thrombo unless life threatening ii. Are prepared from fresh whole blood and contains 30-60 mL of plt. Concentrate. iii. Can be kept at room temp for 1-5 days depending on type of collection and storage bag. Fresh frozen plasma i. Indication: bleeding due to deficiency in clotting factors, (DIC, hemorrhage, massive transfusion, liver disease, vitamin K deficiency, excessive warfarin) ii. Is rich in clotting factors but contains no platelets. iii. Can be stored for >1 yr but must be used w/I 24hr after thawing Albumin i. Indication: hypovolemic shock, hypoalbuminemia ii. Albumin is prepared from plasma. It can be stored for 5 yr. iii. Acts by moving water from extravascular to intravascular space. It is heat treated and does not transmit viruses Cryoprecipitate and Commercial Concentrates i. Indication: replacement of clotting factors (VIII, von willebrand factor, and fibrinogen) ii. Prepared from fresh frozen plasma and can be stored for 1 yr. once thawed must be used w/I 5 days.
B. DIC (Disseminated Intravascular Coagulation)
a. Definition: serious bleeding and thrombotic disorder that results from
abnormally initiated and accelerated clotting.
i. It is not a disease but an abnormal response to disease process or disorder
b. Cause --------excessive clotting & hemorrhaging
i. Antithrombin III and protein C, are depressed. Excessive clotting activates fibrinolytic system, which in turn breaks down already formed clots which creates fibrin split products (FSP). These products have anticoagulant properties inhibiting normal blood clotting. 1. Can lead to shock, organ failure, or death
c. Risks i. ii. iii. iv.
Hemorrhagic/ cardiogenic/anaphylactic shock,
septicemia, transfusion of mismatched blood, acute hemolysis, abrupto placentae, amniotic fluid embolism, septic abortion, HELLP, v. acute leukemia, lymphoma tumor syndrome vi. burns/trauma, heatstroke, severe head injury, transplant rejection, postop damage, fat/pulmonary emboli, snakebites, glomerulonephritis, acute anoxia, prosthetic devices fulminant hepatitis vii. liver disease, lupus, malignancy d. S&S i. Integumentary manifestations: pallor, petechiae, purpura, oozing blood, venipuncture site bleeding, hematomas, and occult hemorrhage ii. Respiratory: tachypnea, hemoptysis, orthopnea iii. Cardio: tachycardia, hypotension iv. GI/ GU: upper and low GI bleed, abd. Distention, bloody stool, hematuria v. Neuro: vision change, dizzy, headache, change in mental status, irritability vi. Skeletal: bone and joint pain. e. Diagnostic tests i. D-Dimer, PT, PTT, aPTT, fibrinogen, plts, fibrin split products, factor assay, Antithrombin III, protein C&S, peripheral blood smear f. Treatment: underlying cause must be treated i. If caused by malignancy-chemotherapy is treatment of choice g. Interventions i. Provide oxygen and volume replacement ii. Blood products such as plts, cryoprecipitate, fibrinogen, fresh frozen plasma (FFP) 1. Plts are usually given if less than 20,000 or 50,000 2. Cryopreciptate is given to replace factor VIII 3. Fibrinogen is given if less than 100 4. FFP replaces all clotting factors except plts. iii. Heparin is only give if the benefit (reduce clotting) outweighs the risk (further bleeding)
C. Thrombocytopenia a. Definition: A reduction of plt below 150,000.
i. Acute, severe, or prolonged decrease can result in abnormal
b.
c.
d.
e. f.
hemostasis and manifest prolonged bleeding from minor trauma
or spontaneous bleeding w/o injury 1. ITP (idiopathic thrombocytopenic purpura): autoimmune disease in which Plts are coated w/ antibodies, the spleen then recognizes them as foreign and destroyed. 2. TTP (Thrombotic thrombocytopenic purpura): hemolytic anemia, thrombocytopenia, neuro abnormalities, fever, and renal abnormalities. Plasma enzyme is deficit which in return vWF attaches to activated plts, promoting plt. Aggregation. 3. Heparin-induced thrombo: typically occurs 5-10 days after heparin therapy. Cause: i. Typically inherited but can be caused by ingestion of certain herbs or drugs 1. Hep. C, HIV, aplastic anemia, tumor infiltrating bone marrow, radiation, sepsis, splenomegaly, DIC, 2. Alcohol, thiazide diuretics, chemotherapy, digoxin, NSAIDs, penicillin, sulfonamides, rifampin, aspirin, Haldol, lithium, ginger, cumin, turmeric, cloves, Vitamin C/E, heparin, garlic, ginkgo biloba, ginseng ii. Decreased production of plts. In bone marrow, increased destruction of plts, increased consumption of plts. S&S i. Typically asymptomatic but could have epistaxis or gingival bleeding. ii. Petechiae, purpura, superficial ecchymosis, prolonged bleeding during venipuncture or IM injection, confusion, headache, seizures/coma could occur iii. Biggest concern is hemorrhaging Diagnostic (Table 31-13 pg. 652) i. Plt below 150,000 if below 20,000 life threatening hemorrhage could occur. ii. Pt, aPTT, hgb Treatment: treat the initial cause Interventions i. Drug therapy 1. Provide corticosteroids 2. Plt transfusion ii. Discourage excessive use of Over the counter medications iii. Wear all protective gear when performing an active sport iv. Do not blow nose forcefullyif nose starts to bleed, keep head up and apply firm pressure. Place an ice bag over bridge if necessary v. Prevent constipation or straining when using the restroom
vi. vii. viii. ix.
Shave only w/ electronic razor and do not pluck eyebrows
No tattoos or body piercings Use soft bristle toothbrush to prevent gum injury Ask doctor if it is okay to get dental cleaning, manicure, or pedicure before doing it.
D. ITP (Idiopathic Thrombocytopenia Purpurua)
a. Definition: i. autoimmune disease where the plts. Are coated with antibodies. b. c. d.
e.
The spleen recognizes these antibodies as foreign and destroys
the plts. Reducing the amount of plts. In the body. Cause: Autoimmune disease Diagnostic i. Plts decreased, ITP plt. Antigen-specific assay, C-serotonin release assay, Helicobacter pylori, bone marrow biopsy Treatment i. Drug therapy 1. Corticosteroids are used because of their ability to suppress the phagocytic response of splenic macrophages. a. Danazol(Danocrine), an androgen, may also be used w/ corticosteroid therapy 2. If unresponsive to corticosteroid used will typically get iV immunoglobulin (Anti-Rh(D)) (Anti-D, WinRho) 3. if chronic ITP than Romiplostim(Nplate) and eltrombopag (Promacta) is used which increate plt. Production ii. Splenectomy may be indicated if pt. does not respond to drug therapy iii. Plt. Are only transfused to increase plt. Count in life-threatening hemorrhage but not prophylactically Interventions i. Same Interventions as above ii. Educate about setting up periodic medical evaluations to assess their status
E. HELLP Syndrome (hemolysis, elevated liver, low platelet)
a. Pregnancy i. Definition: severe preeclampsia that involved hepatic
dysfunction. Also known as hemolysis, elevated liver enzyme,
and low plt. Count 1. Typically in 3rd trimester, or w/I 48 hrs after birth 2. Life-threatening pregnancy complication & difficult to diagnose 3. If baby weighs less than 2 lbs. there is a higher risk of fetal demise ii. Patho
iii.
iv.
v.
vi.
vii. viii.
1. Caused due to arteriolar vasospasm, dysfunction in fibrin
deposits, and adherence of plt. In blood vessel. RBC are damaged as they pass through blood vessel and become hemolyzed, causing decreased RBC, low plts, and hyperbilirubinemia. Damaged fibrin deposits in liver leading to impaired liver function Class 1. Class I (Severe thrombocytopenia): AST >60, Plt. Under 50,000 2. Class II (moderate): AST >60, platelet between 50,000 and 100,000 3. Class III (Mild): AST>40 and plt between 100,000 & 150,000 Complications 1. Placenta abruption, pulmonary edema, DIC, ARDS, liver hematoma, renal Failure, infant respiratory distress syndrome, Risks 1. Caucasian women, preeclampsia, women over the age of 25, multiparous (two or more pregnancies), pulmonary edema, acute renal failure, DIC, placental abruption, liver hemorrhage or failure, ARDS, sepsis, stroke S&S 1. Typically have malaise, flu-like symptoms, epigastric/right upper quadrant abd. Pain, N/V, headache, visual disturbance, bleeding 2. May have thrombocytopenia like symptbruising/ hematuria 3. Blood pressure is typically high and protein is in the urine as well as elevated liver enzymes Diagnostic: no definitive diagnostic tests 1. CBC, H&H, bilirubin >1.2, plt count, serum aspartate >70, lactate dehydrogenase >600 Interventions 1. For fetus <34 wks a. Bed rest b. Corticosteroid c. Meg sulfate d. Blood transfusion if plt too low e. Blood pressure medication (must be approved) f. Fetal monitoring and test including biophysical test, sonograms, etc. 2. For fetus >34 wks a. Deliver is needed. b. Should be given a trial of labor