Question 21

Created on Tue, 05/26/2015 - 19:31
Last updated on Sun, 04/30/2017 - 01:50
Pass rate: 83%
Highest mark: ?

Other SAQs in this paper

Other SAQs on this topic

Examine the list of blood or plasma products listed in the table below. Indicate in your answer,
a)  whether crossmatch is essential with the use of each of these products
b)  one major indication for the use of each of these products.

Need for crossmatch

One major indication for use

Packed red blood cells

   

Platelets

   

Fresh frozen
plasma

   

Cryo precipitate

   

Prothrombin concentrate

   

Granulocyte concentrate

   

Intravenous immunoglobulin

   

c)  List one contraindication to the use of

i)          Platelet transfusion
ii)         IV immunoglobulin infusion

d)  Very briefly, outline the role of erythropoietin in the management of anaemia of critical illness?

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College Answer

Examine the list of blood or plasma products listed in the table below. Indicate in your answer,
a)  whether crossmatch is essential with the use of each of these products
b)  one major indication for the use of each of these products.

Need for crossmatch

One major indication for use

Packed red blood
cells

Yes

a) Acute blood loss
b) Hb < 100 with concomitant IHD, c) severe anaemia, in absence of blood loss (Hb<70

Platelets

No

Platelets < 20,000 or <50,000 with bleeding, or pending interventional/surgicalprocedure, bone marrow failure - <10,000 in absence of risk factors, <20,000 in presence of risk factors

Fresh frozen
plasma

No

Warfarin overdose, coagulopathy post transfusion, post bypass bleeding

Cryo precipitate

No

DIC, coagulopathy post transfusion with low fibrinogen, hereditary hypofibrinogenemia, Hemophilia,Von willebrand’s disease

Prothrombin
concentrate

No

Warfarin overdose where FFP may be difficult to administer because of volume considerations

Granulocyte
concentrate

Yes

Neutropenic sepsis

Intravenous
immunoglobulin

No

LGB syndrome,
immune thrombocytopenia, vasculitis, myasthenia gravis, ITP

c)  List one contraindication to the use of

i)          Platelet transfusion -ITP . immune thrombocytopenia 
ii)         IV immunoglobulin infusion - Hereditary IgA deficiency

d)  Very briefly, outline the role of erythropoietin in the management of anaemia of critical illness?

Anaemia of critical illness is characterised by blunted EPO production and altered iron metabolism. EPO use has been shown to reduce transfusion requirements, but there in no proven benefit in terms of clinical outcome. A potential benefit may exist in patients who are in ICU for > 1 wk, but data are lacking. Potential side effects include red cell aplasia, EPO resistance, thromboembolic complications and hypertension.

Discussion

This question closely resembles other questions where one is expected to match a blood product with a need for transfusion.

These questions are:

  • Question 1 from the second paper of 2012
  • Question 24.2 from the second paper of 2010 (this contains a detailed dissection of crossmatching practice)

However, in contrast, this one also demands indications. These gan be dug out of the old 2001 NHMRC guidelines, or read about broadly in this article. More modern guidelines are available from the Australian Red Cross Blood Service website, and these were used to construct the list below.

In brief, the indications are as follows:

  • Packed red blood cells
    • Uncontrolled bleeding
    • Symptomatic anaemia
  • Platelets
    • Uncomplicated bone marrow failure (<10,000)
    • Bone marrow failure with additional risk factors for bleeding(<20,000)
    • Simple surgical procedures (<50,000)
    • Neurosurgical procedures (<100,000)
  • Fresh frozen plasma
    • Replacement of clotting factors in coagulopathy; according to the ARCBS, "You may give fresh frozen plasma to replace labile plasma coagulation factors during massive transfusion, cardiac bypass, liver disease or acute disseminated intravascular coagulation in the presence of bleeding and abnormal coagulation."
    • Replacement of ADAMTS-13 for plasma exchange in TTP
  • Cryo precipitate
    • Replacement of factor VIII, fibrinogen, factor XIII, von Willebrand factor and fibronectin.
    • Indicated specifically for the replacement of fibrinogen for the management of low fibrinogen levels or to relpace functionally abnormal fibrinogen
  • Prothrombin concentrate
    • Relacement of prothrombin to correct over-anticoagulation with Warfarin
  • Granulocyte concentrate
    • The college says "neutropenic sepsis". This is consistent with the UK guidelines. There is little Australia-specific information about this, which is reflected in this policy documentfrom The Alfred in Melbourne (an almost verbatim copy of the UK guidelines).
  • Intravenous immunoglobulin
    A good article from 2005 contains a detailed table of indications for IVIG. This table is massive and cannot (should not) be reproduced here. Highlights are as follows:
    • Guillain-Barre syndrome
    • ITP
    • Myasthenia gravis
    • Lambert-Eaton syndrome
    • Autoimmune haemolytic anaemia
    • Streptococcal toxic shock syndrome

References

Sharma, Sanjeev, Poonam Sharma, and Lisa N. Tyler. "Transfusion of blood and blood products: indications and complications." American family physician83.6 (2011): 719.

Massey, Edwin. "CLINICAL GUIDELINES FOR THE USE OF GRANULOCYTE TRANSFUSIONS."

Jolles, S., W. A. C. Sewell, and S. A. Misbah. "Clinical uses of intravenous immunoglobulin." Clinical & Experimental Immunology 142.1 (2005): 1-11.