hematopoietic system

patho/pharm exam 3

hematopoietic system

the body’s blood forming system with the function to produce, mature, and regulate blood cells that carry O2, fight infection, and control clotting

bone marrow

soft spongy tissue inside bones and source of all blood cells (RBCs especially) except lymphocytes

red bone marrow

vascular (found in pelvis, sternum, and vertebrae)

RBC count, WBC count, platelet count

most important things in CBC?

hemoglobin (Hgb)

responsible for carrying O2 to tissues

hematocrit (Hct)

measure volume of blood (thickness)

anemia

the loss of RBCs, decreased production of RBCs, and the increased destruction of RBCs which causes less O2 to be carried to tissues

treatment for Iron deficiency anemia

ferrous sulfate (which can cause black stool, nausea, vomiting, and constipation)

megaloblastic anemia

B12 deficiency which causes impaired DNA synthesis and leads to large immature RBC made in the bone marrow.

these pts will be malnourished 

sources of B12

dairy, eggs, poultry, meat, fish

sickle cell anemia

crescent shaped RBCs which cause blood to sludge. Crescent shaped RBCs will catch/ get stuck on blood vessels causing blood to get thicker since blood clotting and not receiving O2

pts will be SOB and in agony 

African Americans 

what type of pts are predisposed to sickle cell anemia?

treatment for sickle cell anemia

HYDRATION (if not then clots will form in joint areas), pain management (always fist), blood transfusion + O2

symptoms of anemia

pale, SOB, weakness + fatigue, dizziness, tachycardia, smooth red tongue (B12), GI symptoms

hemorrhage

excessive/uncontrolled bleeding, happens in the kidneys (kidneys produce erythropoietin which helps make RBCs, so if kidneys dont work then pt will be anemic)

causes of anemia

leukemia, bone marrow, hemorrhage

WBC normal range

4,000 - 10,000

platelet normal range

150,000 - 450,000

hemoglobin (hgb) normal range

11 - 17

hematocrit (hct) normal range

W: 39% - 48%

M: 42% - 50%

reticulocyte count

immature red blood cells

an increase indicates that the body senses a issue (blood loss or anemia) and is overproducing RBCs, but these cells are underdeveloped and don’t work yet

example of reticulocyte count increase

pt with breathing issues → low O2 → increase in erythropoietin → increase in RBCs → increase in X

polycythemia vera

proliferative disorder (cells multiply too quickly) where bone marrow makes RBCs without normal control, so body will make way too many RBC’s causing blood to turn into sludge and further causing circulation issues

secondary polycythemia

responds to low O2 (like with COPD or heart disease)

symptoms of polycythemia

SOB, fatigue, pulmonary issues, enlarged spleen

treatment for polycythemia

splenectomy, therapeutic aphaeresis (removes certain cells from blood), therapeutic phlebotomy

whole blood

contains all natural components of blood (RBCs, platelets, plasma, WBCs)

packed RBCs

concentrated RBCs made by removing plasma from the blood. Must get type and cross test before giving to pts to determine their blood type. Protein Source.

anemic pts, hemorrhage pts, post-op

what pts are given packed RBCs?

platelets blood component

pooled platelets separated from blood

thrombocytopenia pts, chemotherapy pts, mylosupression pts, leukemia pts

what pts get platelets blood component?

fresh frozen plasma

liquid portion of whole blood (plasma) that is frozen after donation to preserve clotting factors 

contains Factor 8, Factor 9, albumin, immune globulin, factor 7

Factor VII (7)

natural (liver) and man made clotting factor which allows body to stop bleeding for a set amount time. Very expensive and will cause no active bleeding within 3-4 hrs. Used during surgery.

pts who dont have enough clotting factors (coagulopathy), used to help stop or prevent bleeding

what pts get fresh frozen plasma?

washed RBCs

removes every antigen possible. Removes most of plasma, proteins, and antibodies in blood. FOR EXTREME ALLERGIES. Must be used within 24 hrs.

immunocompromised pts

what pts get washed RBCs?

cryoprecipitate

blood product made from fresh frozen plasma and contains factor VIII (8)

pts who dont have Factor VIII (8), pts who have low fibrinogen levels

what pts get cryprecipitate?

febrile, non-hemolytic reactioin

most common transfusion reaction caused when pts are sensitive to blood even w/ closest match, pts are sensitive to doner’s WBCs + cytokins), no RBC destruction

no pain, FEVER may occur

acute hemolytic reaction

life-threatening reaction where transfused RBC’s are destroyed (hemolyzed) by pts immune system, usually due to wrong blood type being given

happens within minutes of transfusion

kidney pain and hypotension

MUST STOP IMMEDIATELY 

4 hrs

how long are transfusions given over?

blood transmitted diseases

AIDS/HIV, hepatitis

circulatory overload

when pt gets too much blood or fluid too quickly leading to overload and pulmonary edema

long-term transfusion therapy

citrate is put in so blood or fluid wont clump, citrate love Ca+ and can take Ca_ out of commission

white blood cells

leukocytes, body’s infection fighting cells in the blood and immune system

hemostasis

body’s process of stopping bleeding with platelets and fibrin/clotting factors

platelets (thrombocytes)

in blood and help form clots to stop bleeding, they will adhere to damaged vessel wall and change shape further exposing surface receptors and clumping together to from a plug, first responders

lifespan= 10 days

thrombocytosis

increase in circulating platelets ( > 450,000)

makes platelets harder to stick together further preventing clotting factors which are needed

why must patients stop taking aspirin before surgery?

antibiotics (piptazo), aspirin, anticoagulants

medications that impact platelets (eat platelets)?

thrombocytopenia

decrease in circulating platelets (< 150,000) which causes increase risk of bleeding and bruising (ecchymosis)

heparin-induced thrombocytopenia (HIT)

allergic reaction to heparin that causes low platelets and increased clotting (due to increased bleeding) since platelets get used up

bad for pts with dialysis 

clotting cascade

• extrinsic (damage to tissues) and intrinsic (damage to blood vessels) factors meet at common pathway where Factor X (10) is activated into Factor Xa (10a)

• Factor Xa (10a) converts prothrombin into thrombin

• thrombin converts fibrinogen into fibrin which forms a stable clot 

• clot dissolves

3- stages of hemostasis

• vessel spasm (vasoconstriction)- after injury to limit blood flow and reduce blood loss

• platelet plug formation (first responders)- platelets stick to exposed collagen at the injury site

• coagulation- clotting factors are activate in a chain reaction w/ intrinsic and extrinsic pathways

disseminated intravascular coagulopathy (DIC)

mother-load of all clotting problems, will release all clotting factors at once and cause many small clots to form until depletion

second phase is bleeding out (hemorrhage) since all clotting factors are depleted 

shock, sepsis, childbirth, trauma, tumors

what causes disseminated intravascular coagulopathy (DIC)?

will give fluid and try to stop bleeding but can cause multiple organ system failure quickly!

what do we do to help DIC?

anticoagulants

prevent clot formation and extension. Prevents new clots from forming and stops existing clots from getting bigger. Interferes w/ clotting cascade. DOES NOT DESTROY EXISTING CLOTS!

warfarin, heparin

antiplatelet drugs

prevent platelets from sticking together, stops platelet plug formation.

Clopidogrel (plavix), aspirin

thrombolytic agents

dissolves existing clots, converts plasminogen to plasmin which digests fibrin clots, cannot give if pt is on anticoagulants or has stokes

streptokinase, alteplase (tPA)

heparin

rapid acting anticoagulant that helps prevent new blood clots and stops existing ones from growing (will see effects within 1 hr)

works by activating antithrombin III, which blocks conversion of prothrombin to thrombin and fibrinogen to fibrin overall stopping the clotting cascade.

NEVER GIVE IM, WILL CAUSE BLEEDING

pulmonary embolism (clots traveling to lungs), stoke, DVT (overall so pt wont clot as fast)

what is heparin used for?

adverse effects of heparin

HEMORRHAGE, thrombocytopenia, hypersensitivity reactions (like HIT)

aPTT

platelets, Hgb, Hct (will cause these to decrease)

what to monitor for pts taking Heparin?

aPTT

measures how long it takes blood to clot

therapeutic range for aPTT

60-70 s

anything higher than 70 is bad and means blood is too thin

anti-Factor Xa

lab test that measures effectiveness of heparin by checking how well factor Xa is being inhibited

high → blood is too thin and increase risk of bleeding which means dose of heparin will need to be decreased

low → blood is too thick which means more clotting is happening still and dose of heparin will need to be increased

low molecular weight heparin

a modified from of heparin that’s smaller and more predictable and longer acting. ONLY INACTIVATES FACTOR Xa

normal range for aPTT

30-40 s

protamine sulfate

reverses heparin by binding to heparin and neutralizing its anticoagulation effects

max does = 50 mg delivered at 5 mg per min (10 mins total)

CAUTION WITH FISH ALLERGIES (has iodine base)

anaphylaxis, circulatory collapse, pulmonary edema

adverse effects of protamine sulfate

side effects of protamine sulfate

hypotension, bradycardia, dyspnea, flushing, nausea + vomiting

lovenox (enoxaparin)

a low molecular weight heparin used for joint (joint replacement) and abdominal cases

risk for HIT

no lab surveillance needed

warfarin

oral anticoagulant that helps  prevent blood clots from forming and growing. Works by blocking Vitamin K from making clotting factors VII (7), IX (9), X (10), and prothrombin

HEART VALVE REPLACEMENTS!, atrial fibrillation, post MI, stoke, cardiac embolism

what is warfarin used for?

adverse effects of warfarin

unusual bleeding, excessive menstrual bleeding, blood in stool or urine, bruising, excessive nose bleeds, bleeding gums

PREGNANT, uncontrolled alcohol/drug use, unsupervised dementia/psychosis

what pts should not use heparin?

international normalized ratio (INR)

used to monitor warfarin levels, allows for comparison of results between labs and standardizes reporting of prothrombin time (transferable from hospital to hospital)

normal range for INR

2.0-3.0

warfarin drug interactions

ibuprofen (acetamin), steroids, aspirin, clopedagril, antifungals → increase warfarin levels

oral contraceptives, vitamin K → decrease warfarin levels

conversion from heparin to warfarin

1. start warfarin while pt is still on heparin

2. heparin should be continued for minimum of 4 days bc even if INR rises, the antithrombotic (clot prevention) effect of warfarin takes about 96 hrs/4 days. SO MUST CONTINUE BOTH DRUGS FOR 4 DAYS!

3. monitor INR until therapeutic range is met (2.0-3.0)

4. when INR reaches desired therapeutic range, STOP heparin (after a min of 4 days) and continue warfarin only

Eliquis (Apixaban)

oral anticoagulant that is a direct Factor Xa inhibitor. Decreases stroke risk more than warfarin.

Used for non-valve Afib, pulmonary embolism

must have frequent lab surveillance

what must pt on warfarin do regularly?

aspirin

causes inhibition of cyclooxygenase, an antiplatelet drug used for pain relief, inflammation, fever, and clot prevention (stop EARLY clot formation)

encotrin= coating on drug that allows it to break down in the bowl instead of the gut

clopidogrel (plavix)

an antiplatelet drug that works by blocking platelet surface receptors and helps to prevent blood clots in arteries

major use in vascular stent maintenance 

thrombolytic drugs

“clot busters”, drugs that dissolve existing blood clots quickly. Cause conversion of plasminogen to plasmin.

streptokinase, reteplase, alteplase

DVT, MI, massive pulmonary embolism

what are thrombolytic drugs used for?

HYPOTENSION, bleeding, fever

adverse effects of thrombolytic drugs

what must you monitor before and after with thrombolytic drugs

aPTT, INR, Hgb/Hct

deep vein thrombosis (DVT)

a blood clot in a deep vein, often in one of the legs

S+S → unilateral swelling, pain + tenderness, warmth, redness

treatment for DVT

compression stockings, warfarin, heparin