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A continuacin tienes un texto en el que algunos prrafos han sido divididos en

dos partes. Los prrafos que han sido divididos se indican por una lnea al final
del prrafo. De las opciones de la A a la BB debes seleccionar de las opciones
en la parte inferior de este documento cul es la segunda parte del prrafo en
cuestin y escribirla sobre la lnea entre corchetes correspondiente.
Una vez hayas terminado de responder el ejercicio gurdalo en tu computadora
y, despus, envalo a tu profesor en la pgina correspondiente de la plataforma
del curso. Recuerda que tu calificacin aparecer como cero hasta que tu
profesor te califique.
Nombre: ________
Some Alternative Treatments for Blood Transfusions
In these cases always remember: a multidisciplinary approach is better than a
single-approach.
Imagine a patient sent to your unit for further management.
To compensate a low hematocrit, you prescribe an inspired oxygen
concentration higher than the one he received last week; so that his blood
oxygen concentration increases.
His electrocardiogram shows a worse condition of the heart. He needs an
operation; and preoperatively donated blood is ready to be used later.
Your patient states refusal of blood as a benefit higher than life itself.
A more complex situation arises because he expects and demands alternative
therapies, which are either more expensive or harder to do.
Such moral and ethical issues are more challenging and more frustrating for
you. You decide to do your best. After all, the patient shows a Durable Power of
Attorney Card, which details that the patient refuses whole blood and the four
__A_
To start, you restrict or decrease blood drawing. Since, this way, the hematocrit
will not diminish due to sample taking. Therefore, you order the use of
pediatric-sized samples __I_
You think of hemodilution, the infusion of crystalloid or colloid solutions into the
patients blood vessels, as a possibility; ___Z__
The hospital also has a red cell salvaging device (e.g.: Haemonetics 30 blood
cell processor Braintree, Massachusetts) which makes the amount of blood loss
less dangerous for the patient, since this machine recovers the blood lost by
the patient during surgery, ___F_
You estimate the amount of erythropoietin (epo) (a stimulant of erythropoiesis,
the production of erythrocytes) needed by your patient. Doses of erythropoietin
__X__
Since these doses of erythropoietin are recommended in patients with
erythropoietin levels of less than 500 U/L, whereas in anemic patients with
already elevated erythropoietin levels much higher doses may be required; you
consider that your patient will need 150 units/kg of epo. Even though slightly
higher doses, ranging __H__

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Your patient has a hematocrit of 8 mg/dL, but you are not too concerned,
because even though most doctors take as a rule that a hematocrit of 10
mg/dL or lower is an indicator for transfusion, you know that in the last years
different studies practiced on surgical, __S_
You consider the use of recombinant factor VII (rFVIIa), which _J__
You also consider some currently available synthetic plasma volume expanders,
such as hydroxyethyl starch _A__
In this case you decide not to use dextran 40, HES 264/0.43, and the gelatins,
since they are more potent oncotic agents, and __V_
You choose dextran 70 and HES 450/0.70 because they are __C_
Anaphylactoid reactions, one of the side effects of _L__
Synthetic colloids administered in amounts larger than 2 _S__
In this respect, modified fluid gelatin seems safer to administer in larger
amounts (e.g.: 4 liters infused in less than 24 hours produced no effect on
coagulation). Nevertheless, this gelatin __BB_
Some considerations about oxygen carriage are important. In normal
conditions, bloods oxygen content depends on oxygen bound to __O_
In severely anemic patients, the amount of dissolved oxygen is higher (up to
25% of the oxygen content in the blood). Therefore, PO2 values higher than
normal may __O_
Conceivably, oxygen transport is further augmented with the use of a
hyperbaric chamber.
Nevertheless, the risk of oxygen toxicity _D__
Hemoglobin solutions bind and carry oxygen in a manner more similar to the
way red blood cells do; which reminds you that you also have some bioartificial oxygen carriers: hemoglobin-based oxygen __Z_
Fluorocarbon emulsions carry dissolved oxygen in a manner more similar to the
way plasma does.
The efficacy of human hemoglobin solutions, however, __T_
Measures that decrease the patients metabolic rate are also used because the
patient consumes less oxygen. Hypothermia is one example.
A target core temperature lower than 37C (30C-32C) reduces oxygen
consumption to less than 50% below control values.
The oxy-hemoglobin dissociation curve during hypothermia shifts leftward;
therefore, the affinity of hemoglobin for oxygen is higher. Nevertheless, __N_

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Actually, one study showed that tissue affinity for oxygen during hypothermia
may become as high as that of hemoglobin.
With a lower body temperature, the solubility of oxygen is higher. Thus, plasma
dissolved oxygen content is higher under these circumstances.
However, with a lower body temperature, blood viscosity is higher. In order to
counteract this side effect, __Y_
You also have antifibrinolytic medicines, which prevent the destruction of clots
that stop bleeding. Aminocaproic and tranexamic acids make blood loss less
important , namely lower , during __G_
There are also some substances to control or stop bleeding, such as fibrin glue
or tissue adhesives, topical hemostatic agents, erythropoietin, desmopressin,
antifibrinolytics, colloids, crystalloids and __K_
You also have certain devices available, such as ultrasonic scalpels and
electrocautery (devices that use electricity to cut and burn at the same time,
which closes the vessels immediately after they are cut, thus preventing
excessive bleeding), blood cell salvage machines, and even tourniquets to
make blood loss and bleeding more controlled and more limited too.
Tourniquets are used in orthopedics, for instance. When _AA__
You can also use techniques such as meticulous surgery and strict hemostasis
during __B
You also want to assess the perfusion of the vital organs, for which you can use
cardiac output and thermodilution using a pulmonary artery catheter. You
prefer measuring cardiac __R_
Now, you feel more reassured because you realize that managing a patient who
refuses blood _L__
The alternatives chosen apply in this case, but you realize that you must assess
every single case individually.
In Medicine, there were, there have been, there are, and there will always be
diseases or situations (syphilis, tuberculosis, AIDS, cancer, malnutrition, allergy
to penicillin or other substances, etc.), with no appropriate treatment at the
moment; but the philosophy of medicine has never been TO DENY TREATMENT.
On the contrary, __P_
Opciones de respuesta.
A
(HES) 450/0.70, HES 264/0.43, dextran 70, dextran 40, urea-bridged gelatin,
and modified fluid gelatin, among others.
B
surgery.
C

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less potent oncotic agents and have a longer lasting effect.

D
is greater with these chambers; hence, it is important to be more careful using
them.
E
colloid solutions, are more severe with dextrans but, overall, are rare.
F
cleans it and recirculates the patients blood again in his/her body. Your patient
accepts this machine because he considers that his blood never stops
circulating and it is not the same as a transfusion of a stored package of blood.
G
surgery; in addition to electrosurgery, hemodilution, and fluid and volume
control, which have proved to cause a milder bleeding.
H
from 100 units/kg to 300 units/kg are sometimes used. Moreover, you know
that iron is also needed by your patient so that his hematocrit can increase
with epo, because iron is used in the production of erythrocytes and
hemoglobin (and erythrocytes are, in some way, bags of hemoglobin).
I
which is more advisable, because the amount of blood drawn is lower than with
normal size samples. Since, according to one study, a patient may lose about
500 mL (half a liter), or even more, at the end of his/her stay in the Intensive
Care Unit due to blood sample taking; since, sometimes, blood samples are
taken three times a day (or even more) in these patients.
J
rFVIIa, among others, which make bleeding easier to control or more
manageable .
K
helps control bleeding and promotes a tighter and firmer plug (clot).
L
basic blood components: erythrocytes, platelets, plasma, and leukocytes. In
addition to that, you know that you are neither the first one nor the only one;
since thousands of doctors routinely apply successfully bloodless treatments to
some patients. You remember an article about a program at the University of
Rome, Italy, in which 51 Jehovahs Witnesses were given bloodless treatment
for both major and minor surgery procedures; in which the morbidity and
mortality rates were lower than expected. Even if a more aggressive
management is required, the statistics are reassuring. You also decide to call
other specialists if necessary. Moreover, you also remember that not all the
alternative treatments are more expensive or more difficult than any traditional
procedure.

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M
have much shorter half-lives than the other agents.
N
deliberate hypothermia is induced with simultaneous hemodilution so that
blood viscosity is not increased.
O
hemoglobin (the greater amount) and dissolved oxygen (the smaller amount,
only 1% to 2%).
P
doctors, researchers, clinicians, surgeons, and all the health personnel always
work on the basis of offering the patient the best treatment available at the
moment, according to the patients circumstances, and look for more
appropriate or more satisfactory options for both the patient and the doctor.
Q
improve oxygen carriage to the tissues in severely anemic patients.
R
output since thermodilution is more invasive. There are different techniques for
measuring cardiac output, some are more convenient than or more useful than
the others.
S
intensive care unit, trauma and cardiac patients have shown that withholding
transfusions to hematocrits of 7mg/dL or even lower is as safe as and provokes
as many complications as applying the rule of 10 mg/dL of hematocrit.
T
is more limited than that of hemoglobin in vivo, because its oxygen release to
the tissues is poorer, and its potential side effects are more severe .
U
transfusions is not as impossible as some clinicians and surgeons think.
V
has a shorter half-life than dextrans. Therefore, you decide to have both kinds
of gelatins at hand.
W
the delivery of oxygen to the tissues is not lower, since no evidence of impaired
tissue oxygen extraction has been found.
X
of 50 units/kg increase hematocrit in about 4 weeks. Larger doses of
erythropoietin (150 units/kg) produce a more substantial rise in hematocrit in
about 2 weeks.

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Y
since this makes the patients blood contain fewer red blood cells per unit of
volume. In case of bleeding, he will lose more liquid than erythrocytes. You also
know that blood viscosity is lower , and microcirculatory flow is better with this
technique, which allows a better perfusion.
Z
carriers (HBOC), human or bovine hemoglobin; and synthetic emulsions,
especially perfluorocarbon oxygen carriers (PFOC).
AA
the member (arm or leg) of a person is to be operated, a rubber bandage is put
on the limb, in distal to proximal direction (so that blood is drawn from the
member), when it reaches a certain point, the bandage is removed, in a distal
to proximal direction, but the tourniquet is left, which prevent blood to circulate
in the limb while the patient is being operated.
BB
liters in a short period of time may produce severe coagulopathy.