harris ghest nov18 06 massivetx

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2 Case Studies on Massive Transfusion

Effect on Coagulation

Presented by: Debbie Harris

Date: November 18, 2006 for GHEST



Massive transfusion is defined astransfusion of the equivalent of one blood

volume (8-10 units) within a 24 hour time

frame.



Complications of Massive Transfusion

Based on

Number of units transfused

Rate of transfusion

Patient condition



Complications (con’t)

Dilutional Coagulopathy

Ascribed to dilution of platelets and clotting factorswhich occurs as patients lose hemostatically activeblood.

50% of patients develop an INR>2.0 and 33% haveplatelets <50x109/L

Prospective studies- # of RCC does not accuratelypredict the need for factor replacement-based onlaboratory results and clinical monitoring.



Complications (cont’d)

Hypothermia Hypocalcemia/Citrate toxicity

Metabolic acidosis

Hyperkalemia



Case 1

59 year old male presented in ER, August 5

th

at08:00 with a AAA (abdominal aortic aneurysm)

Ruptured in elevator on the way to OR-11:45

Preliminary blood work in ER- 08:45

Hgb-150g/L Plts-292x109/L INR-1.0



ER ordered 2 units RCC at 11:21

Tech read diagnosis on Meditech requisitionand set up 8.

TM issued

4 RCC 12:00

4 RCC 12:15 4 FFP 12:36



OR

12:51 Hgb-78g/L

Plts-65x109/L

INR-2.1

TM Issued

13:00 5 RCCS



OR

13:38 Hgb-88g/L

Plts-47x109/L

INR-1.8

APTT-47sec

Fibrinogen-0.96g/L

TM Issued to OR

13:55 4FFP



ICU

14:50 Hgb:98g/L

Plts-57x109/L

INR-1.4

APTT-38sec

TM Issued to ICU

15:25 1RCC

10 Cryo

17:00

3RCC



ICU

19:15 Hgb – 81g/L

Plts – 97x109/L

INR – 1.4

APTT – 39 sec

Fibrinogen – 1.46g/L

TM Issued to ICU

20:00 2 RCC



ICU

21:20 Hgb – 72g/L

Plts – 77x109/L

INR – 1.6

APTT – 47sec

TM Issued to ICU

21:50 2 RCC

4 FFP

10 Cryo



Patient returns to the OR at 22:20 for

exploration of the abdominal aneurysm repair TM issues 6 RCC at 22:37



OR

23:20 Hgb 110g/L

Plts 33x109/L

INR 1.4

APTT 47 sec

Fibrinogen 1.73g/L

TM Issued

23:20 4 RCC

2 FFP

4 Plts



Patient leaves the OR at 00:50, August 6th

and returns to ICU 01:18

Hgb 119g/L

Plts 66x109/L

INR 1.4

APTT 33 sec



TM issues 10 units of Plts at 02:20

03:24 Hgb 117g/L

Plts 192x109/L

INR 1.3

APTT 31 sec



05:00

Hgb 115g/L Plts 208x109/L

INR 1.3

APTT 29 sec

Fibrinogen 2.26g/L



07:00

Hgb 97g/L

Plts 189x109/L

INR 1.3

APTT 30 sec

Dilutional Coagulopathy

Patient received couple of more units of RCCover next couple of days

Coagulation remained good



Items of Interest

Patient had normal cardiac enzymes up until

21:20-Aug 5 when his CK and TnI spiked. CK 2226 u/L

TnI 2.23 ug/L

Patient’s had an MI

Patient also had iliac artery repair and a

splenectomy during the second OR.



Case 2

66 year old male booked for elective surgery

August 16,2004-Renal Stones Pre-op Hgb-120g/L

Plts-153x109/L

Second procedure Aug 19th more renal stone

removal*HUGE STONES



August 17-19 patient is stable

Average blood work Hbg- 115g/LPlts- 110x109/L

No coagulation ordered



August 20th- hypotension and ↓ levels of

consciousness→ICU CT scan-large uretal peritoneal bleed-

duodenum



09:45 Aug 20

Hbg-85g/L Plts121x109/L

INR 8.2

APTT-48sec

2 RCC,4 FFP-11:55-14:12

11:42

INR-8.8 APTT-53sec

Fibrinogen 3.41g/L

D-Dimer 468ng/ml



16:30 Aug 20

Hgb-77g/L Plts-83x109/L

INR1.3

APTT-30sec Fibrinogen-3.21g/L

D Dimer 315ng/ml

2 RCC

23:35


INR-1.0

APTT-26sec



August 21-rescoped-no visible evidence of

active bleed. August 22-26 low hemoglobin

3 unit of RCC over these days-Hbg-100g/L

Coagulation-normal



August 27- patient fell very ill

2L Melena stool loss Unresponsive→OR



OR

16:00 Hgb-59g/L

Plts 256x109/L

INR-1.4

APTT-34sec

TM Issued

16:00- 22:18 12 RCC

2 FFP



OR Aug 27

23:37 Hgb-97g/L

Plts-89x109/L

INR-1.4 APTT-34sec

TM issued 14 RCC,6 FFP,10 units of plateletsbetween 00:24-01:19.

OR Aug 28

00:15 Hg 62g/L

Plts- 32x109/L



Pt leaves OR at 04:25 August 28th→ICU

04:45

Hbg-114g/L

Plts-52x10x109

/L INR-1.6

APTT-53sec

Received 10 units of platelets at 10:20



17:00-August 28th


INR-1.3

APTT-36sec

Troponin-1.14 –Indicative of MI



Post-op diagnosis

Iatrogenic splenic injury-splenectomy GI bleed secondary to duodenal ulcers

Abdominal adhesions

Patient remained hemodynamically stable for

the remainder of his hospital stay.



References

Bloody Easy 2, Blood Transfusions, Blood

Alternatives and Transfusion Reactions, AGuide to Transfusion Medicine; Second

Edition; JL Callum MD,FRCPC and PH

Pinkerton,MD,FRCPC,FRCPATH. Clinical Guide to Transfusion Medicine;

Canadian Blood Services,2006.

Technical Manual ; AABB 14th Edition,2003



Special thanks to Jackie Cushnie who helped

me prepare the cases.

harris ghest nov18 06 massivetx

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