Case Presentation(Transfusion Medicine)

Dr. RAFIQ AHMADDr. RAFIQ AHMAD

Case IClinical History:A 72 year-old woman H/O of gastrointestinal bleeding. Physical Examination: - BP: 110/60 mmHg, - Pulse:110 beats/minute. Laboratory studies: - Hb. : 7.6 (normal : 12- 16 g/dL) - Hct : 22% (normal : 38-47%). - PT :12 seconds (normal : 10-13 seconds)- PT :12 seconds (normal : 10-13 seconds) - PTT : 32 seconds (normal : 25-35 seconds)- PTT : 32 seconds (normal : 25-35 seconds) - Platelet count : 140 X 109/L (normal : 150-450 X 109/L). - Sr. Electrolytes

- Sodium :152 mEq/L (normal : 136-144 mEq/L) - Chloride : 115 mEq/L (normal : 101-111 mEq/L)- Serum creatinine - normal for her age and size.

- Stool for occult blood: Positive

Choice of product

RBC’s

FFP

Platelets

Cryoppt.

Crystalloids

Colloid

Case 2

- A 30 year-old pregnant woman- H/O third trimester vaginal bleeding and the

sudden onset of marked pelvic pain.- Hct: 25% (normal : 38 - 47%)- USG: fetal monitoring shows severe fetal

distress due to placental abruption. - An emergent CS is performed, - packed red cells are given. - post delivered- the vaginal bleeding increases.

Case 2Post delivery Laboratory resultsPost delivery Laboratory results- Hb : 7.6 g/dL (normal : 12-16 g/dL)- Hb : 7.6 g/dL (normal : 12-16 g/dL)- Hct : 25% (normal : 38-47%) - Hct : 25% (normal : 38-47%) - PT :150 seconds (normal : 10-13seconds)- PT :150 seconds (normal : 10-13seconds)- PTT :150 seconds (normal : 25-35seconds)- PTT :150 seconds (normal : 25-35seconds)

A correction study is performed. When normal plasma is A correction study is performed. When normal plasma is added to the patient's plasma, the PT and PTT correct back to added to the patient's plasma, the PT and PTT correct back to within normal range.within normal range.

- Fibrinogen : 30 mg/dL (normal : 200-400 mg/dL)- Fibrinogen : 30 mg/dL (normal : 200-400 mg/dL)- D-Dimer :- 1: 256- D-Dimer :- 1: 256- Platelet count : 15 X 10- Platelet count : 15 X 1099/L (normal : 140-440 X 10/L (normal : 140-440 X 1099/L)/L)

Choice of product

- RBC’s

- FFP

- Platelets

- Cryoppt.

- Crystalloids

- Colloid

Case 3- A 65 year-old man

- H/O of marked abdominal pain for several hours

- An abdominal CT scan reveals a 7 cm abdominal aortic aneurysm (ruptured)

- Emergency Surgery planned

- One hour post surgery Lab results

Case 3

- Hb : 10.0 g/dL (normal : 13.5-18 g/dL) - Hb : 10.0 g/dL (normal : 13.5-18 g/dL)

- Hct : 30.0% (40-54%)- Hct : 30.0% (40-54%)

- Platelet count : 60 X 10- Platelet count : 60 X 1099/L (normal : 150-450 X 10/L (normal : 150-450 X 1099/L)/L)

- PT : 150 seconds (normal : 10-13 seconds)- PT : 150 seconds (normal : 10-13 seconds)

- PTT :150 seconds (normal : 25-35 seconds)- PTT :150 seconds (normal : 25-35 seconds) - A correction study is performed. When normal plasma is - A correction study is performed. When normal plasma is

added to the patient's plasma, the PT and PTT correct back added to the patient's plasma, the PT and PTT correct back to within normal range.to within normal range.

- Fibrinogen : 50 mg/dL (normal : 200-400 mg/dL)- Fibrinogen : 50 mg/dL (normal : 200-400 mg/dL)

- D-dimer titers:- 1:8 - D-dimer titers:- 1:8

Choice of product

- RBC’s

- FFP

- Platelets

- Cryoppt.

- Crystalloids

- Colloid

Case 4

- 4 year-old boy - 4 year-old boy

- H/O of large bruises for no obvious reason, and - H/O of large bruises for no obvious reason, and the onset of fever. the onset of fever.

Case 4Laboratory ResultsLaboratory Results - Hb : 8.3 g/dL (normal : 13 -16.9 g/dL)- Hb : 8.3 g/dL (normal : 13 -16.9 g/dL) - Hct : 25% (normal : 39 -51%)- Hct : 25% (normal : 39 -51%) - WBC count : 90 X 10- WBC count : 90 X 1099/L (normal : 5 -15.5 X 10/L (normal : 5 -15.5 X 1099/L)/L) - Platelet count : 20 X 10- Platelet count : 20 X 1099/ L (normal : 150-350 X 10/ L (normal : 150-350 X 1099/L)/L) - PT: 10 seconds (normal : 10 -13 seconds)- PT: 10 seconds (normal : 10 -13 seconds) - PTT : 26 seconds (normal : 25-35 seconds)- PTT : 26 seconds (normal : 25-35 seconds) - The peripheral smear reveals a predominant population - The peripheral smear reveals a predominant population

of large white blood cells with a high nuclear-to-of large white blood cells with a high nuclear-to-cytoplasmic ratio, and fine chromatin, suspicious for cytoplasmic ratio, and fine chromatin, suspicious for blastsblasts..

Choice of Product

- RBC’s- RBC’s

- FFP- FFP

- Platelets- Platelets

- Cryoppt.- Cryoppt.

- Crystalloids- Crystalloids

- Colloid- Colloid

Case 5A 41 year old woman A 41 year old woman H/O of headaches with blurred vision for several H/O of headaches with blurred vision for several

days. increasing mental confusion. days. increasing mental confusion. General ExaminationGeneral Examination -Temperature 37.9 C -Temperature 37.9 C - Pulse 104/minute- Pulse 104/minute - Respirations 25/minute - Respirations 25/minute - BP 70/40 mmHg. - BP 70/40 mmHg. Physical Examination:Physical Examination: - Petechial hemorrhages noted over her arms - Petechial hemorrhages noted over her arms

and trunkand trunk, ,

Case 5Laboratory TestsLaboratory Tests CBC CBC - Hb: 9.1 g/dL - Hb: 9.1 g/dL (normal = 12 - 16 g/dL)

, Hct : 27.2%, , Hct : 27.2%, (normal = 38 - 47%).

- WBC count of 9 X 10- WBC count of 9 X 1099/L (normal 4.5 – 11 X 10/L (normal 4.5 – 11 X 1099)) - MCV 92 fL, RDW 19%- MCV 92 fL, RDW 19% - Platelet count : 9 X 10- Platelet count : 9 X 1099/L (normal = 150-450 X 10/L (normal = 150-450 X 1099/L)/L) - Peripheral blood smear shows schistocytes. - Peripheral blood smear shows schistocytes. - serum electrolyte = sodium 147 mmol/L, potassium 5.0 - serum electrolyte = sodium 147 mmol/L, potassium 5.0

mmol/L, chloride 105 mmol/L,mmol/L, chloride 105 mmol/L, - Other biochemical tests: creatinine 2.9 mg/dL, urea nitrogen 32 - Other biochemical tests: creatinine 2.9 mg/dL, urea nitrogen 32

mg/dL, and glucose 80 mg/dL.mg/dL, and glucose 80 mg/dL.- CO2 26 mmol/L,- CO2 26 mmol/L,- Stool for occult blood: Positive- Stool for occult blood: Positive

Choice of Product

- RBC’s- RBC’s

- FFP- FFP

- Platelets- Platelets

- Cryoppt.- Cryoppt.

- Crystalloids- Crystalloids

- Colloid- Colloid

Case 6- - A 30-year-old female is diagnosed with TTP. A 30-year-old female is diagnosed with TTP. - Treatment give: 7 Plasmapheresis- Treatment give: 7 Plasmapheresis Post plasmapheresis Post plasmapheresis - Platelet count : in the normal range.- Platelet count : in the normal range. - Stools occult blood: Positive. - Stools occult blood: Positive. - General condition: unconscious, without a palpable pulse and - General condition: unconscious, without a palpable pulse and

with a melanotic stool in the bed. with a melanotic stool in the bed. - The code team suspects the patient is having a large GI bleed - The code team suspects the patient is having a large GI bleed

and they begin fluid replacement through the large central line and they begin fluid replacement through the large central line that has been used for plasmapheresis. that has been used for plasmapheresis.

- The patient is moved to ICU and emergency red cells - The patient is moved to ICU and emergency red cells transfusion requested from the blood bank. While the red cells transfusion requested from the blood bank. While the red cells are infusing, are infusing,

Case 6

laboratory results :laboratory results :

- PT and PTT both > 150 seconds. - PT and PTT both > 150 seconds.

- The patient appears to still be bleeding. The - The patient appears to still be bleeding. The ICU attending physician calls the blood bank ICU attending physician calls the blood bank physician to ask for help.physician to ask for help.

The end!!

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