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2 Case Studies on Massive Transfusion
Effect on Coagulation
Presented by: Debbie Harris
Date: November 18, 2006 for GHEST
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Massive transfusion is defined astransfusion of the equivalent of one blood
volume (8-10 units) within a 24 hour time
frame.
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Complications of Massive Transfusion
Based on
Number of units transfused
Rate of transfusion
Patient condition
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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.
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Complications (cont’d)
Hypothermia Hypocalcemia/Citrate toxicity
Metabolic acidosis
Hyperkalemia
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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
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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
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OR
12:51 Hgb-78g/L
Plts-65x109/L
INR-2.1
TM Issued
13:00 5 RCCS
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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
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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
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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
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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
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Patient returns to the OR at 22:20 for
exploration of the abdominal aneurysm repair TM issues 6 RCC at 22:37
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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
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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
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TM issues 10 units of Plts at 02:20
03:24 Hgb 117g/L
Plts 192x109/L
INR 1.3
APTT 31 sec
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05:00
Hgb 115g/L Plts 208x109/L
INR 1.3
APTT 29 sec
Fibrinogen 2.26g/L
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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
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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.
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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
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August 17-19 patient is stable
Average blood work Hbg- 115g/LPlts- 110x109/L
No coagulation ordered
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August 20th- hypotension and ↓ levels of
consciousness→ICU CT scan-large uretal peritoneal bleed-
duodenum
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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
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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
Hgb-105g/L Plts-94x109/L
INR-1.0
APTT-26sec
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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
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August 27- patient fell very ill
2L Melena stool loss Unresponsive→OR
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OR
16:00 Hgb-59g/L
Plts 256x109/L
INR-1.4
APTT-34sec
TM Issued
16:00- 22:18 12 RCC
2 FFP
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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
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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
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17:00-August 28th
Hgb-128g/L Plts-132x109/L
INR-1.3
APTT-36sec
Troponin-1.14 –Indicative of MI
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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.
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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
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Special thanks to Jackie Cushnie who helped
me prepare the cases.