A 72 year-old woman with a history of gastrointestinal bleeding is brought to the emergency room after being found slightly confused at home by one of her neighbors. Her blood pressure on arrival is 110/60 mmHg, and her pulse is elevated at 110 beats/minute. Further examination reveals that her stool is positive for occult blood, suggesting that she again has gastrointestinal bleeding. Laboratory studies reveal that coagulation parameters (PT, PTT) are within normal ranges, and her hematocrit is 22% (normal = 37-51%). Platelet count is 140 X 10⁹/L (normal = 140-440 X 10⁹/L). Serum chemistries show sodium is 152 mEq/L (normal = 136-144 mEq/L) and chloride is 115 mEq/L (normal = 101-111 mEq/L). Serum creatinine is normal for her age and size.

1. What is the main blood product needed in this situation?



Packed red blood cells. Coagulation parameters and the platelet count are normal, thus a coagulation defect or low platelet count is not contributing to this patient's bleeding (which means that fresh frozen plasma [FFP] or platelets will not help and are not indicated).

2. How many units would you order?

One unit of packed red cells should raise the hemoglobin by 1 mg/dL, or the hematocrit by 3%.

If we decide we want a final hematocrit of 30% in this patient, we will need an 8% change in her present hematocrit, or almost 3 units of packed red blood cells.

You decide, based upon your physical examination and laboratory findings of an elevated serum sodium and chloride, that the patient is dehydrated and would benefit from some intravenous fluid administration.

Which of the following is the more appropriate choice here: 0.9% normal saline, albumin, or fresh frozen plasma?

The wrong answer here is fresh frozen plasma (FFP), and the point of the question is that FFP should NOT be used only for the expansion of intravascular volume.

The issues here are effectiveness, accessibility, expense, and risk of exposure to transfusion-transmissible diseases such as HIV and hepatitis B and C.

Normal saline is the first choice because it will effectively hydrate the patient, it is more readily accessible than albumin or FFP, it is relatively inexpensive, and it does not have risk of viral transmission.

Albumin will work, although more free water for hydration will be available with saline. Albumin is not always readily accessible, and it is expensive. It does not have risk of viral transmission.

FFP will work, although again it will provide less free water than normal saline. FFP is usually accessible (although it will take time for the plasma to thaw), but it is much more expensive than saline, and it poses the risk of transmitting viruses. While the current transmission risks are quite small, there is no need to expose a person with normal coagulation parameters to this risk.