Blood Product Usage Case Studies


CASE 8


Clinical History:

A 59-year-old man developed congestive heart failure following a heart transplant. He had a history of idiopathic thrombocytopenic purpura (ITP). He also had hypertension and developed acute renal failure. A vascular access line was placed for hemodialysis. He received dialysis in the evening. Following this procedure, it was noted that there was a hematoma and continued bleeding at the site of the line placement. The bleeding continued through the night. In the morning, a CBC showed a platelet count of 80,000/microliter. The blood bank received an order for platelets for transfusion.

Questions:

  1. What issues need to be considered in this case?

    2. If platelets were to be given, he may need intravenous immunoglobulin (IVIg) for effective platelet transfusion in view of his history of ITP. However, the more important issue is whether platelet transfusion is indicated. It is unlikely that bleeding will be due to a platelet count of 80,000/microliter. Another question to consider is whether the patient has a history of a bleeding disorder. The soluble coagulation system needs to be evaluated.

    Further laboratory testing revealed that both the prothrombin time (PT) as well as the partial thromboplastin time (PTT) were >150 seconds.

  2. What additional test needs to be done?

    3. A mixing study. When the patient sample is mixed with normal plasma, the PT and the PTT do not correct and are still >150 seconds.

  3. What is the explanation for these findings?

    4. The dialysis line was flushed with a large amount of heparin. Thus, the patient is overheparinized and bleeding. Thrombocytopenia is not the cause for his bleeding.

  4. Should the patient receive fresh frozen plasma (FFP)?

    5. No, any FFP given to the patient will also become heparinized. The patient needs to receive protamine sulfate to reverse the heparin effect.