Case 1

Clinical History:

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.

Questions:

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

2. How many units would you order?

Further history:

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?

Case 2

Clinical History:

A 30 year-old pregnant woman presents to the emergency room with third trimester vaginal bleeding and the sudden onset of marked pelvic pain. She is quickly admitted to the labor and delivery floor, where fetal monitoring shows severe fetal distress and ultrasound reveals placental abruption. An emergent cesarean section is performed, and packed red cells are given for a maternal hematocrit of 25%. A few minutes after the infant is delivered, the vaginal bleeding increases notably. Laboratory tests are ordered and the results are as follows:

• PT = 150 seconds (normal = 10.7-15 seconds)

• PTT = 150 seconds (normal = 25-40 seconds)

• Platelet count = 15 X 10⁹/L (normal = 140-440 X 10⁹/L)

• Hematocrit = 25% (normal = 37-51%)

• Fibrinogen = 30 mg/dL (normal = 150-350 mg/dL)

• D-Dimer = 1:256

A correction study is performed by the laboratory to further evaluate the prolonged coagulation times. When normal plasma is added to the patient's plasma, the PT and PTT correct back to within normal ranges.

Questions:

1. What process is occurring to cause the increased bleeding in this case?

2. Are there other types of obstetrical complications that can cause this?

3. What blood products are indicated in this situation?

4. Does cryoprecipitate have all of the clotting factors that a unit of fresh frozen plasma has?

5. Why is cryoprecipitate indicated here?

6. How many units at a time of cryoprecipitate would one order in the above situation?

7. Are blood products typically the "cure" for disseminated intravascular coagulation? What else is usually needed before the DIC will resolve?

Case 3

Clinical History:

A 65 year-old man has had marked abdominal pain for several hours and goes to the emergency room of a local hospital. An abdominal CT scan reveals a 7 cm abdominal aortic aneurysm that has ruptured. He is rushed to the operating room. An hour into the surgery, labs are drawn. These are as follows:

• Hemoglobin = 10.0 g/dL, Hematocrit = 30.0% (normal = 13-18 g/dL, 43-52%, respectively)

• Platelet count = 60 X 10⁹/L (normal = 140-440 X 10⁹/L)

• PT = 150 seconds (normal = 10.7-15 seconds)

• PTT = 150 seconds (normal = 25-40 seconds)

• Fibrinogen = 50 mg/dL (normal = 150-350 mg/dL)

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

Questions:

1. What do you think the D-dimer will be in this situation? Would it be a useful test here?

2. If the D-dimer is 1: 8, what blood products would be in order?

3. Would you give cryoprecipitate?

4. What is the main mechanism that leads to the above lab values in this case?

Case 4

Clinical History:

The parents of a 4 year-old boy bring him to the pediatrician to ask about the child's new propensity to form large bruises for no obvious reason, and the onset of fevers. A complete blood count and peripheral smear are obtained. These reveal the following:

• White blood cell count = 90 X 10⁹/L (normal = 5.3-11.5 X 10⁹/L)

• Hemoglobin = 8.3 g/dL (normal = 10.5-12.7 g/dL)

• Hematocrit = 25% (normal = 31.7-37.7%)

• Platelet count = 20,000 / mm³ (normal = 204-405 X 10⁹/L)

• PT = 10 seconds (normal = 10.7-15 seconds)

• PTT = 26 seconds (normal = 25-40 seconds)

The peripheral smear reveals a predominant population of large white blood cells with a high nuclear-to-cytoplasmic ratio, and fine chromatin, suspicious for blasts.

The pediatrician explains to the parents that the most likely diagnosis is acute lymphoblastic leukemia (ALL). He explains the need for their consent to draw more blood to send for flow cytometry, get a bone marrow biopsy, and to perform a lumbar puncture as part of the staging process. He also asks their consent to give blood products.

Questions:

1. If you were the pediatrician, which product would be your first priority? Why?

2. For an invasive procedure, above what value do you want to help assure that a patient will not bleed?

3. What other blood products is this child likely to need during the course of his therapy?

4. The physician evaluates the child's fever and finds evidence on physical examination and chest radiograph for a pneumonia in one lung. Antibiotics are administered and acetaminophen is given for the fever. Do fevers and drugs impact how well a person will respond to a unit of platelets?

5. What is the difference between a platelet pool and an apheresis unit of platelets?

Case 5

Clinical History:

A patient with risk for thrombosis is first started on heparin while warfarin (Coumadin®) is administered.

Questions:

1. Why is the patient initially started on heparin rather than warfarin?

2. How does one reverse the effects of warfarin?

3. How does one reverse the effects of heparin?

Case 6

Clinical History:

A 41-year-old woman has had headaches with blurred vision for several days. Over the past day she has developed increasing mental confusion. On admission to the hospital, she has vital signs showing temperature 37.9 C, pulse 104/minute, respirations 25/minute, and blood pressure 70/40 mmHg. She has petechial hemorrhages noted over her arms and trunk on physical examination, along with stool positive for occult blood. Her CBC showed a WBC count of 8950/microliter, hemoglobin 9.1 g/dL, hematocrit 27.2%, MCV 92 fL, RDW 19%, and platelet count 8900/microliter. The peripheral blood smear shows schistocytes. A serum electrolyte panel shows sodium 147 mmol/L, potassium 5.0 mmol/L, chloride 105 mmol/L, CO2 26 mmol/L, creatinine 2.9 mg/dL, urea nitrogen 32 mg/dL, and glucose 80 mg/dL.

Questions:

1. What is the most likely diagnosis?

2. What should you do to treat this condition?

3. What is contraindicated?

Case 7

Clinical History:

A 30-year-old woman is diagnosed with thrombotic thrombocytopenic purpura (TTP) in the hospital and treatment with plasmapheresis is given. After seven plasmapheresis procedures, her platelet count is now back in the normal range, but she continues to have stools which are positive for occult blood. A nurse finds the patient unconscious, without a palpable pulse and with a melanotic stool in the bed. She calls a code. The code team suspects the patient is having a large GI bleed and they begin fluid replacement through the large central line that has been used for plasmapheresis. The patient is moved to the intensive care unit (ICU) and emergency O negative red cells are requested from the blood bank. While the red cells are infusing, laboratory results are called to the unit and the prothrombin time (PT) and the partial thromboplastin time (PTT) are both greater than 150 seconds. The patient appears to still be bleeding. The ICU attending physician calls the blood bank physician to ask for help.

Questions:

1. What did the blood bank physician recommend?

2. What laboratory test or tests could be ordered to confirm this?

3. Why did the blood bank physician suspect the cause for this problem, even without laboratory testing to confirm it?

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?

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. What is the explanation for these findings?

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