CASE 1:

History:

A 40-year-old woman presents with right upper quadrant pain and your surgical team decides to perform a cholecystectomy. Your resident asked you to write pre-operative orders and to include a "type and screen". While performing the assigned task, your intern looks at the orders, makes a condescending remark, and tells you to order a "type and crossmatch" for four units.

Questions:

1. What is a "type"?
2. What is a "screen"?
3. What is the cost of a "type and screen"?
4. What is a "type and cross"?
5. What does a "type and cross" cost?
6. How does a type and crossmatch impact the Blood Bank inventory?

Further History:

You decide to order a type and screen. During the cholecystectomy the patient starts hemorrhaging. The Blood Bank is told to crossmatch 8 units of blood. The Blood Bank says that the crossmatch will take 45 minutes, but type specific blood is available immediately, if a physician will sign an Emergency Release Form. The patient's blood pressure is dropping quickly, but your intern tells the Blood Bank to have the crossmatched blood ready in 10 minutes, or else. The intern refuses to take blood unless it is crossmatched.

Questions:

1. What should be done?
2. What is the risk of a hemolytic transfusion reaction with type specific blood, if the screen is negative?
3. Were you wrong for not getting blood crossmatched preoperatively?

CASE 2:

History:

The next day your surgical team responds to a Trauma One call to find an 18-year-old woman status post motor vehicle accident flown in by Air Med from a remote location. She is transfused during transport. She is hypotensive and she is immediately taken to the operating room with obvious abdominal trauma.

Question:

1. What blood was issued to the Air Med team?

Further History:

The Blood Bank calls the OR because they received a sample which was not clearly labelled and are requesting a new specimen. Your intern takes the phone and tells the Blood Bank that he personally drew the sample and that the label was fine.

Questions:

1. What should you do?
2. What information is required on the specimen clot tube?
3. Why is this information important?

Further History:

The patient has used 8 units of O-neg packed red cells and another 8 units of O-neg packed cells are in the OR. Another 10 units of A-neg packed cells are delivered to the OR (a total of 18 units). The anesthesiologist says he does not want to use the A-neg blood because his literature recommends staying with Type O-blood after 6 units of O-blood are used on a patient.

Questions:

1. Which blood type should be given to the patient? Why?
2. Why might the anesthesiologist be confused?
3. The Blood Bank may ask you for yet another clot tube in a trauma situation. Why?

Further History:

The pathologist calls into the OR requesting an update on the condition of the patient. At that point in time the patient has used some fresh frozen plasma, platelets, 16 units of O-neg packed RBC's, and 15 units of A-neg packed RBC's.

Question:

1. What decision does the pathologist have to make that requires an accurate update on the clinical condition of the patient?

CASE 3:

History:

You are nearing the end of your three month surgical rotation and are spending two weeks on the Orthopedic Service. A 50-year-old woman is an a.m. admit for total hip replacement following an accidental fall at home. You notice that she has a CBC which includes: hematocrit 35%, WBC count 8000, and platelet count 30,000. Concerned about the low platelet count, you call this to the attention of your resident who referes you to an Internal Medicine physician's pre-operative workup. You discover the following: (1) the patient has a long history of chronic alcoholism that includes one hospitalization two years ago for upper GI bleeding, and (2) the physician has recommended platelet transfusion prior to surgery.

Questions:

1. What additional history do you want?
2. Why are you nervous about taking this patient to the OR?

CASE 4:

History:

A two-day old term infant was transferred from a local hospital to newborn intenstive care unit (NBICU) in respiratory distress. On arrival the neonate had ecchymoses over the trunk and legs. Coagulation studies included prothrombin time (PT) and partial thromboplastin time (PTT) each >100 seconds, platelet count 170,000/microliter, and fibrinogen 0 mg/dl. D-dimer levels were not elevated.

Questions:

1. What additional coagulation test should be ordered immediately?

Further History:

A pathologist was contacted for help in interpreting the results above. Unfamiliar with the reagents used to obtain the current values, he requests a new sample and has the same tests run at UUMC. Results include: PT and PTT each >150 seconds, platelet count 134,000/microliter, fibrinogen 202 mg/dl, and D-dimers were not elevated.

1. Can you explain the difference in fibrinogen levels between the labs?

Further History:

The pathologist was now convinced the infant had been given an overdose of heparin. The nursing staff in the NBICU were surprised when given this information, stating "this child has not even been in the same room with a bottle of heparin."

1. What additional test can be run to convince the staff of the problem?
2. FFP was ordered for the infant. Will FFP help?
3. What should be given to reverse a heparin overdose?