Case 8 (9/22/2013): Case Management Commentary

Click this link to download the case file from box.net:https://app.box.com/s/uz7r82y1bs82qzc1h23s

…Case 8 is a 60 year-old male who presents with complex medical issues and renal failure and creatinine 6.3 mg/dL. The platelet count is 75,000 and 80,000/uL, 4:14 and 15:09 hours post-admission. The patient underwent dialysis 24:34 hours post-admission and subsequent platelet counts are 65,000 and 62,000/uL 39:12 and 42:19 hours post-admission. A 43:29 hours post-admission the handwritten physician progress note states “bleeding from (illegible) PC site even with pressure”, presumably the shunt site for dialysis.

The patient received back-to-back platelet-pheresis units at 44:54 and 45:49 hours post-admission, prior to dialysis that started 46:39 hours post-admission. At 49:49 hours, during dialysis, the platelet count is 150,000/uL (up 88,000/uL post-transfusion) and 130,000/uL post-dialysis, 63:47 hours post-admission. The platelet counts fell successively 107,000, 80,000, 88,000, 66,000 and 80,000/uL at 110:52, 136:09, 158:24, 185:45, and 206:59 hours post-admission. The patient was discharged 218:52 hours (9.1 days) post-admission.

Assessment

Platelet function is impaired in an uremic environment, so the best therapy in a bleeding patient may be dialysis. The documentation does not provide basic information needed to provide an assessment of this patient’s bleed: extent, character and duration, which would all be essential information to make an informed decision. Too often physicians fail to provide sufficient documentation about bleeding in a chart. If bleeding is small, then perhaps platelet transfusion is not urgently required. Desmopressin (22.0 mcg) was given IV x 1 during hospitalization, 29:58 post admission and 15 hours prior to platelet transfusion. Might the patient have received earlier desmopressin and additional dosing (q 12 hours)?

Platelets may be activated by some dialysis membranes and removed from the circulation by dialysis. Due to potential platelet activation and removal by dialysis and uremia-induced platelet dysfunction, platelet transfusion during dialysis or prior to dialysis (as in this case) may not be optimal. Unless a compelling reason exists, platelet pheresis units should not be given back-to-back and an interval assessment should be performed between platelet transfusion. The goal of therapy is to give the least amount of blood product to accomplish the goal. In this case, would the administration of one pheresis be sufficient? “One is good, two is better” reasoning is not acceptable because blood products (especially platelets) can be harmful in ways frequently unrecognized by physicians.

This is a complex case and complete analysis is always limited by less than optimal documentation and less than optimal management. Display of data in this chronological format provides a unique opportunity for attending physicians to study case management in hindsight and to conduct educational discussion by the broader physician community. There are other things I could have commented on and undoubtedly things I did not pick up. The comments are not intended to be complete or authoritative, but instead are intended to stimulate discussion. Others are encouraged to share their comments and encourage others to join in the discussion.

Conclusion: The first platelet transfusion is “DEFER” due to incomplete clinical information, uncertain benefit prior to dialysis and other factors mentioned above. The second platelet transfusion is “AVOID” due to back-to-back transfusion and an 88,000 incremental rise in post-transfusion platelet count, which may have overshot the amount necessary to control bleeding.

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