First Case July 29, 2013 Final Case Critique

This is a link to the final chart critique store on box.net:

https://app.box.com/s/8sfi268icb9y1y7qu7ip

Click the download on box.net to fully view the case summary and critiques.

Objective data from chart:

Row 18: Anemia; hemoglobin 9.4 with no iron studies (or reticulocyte count)

Row39: Hemoglobin 7.9, down 1.5 grams from admission. Due to dilution. Any evidence of active bleeding?

Row 52: PRBC transfused. Deferred opinion about necessity. Successive post hemoglobin of 10.9 and 11.0, roughly 4 and 15 hours post-transfusion, suggesting transfusion was not essential.

Row 68: Rapid Response Record: SpO2 less than 90%, hypertensive 14.5 hours post-transfusion. Possible transfusion reaction?

Row 74: Rapid Response Record: Rapid improvement after lasix, nitro, duoneb; possible volume overload; IV fluids stopped; transfer to tele

Row 76: Episode of dyspnea, chills, rash

Row 90: Pt made aware of metastatic nature of disease, terminal condition without chem.

Assessment:

This is an elderly female patient with presumed history of metastatic endometrial cancer who was admitted for a constellation of problems and fall with head injury the morning of admission. The goal of acute care hospitalization is unclear. Is patient a candidate for palliative care, rather than acute care? There were no imaging studies following head injury.

The indication for PRBC transfusion is unclear. There is no evidence of bleeding. The hemoglobin dropped 1.5 gm/dL 16:49 hours post-NS bolus and presumably IV hydration. Patients’ hemoglobin typically fall 1 gm/dL post admission in elderly patients. At 32:43 hours post-admission it is not possible to say, based on information in chart, that PRBC transfusion was appropriate or totally inappropriate, so the critique was “Defer”. But in retrospect it is probably apparent that the patient did not require a transfusion. Had the patient been treated in a facility with an active blood management program the patient would likely have not been transfused. If the patient had not been transfused she likely would have done fine and perhaps had a shorter length of stay than 5.1 days. The post-transfusion event was not cited in the discharge summary.

The patient had a crisis 14.5 hours post-transfusion characterized by respiratory distress, chills and rash; and was subsequently moved to telemetry. This raises the prospect of a transfusion reaction due to fluid overload at a minimum, yet no reaction was reported to or workup performed by the blood bank; and consequently a possible transfusion reaction was not reported to the FDA or CDC.

It is difficult to second-guess physicians’ use of blood in many situations, especially when chart documentation is sparse. However, evaluations of this type provide physicians with a unique opportunity to review case management, gain further insight, and hopefully better manage future patients. If the patient had been managed in a more conservative manner, without blood, would care and length of stay have been better? Is there a role for IV iron therapy in this setting, rather than PRBC transfusion?