Second Case: Assessment and Conclusion

Assessment:

Using a principle-based approach to transfusion medicine it is easier to focus on what management is not appropriate rather than management that is appropriate. There is no conclusive information in the medical record about use of anti-platelet medication in this patient. It would be better to specifically know if the patient was on anti-platelet medication, the patient was not on anti-platelet medication or if it is unknown whether the patient has been on anti-platelet medication. The provider is relying on a bleeding time to measure platelet function, rather on a current, standardized platelet function measure. The bleeding time procedure has been supplanted by better measures of platelet function for more than 10 years and should not be in clinical use.

The patient received three sets of transfusion of 2 platelet pheresis units each. The start times for three units and the stop times for 5 units were not recorded, which are deficiencies of transfusion standards. The rationale for giving two platelet pheresis units at a time is uncertain. The bleeding time became prolonged by 2 minutes (from 11 to 13 minutes) post the first and second platelet pheresis transfusions, which is hard to explain. The bleeding time remained unchanged (13 minutes) post the third and fourth platelet pheresis transfusions, which is similarly hard to explain. The platelet count rose 110,000 following four platelet pheresis transfusions, indicating a platelet transfusion “bump”, if not an acute phase reaction.

The repeat head CT 18:55 hours post admission shows no extension and perhaps resolution of the CT findings in the ER, yet the patient was transfused with two additional platelet pheresis units (#5 and #6), back-to-back with lowering of the bleeding time from 13 to 8 minutes. An H&H was performed, rather than a CBC, 8:37 hours post-release of last (sixth) platelet unit.

Conclusion:

1. The bleeding time is an outdated test and should be replaced by a current specific measure of platelet function. The bleeding time is reported to 2 decimal places which is listed to too many significant digits. Continuing platelet transfusion to normalizing the bleeding time (or platelet function) might not be necessary in the presentation of mild cerebral contusion.

2. CT findings 18:55 hours post-admission showed no progression and perhaps improvement, so platelet transfusion after this point is likely unnecessary.

3. Transfusion of six platelet pheresis units ($3,000 or more in hospital supply cost) is likely overly aggressive transfusion management and most patients with this presentation would be transfused with 2 or less platelet pheresis units. Jehovah Witness patients would not receive any platelet therapy in this setting and likely would do well. Would this patient benefit from DDAVP?

4. The start and stop time should be recorded for all transfusions and several transfusion practice deficiencies occurred in this case. The transfusion consent form had a field for time, as well as date, of consent which was not captured. Time as well as date capture is generally important in medical documentation.

5. There is no indication for performing an H&H in an inpatient setting, other than need for an immediate reading with a point-of-care device, especially in circumstances surrounding platelet transfusion. Generally if a physician orders an H&H by the laboratory the full CBC is performed or it is just as convenient to perform a full CBC as an H&H. There are no significant time or cost savings by performing an H&H rather than an full CBC as there were decades ago.

6. None of the platelet transfusions were deemed to be totally appropriate. No Critique was provided in three transfusions because the start time was not recorded, however had the start times been recorded the last two platelet transfusions would have been assigned a critique of Avoid. The fourth, third and even the second platelet transfusions are also likely unnecessary.