Third Case (August 11, 2013): Case Management Commentary

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This discussion follows the initial patient presentation posted August 11, 2013 and includes our commentary about blood management in this patient. If you encounter a problem with the box download, notify me at djadwin@columbia-analytics.com.

Objective Data
Row 13: Two hours prior to admission: The patient is “not actively bleeding and hemodynamically stable”. The patient’s pulse is 108.
Row 14: Occult blood is negative. Coffee ground emesis x 3 days.
Row 16: NS 1000 mL bolus, 1 hour 42 minutes prior to admission.
Row 18: Laboratory studies (1 hour 42 minutes prior to admission): hemoglobin 11.6 gm/dL and INR 7.1. (No iron studies were performed during hospitalization).
Row 26: Vitamin k 5 mg IV, 48 minutes post-admission.
Row 30: Hemoglobin 9.8 gm/dL (H&H) 6 hours 08 minutes post-admission, down 1.8 over 7 hours 50 minutes.
Row 31: INR 1.2, down 6.9, 9 hours 20 minutes post IV vitamin k
Rows 33 and 36: Hemoglobin 8.5 and 7.6 mg/dL, 13:33 and 31:48 hours post-admission, down 3.3 and 4.2 from initial hemoglobin.
Row 36: Platelet count 180,000/uL, down 69,000 (28%) over 33.5 hours.
Rows 41 and 52: PRBCs, 2 units transfused 23:31 and 25:32 hours post-admission.
Rows 59, 62, 64 and 68: Hemoglobin 10.6, 10.3, 10.4 and 10.5 gm/dL (30:03, 37:46, 45:51 and 69:43 hours post-admission).
Row 70: Hospital length of stay: 3.4 days.

Assessment
The supra-therapeutic INR was well managed with IV vitamin k and avoided the use of unnecessary plasma transfusion. No specific documentation was found in the chart about Coumadin use at home.

Iron studies were not performed and patient did not receive IV iron therapy during hospitalization. The patient had four H&H sets, rather than CBC hemogram. The INR reversed from 7.1 to 1.2 over 12 hours (9:20 hours post-IV vitamin k). Even though relatively stable and no active bleeding, other than an apparent 4.2 gm/dL drop from initial hemoglobin, the patient received 2 units PRBCs back-to-back without interval monitoring, with post-transfusion hemoglobin values in the 10.3 to 10.6 range. The post-transfusion hemoglobin exceeds 10 suggesting that one if not both PRBC units were unnecessary. Typically 15 to 20 percent of PRBC transfusions result in a stable post-transfusion hemoglobin of 11 or higher. The drop in hemoglobin may have been due to IV hydration therapy post emesis.

The patient may have benefited from IV iron rather than PRBC transfusion. Unless performed as an essential POCT, there is little benefit from performing a laboratory H&H in lieu of a standard hemogram. This is especially true in this case in which the platelet count fell from 249,000 to 180,000 to 159,000 over 48 hours. Four sets of H&H assays prevented better assessment of falling platelet level. An H&H cannot alert the physician about the presence of platelet consumption, which is important to identify in a bleeding patient.

Conclusion:
The appropriateness of the first unit PRBC is classified as “Defer” because we cannot conclusively say the blood use was essential at the administered time. The appropriateness of the second PRBC is classified as “Avoid” because the need for back-to-back units in the absence of life threatening bleeding is uncertain and the post-transfusion hemoglobin is above 10 gm/dL. This patient likely did not require blood transfusion. If the patient had been a Jehovah Witness member, he would not have received blood and would likely have recovered adequately, with lower cost care and perhaps shorter length of stay.

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