Case 4 (August 18, 2013): Case Management Commentary – Assessment & Conclusion Part 1
Assessment
The patient presented with acute distress of three days duration and pericardial effusion. The medical history is significant for multiple myeloma. Initial laboratory studies were delayed and performed 5:30 hours post-ER triage. There is an incomplete medication history and the cause of the supra-therapeutic INR is uncertain. Was the patient recently placed on medication that initiated an interaction with warfarin? The patient presents with a normocytic anemia (hemoglobin 10.1 gm/dL), but no anemia workup (reticulocyte count, iron studies, etc) was performed and the patient did not receive IV iron therapy.
Vitamin k was administered just prior to admission and there is a documentation discrepancy involving the route of administration (SQ vs IM), as the medication is ordered SQ and documented as administered IM. IM is perhaps not the best route for administration of vitamin k. A pre-transfusion mixing study was not performed to exclude the presence of a coagulation inhibitor. The patient received 1000 mL plasma (four units) between 3:45 hours and 5:50 hours post-admission, which should be sufficient to correct a supra-therapeutic INR. The post-transfusion INR is 2.2, down 3.5 post four units plasma. The hemoglobin fell from an initial 10.1 to 8.9 and 9.1 post-plasma infusion, likely due to hemodilution. The post-plasma 2.2 INR was treated with four additional plasma units, including two units during the pericardiocentesis procedure. The post-transfusion INR is 1.8, down 0.4 post four additional plasma units. The initial laboratory studies include serum protein 7.0 gm/dL, albumin 3.7 gm/dL and globulin 3.3 gm/dL; no immunoglobulin studies or urinalysis were performed. The patient required a large number of plasma transfusions to make a modest INR correction suggesting the presence of an inhibitor. Since mixing studies were not performed and despite an unremarkable globulin level (and no further information about the “multiple myeloma”), an inhibitory paraprotein should be considered.
The post-transfusion hemoglobin is 8.8, 8.3 and 7.9 gm/dL, expectedly down 1.2 post 4 plasma units and down 2.2 from initial hemoglobin post 8 plasma units. The patient then received 2 PRBC units back-to-back with post-transfusion hemoglobin levels of 9.3, 8.5 and 9.2 gm/dL, followed by 2 additional PRBC units back-to-back with post-transfusion hemoglobin 11.4 gm/dL.
The interventionalist had to make several (unspecified number) unsuccessful passes during a 197 minute pericardiocentesis procedure, and ”with some luck” obtained “dark bloody fluid”. One liter of fluid was removed from the patient, yet only 40 mL was submitted to cytology and the amount received was not recorded by the clinical laboratory. The total amount of fluid removed and fluid analysis results were not recorded in the cytopathology report. Perhaps the difficult access heightened the interventionalist’s anxiety and prompted the perceived need to administer additional plasma. Should tap of a 1 liter pericardial effusion under ultrasound-guidance require several passes?
The patient consent for transfusion was signed 10 hours post-initial transfusion.