Case 4 (August 18, 2013): Case Management Commentary – Assessment & Conclusion Part 2

Conclusion:
This patient received 8 units plasma and 4 units PRBC. If the patient had been a Jehovah Witness member, he would not have received any blood components and likely would have had a similar outcome and perhaps shorter length of stay. The first two plasma units were critiqued as appropriate, under the circumstances; however earlier INR and vitamin k by non-IM route may have resulted in earlier correction and avoidance or reduced need for plasma transfusion. The subsequent six plasma transfusions are of progressively increasing uncertain benefit. A coagulation mixing study might have indicated reduced benefit from plasma transfusion. Four-factor prothrombin complex concentrate is an expensive therapeutic option and was not FDA approved during the period of treatment. Hospital utilization of 4-factor PCC should be closely monitored to ensure optimal use, especially among providers with limited experience using this product. The third and fourth PRBC transfusions were clearly unnecessary and the patient may have benefited from IV iron rather than (any) PRBC transfusion. There is no evidence for substantial bleeding; therefore, the need for back-to-back PRBC transfusion without interval monitoring is uncertain.

On a final note by a pathologist: In my opinion, the entire pericardial fluid sample should have been submitted to cytopathology, not just 40 mL, to ensure optimal processing of a cell block if not other preparations as well. When a small sample (such as 40 mL) is submitted from a large sample, there is a risk that a cell-poor sample may have been decanted from the top by inexperienced staff and consequently suboptimal for cytopathological examination. Submission of the entire specimen for cytopathology processing helps ensure that an adequate sample is processed by experienced staff. The performance of (expensive) flow cytometry on pericardial fluid in the absence of documented clinical evidence multiple myeloma and a bloody effusion may have been unnecessary.

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; and others are encouraged to share their comments and encourage others to join in the discussion.