A 76-year-old female with a history of hepatitis C cirrhosis and CAD status post three-vessel coronary artery bypass grafting (CABG) 2 years prior is admitted to the ICU with 1 day of melena and hematemesis. She has another episode of hematemesis on arrival to the ICU, with 50 mL bright red blood collected in a basin. Initial vital signs are:
Labs return with:
Large bore IV access is established, and the plan is made for an esophagogastroduodenoscopy (EGD).
What is the best transfusion threshold in this patient?
Correct Answer: B
TRICC trial found that patients had a lower in-hospital mortality when transfused for a restrictive threshold of Hgb <7 g/dL as opposed to a liberal threshold of Hgb <9 g/dL. The trial excluded actively bleeding patients, however, including those with gastrointestinal bleeding. A randomized controlled trial of patients with active upper GI bleeding demonstrated that a restrictive transfusion threshold (Hgb <7 g/dL) was likewise associated with decreased mortality compared to a liberal transfusion threshold (Hgb <9 g/dL). In addition, the study demonstrated a shorter length of stay, fewer adverse events, and fewer rebleeding events in the restrictive group.
Transfusion guidelines for platelets in the setting of active bleeding are typically for count <50 000/mm3 . Counts >75 000/mm3 may be required for massive trauma and central nervous system (CNS) injury with the risk for bleeding, whereas surgery at high-risk sites such as ocular surgery and neurosurgery can require platelets >100 000/mm3 . This patient has active bleeding, but her platelets are already >50 000/mm3 . Hemodynamic stability, including MAP >65, is a more suitable criterion for transfusion in patients with severe, ongoing hemorrhage, as lab values will lag behind the rapidly evolving clinical picture.
References:
A 34-year-old female with no significant past medical history is now gravida 2, para 2 (G2P2) after cesarean section of a term neonate for placenta accreta. Large bore IV access was established preoperatively, and a type and screen was sent in anticipation of intraoperative blood loss. The patient’s blood type is O, and she is RhD−.
Which blood product is most suitable to transfuse?
Correct Answer: A
In red blood cell transfusion reactions, recipient plasma antibodies react against antigens on donor cells. Conversely, the concern with transfusing plasma-containing products such as FFP and platelets is for antibodies in donor plasma to react against recipient red blood cell antigens. As a result, the recommendation is for FFP to be ABO compatible with the recipient, with AB being the universal plasma donor and O, the universal plasma recipient. FFP does not need to be RhD compatible, and anti-D prophylaxis is not needed in RhD− recipients of RhD+ FFP.
Platelet concentrates should likewise be as ABO compatible as possible to ensure an appropriate increase in platelet count, as ABO-incompatible platelets have reduced efficacy. Group O platelet concentrates can be used in patients of a different blood type if resuspended in additive/preservative solutions or if the plasma suspension is negative for high anti-A/B titers. In contrast to FFP, RhD− patients, particularly women of childbearing age, should receive only RhD− platelets if possible or should also be treated with anti-D immunoglobulin.
A 34-year-old male with a history of Hodgkin lymphoma and atrial fibrillation on warfarin presents after a 5-foot fall from a ladder. He was intubated in the field because of obtundation, and a noncontrast head computed tomography (CT) on arrival demonstrates a left subdural hematoma with midline shift. Other trauma burden on primary survey includes left-displaced radial fracture and contusions to the left side of the thorax. The patient is sent to the OR for emergent craniotomy for decompression. Vital signs on arrival to the OR are:
labs show:
How should blood products be prepared for this patient?
Correct Answer: C
Both adults and children diagnosed with Hodgkin lymphoma should receive irradiated red cells and platelets for life because of the risk for transfusion-associated graft-versus-host disease (TA-GvHD). Donor T lymphocytes in cellular blood products react against host antigens, manifesting as multiorgan system dysfunction. Unlike GvHD associated with hematopoietic cell transplant, TA-GvHD also impacts the bone marrow, and the resultant aplastic anemia is the most frequent cause of death. Other immunosuppressed populations that should receive irradiated cell-containing products include:
It is not typically necessary to use irradiated products for patients with human immunodeficiency virus (HIV), solid tumors, autoimmune disease, or after solid organ transplantation. Leukoreduction decreases the number of donor T lymphocytes but does not completely eliminate them. Leukoreduced products minimize the incidence of febrile nonhemolytic reactions and human leukocyte antigen (HLA) alloimmunization, in addition to decreasing transmission of Epstein-Barr virus (EBV) and cytomegalovirus (CMV). Patients with IgA deficiency often develop antiIgA antibodies that can result in an anaphylactic transfusion reaction. Blood cells and platelets for these patients should be washed to decrease the amount of IgA present, and FFP should be from IgA-deficient donors.
A 19-year-old male who sustained two gunshot wounds to the chest is brought in by ambulance. His initial vitals are BP 75/30 and HR 144. While securing the airway, large bore IV access is established.
Which of the following catheters is the best choice for rapid volume resuscitation?
Poiseuille’s law establishes the relationship between catheter size and length and the importance of each. Q = (πPr 4 )/(8 nL), where Q = flow, P = pressure, r = radius, n = viscosity, and l = length. It is important to note that increasing the radius dramatically increases flow, whereas increasing length decreases flow in much smaller proportion. Each manufacturer publishes the flow rate for their catheters. Reddick et al, however, studied catheters in real-life situations and found that Poiseuille’s law still holds. Options C and D are incorrect since a central line is at least 18 cm long, which reduces flow. Though option A has a marginally shorter length, the larger radius on option B will have a greater impact on flow.
Reference:
A 45-year-old female with no past medical history is brought in via ambulance after a motor vehicle accident. Her initial vitals are BP 62/30 and HR 157. On primary survey, she is noted to have significant ecchymosis across her abdomen. Focused assessment with sonography in trauma (FAST) is positive, and she is taken emergently to the OR for ex-lap. In the OR, they find multiple liver lacerations with diffuse bleeding. Along with volume resuscitation, what would be a useful adjunct to obtain hemostasis?
Correct Answer: D
In this patient with hemodynamically significant bleeding, tranexamic acid would be the best adjunct to achieve hemostasis. In the CRASH-2 trial, they found in patients with hemorrhage or at significant risk for hemorrhage that tranexamic acid when given within the first 8 hours reduced all-cause mortality. Prothrombin complex and vitamin K are inappropriate in a patient without a history of taking anticoagulants. Currently there is no evidence for transfusing cryoprecipitate in equal parts with PRBCs.