The SwitchMy worst nightmare

Narelle Whiting

Dandenong Hospital

Case Study

• 17yo female presented to ED 0438hrs

• Altered conscious state, shivering• Yellowish-green vomit at 03:30 and almost unrousable

• Vital signs: •RR34bpm, HR110bpm, SBP74mmHg, SpO2 77% on RA

• Physical exam: •AE equal, jaundiced +++, generalised abdominal tenderness

Past History

• Congenital Biliary Cirrhosis • complicated by portal hypertension, oesophageal

varices with banding in 2011.

• Pancytopenia

• Recent admission to DDH CHD with suspected urosepsis

• Provisional diagnosis. Septic Shock ?SBP -Multiorgan failure- hepatorenal failure

Pathology

0450hrs vbgas• pH 7.2• Hb 104 g/L

0500hrs• FBE-clotted

0528hrs • Coag-clotted

Pathology • 0645hrsFBE-Hb: 75g/L Plts : 157x109/L

• 0658hrs BgasHb: 77g/L pH: 7.29 O2 sat: 43.6%

• 0825hrs BgasHb: 62g/L pH: 7.36 O2 sat: 91.9%

• 0908hrs BgasHb: 41g/L pH: 7.18 O2 sat: 99.3%

In Emergency

• Scans showed presence of fluid in the abdomen.

• ? Ascites

• Noted low Hb.

• Send to theatre for exploratory laparotomy

Bloodbank

• Blood bank Sample arrived at 0920 hrs.

• Massive transfusion protocol called at 0940hrs

• 4 Uncrossmatched O Neg PC + 2 AB FFP 2 Plts issued.

• 1010hrs Patients blood group confirmed as O Neg

Bloodbank

• 1015hrs coag results come thruInr >14.0 APTT >250 Cfib <0.3g/L

• 1030 6 more units pc + 4 FFP + 10 CRYO issued

• 1100 Ordered 6 O Neg from Monash Clayton

• 1107 Ordered replacement of our stocks 13 units PC plus 2 platelets as life threatening order from Red Cross

Blood Bank

• 1120 ARCBS- called do you need all this O Neg? We are on Half reserve.

• Discussed switching patient to O Pos with Haematologist-approved

• 1125 units arrive from MMC and are immediately issued with the last of our O Neg

The Switch

1140hrs issued 10 units of O Pos

Blood Bank

• Continued to issue O Pos blood, FFP and Cryoover the next 2 hrs.

• Overall Patient received 76 units of packed cells• (58 O Pos), 18 FFP, 2 Platelets and 1 250 IU

vial of Rh(D) immunoglobulin.

• Last issued at1315hrs. Units arrived from Red Cross at 1320hrs

In Theatre….

• Intraoperative Management• Abdomen opened – 4 quadrant haemoperitoneum.• Massive transfusion protocol activated

• Splenic aneurysm isolated and repaired. Splenectomy performed, to improve access and gain control

• Vascular surgeon requested, aorta cross-clamp applied. Limited effect on bleeding, or blood pressure. Ongoing significant bleed – thought to be venous.

In Theatre….• 21 litre blood loss

• Intraoperative management• Abdomen packed, and closed.

• Post-operative management• Transferred to ICU. Family meeting, maximal therapy

reached with no signs of improvement.

• Patient passed away 16:00 18/5/17. RIP.

Pathology testing

• time 0945 1045 1120 1300

• PT >14.0 >14.0 6.7 1.7• APTT >250 >250 >250 149• Fibgn <0.3 <0.3 <0.3 1.3• pH 6.85 6.74 6.80 6.88• Hb 53 44 106 100• Plts 58

• Lethal triad

Could we have done better?

• More cryoprecipitate earlier

• Cell salvage - 30min response time

• Ordered more O neg in first instance-liase with MMC Clatyon

• More input from Haematology Registrar

Sensitisation Prevention

• BCSH guidelines recommend exchange transfuse with O Neg to reduce the load of Positive cells.

• Flow cytometry to determine residual volume of D positive cells

• IV Rh(D) immunoglobulin

The Blood Bank TeamNarelle Salmon, Anna Sajdak and Chanarong Sreng

References

• British Committee for Standard in Haematology(2013) Guideline for the use of Anti-D Immunoglobulin for the prevention of haemolytic disease of the fetus and the newborn. Transfusion Medicine,2014,24,8-20

• Nester,T.A., Rumsey, D.M, Howell, C.C, ETAL, Prevention of immunization to D+ red blood cells with red blood cell exchange and intravenous Rh Immune globulin. Transfusion,2004,44,1720-1723

• Laspina,S.,O’Riordan, J.M, Lawlor E., Murphy, W.G. Prevention of post transfusion Rh(D) immunization using red cell exchange and intravenous anti_D Immunoglobulin