The Switch My worst nightmare Narelle Whiting
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