1. 1/12/17 Annie Shepler, PGY4 James Gauldin, PGY1
Interesting Cases
1/12/17
Annie Shepler, PGY4
James Gauldin, PGY1

2. Case 1: FFP call
Call from nurse (question from surgeon)asking about FFP for a patient scheduled to have a surgery in a few hours:
When is the onset
When should we re-dose
Patient is a 63 yo F with h/o stroke, Sjogren’s syndrome, recent dx of SLE, and head and neck cancer with “chronically elevated PTT” and history of previous bleeding during a neck dissection surgery; also recent complete tooth extraction with gingival bleeding 2 days after; resolved spontaneously
OSH: PT: 12.3 (nl 11-14) PTT: 36.7 (nl 25-35)

3. Case Per outside note, “normal coag studies, normal vWB studies”
Hematologist recommended pt have 2 units of FFP prior to surgical procedures
Pt seen by ophthalmologist for brow ptosis repair
Seen first in clinic – no coag workup ordered
No coag labs drawn day of surgery
Back to the questions:
Onset: Immediate (they’re coag factors)
When to redose: depends on why the PTT is elevated…which we don’t know

4. Causes of Prolonged PTT
[UpToDate]

5. Prolonged PTT Algorithm
-If delayed appearance of inhibitor (2 hours > 5 minutes), check factor VIII activity level
-If immediate appearance of inhibitor (2 hours = 5 minutes), check factor VIII, IX, and XI activity
-If inhibitor corrects with phospholipid addition, additional antiphospholipid antibody testing
Testing for intrinsic pathway defects:
VWD testing
Factor VIII, IX, and XI testing
If these are normal, factor XII testing
VWD testing
Factor VIII, IX, XI testing
Factor inhibitors, antiphospholipid
ab testing

6. Cryoprecipitate should be used when fibrinogen or von Willebrand factor is needed. For treatment of hemophilia A, cryoprecipitate or factor VIII concentrates, heated or unheated, are available. For treatment of severe hemophilia B, factor IX complex is preferable. Both of these concentrates are prepared from pooled plasma, and the risk of virus transmission is negligible as there hasn't been an infection since 1985 when techniques were developed to kill off viruses including HIV. The factor IX concentrate carries the additional hazard of thrombogenicity.

7. Pt ultimately received 2 units of FFP, no complications and no significant bleeding during surgery
Indications of FFP:
Correction of congenital or acquired deficiencies of clotting factors (for which there is not a specific concentrate), when the PT or PTT is >1.5 normal range
Except in an MTP type of situation, should clinicians be made to order coag testing to order FFP?

8. Case 3: ABO Discrepancy
26 yo F at 6 and 2/7 weeks gestation presenting for Ob/gyn appointment
Told by ARC that she has a strange blood type

9. Red Cell Phenotype
Anti-A
Anti-B
Anti-A,B
Anti-H
A1 Cells
B Cells A1 4+ A2 2+
0/2+ A3
2+mf 3+ Ax
1-2+
Ael
Aend
wk mf B B3
1+mf Bx
Fung et al., 2014

10. The Ael phenotype is inherited as a rare gene at the ABO locus
Adsorption and elution studies are necessary to show that these RBCs carry the A antigen
We sent it off for testing…
Harmening, 2005
Hosoi, 2008

11. Case 2: Line Infiltration
68 year old female with a history of constrictive bronchiolitis s/p double lung transplant (2009) who has chronic graft rejection, here for her 51st ECP procedure.
Upon return of cells, patient began to complain of pain in accessed arm with L AC infiltration
Ice pack applied immediately above site. Lt AC was deaccessed per protocol, pressure applied per protocol and pressure dressing was applied
R AC access was attempted and unsuccessful; PICC service called and R PIV was placed and ECP completed
The next day, patient sends picture of arm:

13. Patient was otherwise doing well; no fever/chills or limitation in ROM
Advised to seek medical care
PCP concerned could turn into cellulitis-prescribed doxycycline
1 week later, patient reports improvement with only minor pain with full extension/reaching upward

14. Infiltration vs Extravasation
Infiltration: the inadvertent leakage of a
nonvesicant solution into surrounding tissue
Extravasation—the inadvertent leakage of a
vesicant solution into surrounding tissue
Vesicant - any medication
or fluid with the potential for
causing blisters, severe
tissue injury, or necrosis if it
escapes from the venous
pathway
Extravasation injury from cancer chemotherapy is reported to be 11% in children and 22% in adults.3
Hadaway, 2007

15. Signs/Symptoms Pain, tenderness, or discomfort
Edema, at, above, or below the insertion site
Erythema at or above the insertion site
blanching of the area around the insertion site
changes in the temperature of the surrounding skin
numbness, tingling, or a feeling of “pins and needles”
burning at the insertion site or along the venous pathway
fluid leaking from the insertion site
feeling of skin tightness around the insertion site or tightness below the site (such as in the fingers)
bruising
palpable cording of the vein
Before administering the infusion the nurse should:
-assess the patency of the vein and the catheter by checking for lack of resistance when flushing the catheter, brisk blood return from the catheter, and a free-flowing gravity infusion, palpate the area above the insertion site, assess the length of dwell time for the catheter and compare the appearance of the two extremities

16. Things to do Immediately
For a problem involving a short peripheral catheter:
Remove the dressing and withdraw the catheter
attempt aspiration of the residual drug from the IV device
Use a dry gauze pad to control bleeding
Apply a dry dressing to the puncture site, but avoid applying excessive pressure on the area
Do not insert a new peripheral IV catheter distal to a site of infiltration or extravasation.
Measures of prevention include selection of an appropriate site for catheter insertion, selection of an appropriate size catheter, use of appropriate fluids, stabilization of the catheter, and use of proper administration techniques

17. Treatment Definitive treatment has not been established
Elevation of the affected limb may aid in reabsorption by decreasing capillary hydrostatic pressure
However, one study of limb elevation (of approximately 2-4 in) did not demonstrate alleviation of pain or resolution of infiltrate
Although clear benefit has not been demonstrated with thermal applications, it remains standard supportive care, and the recommended application schedule for both warm and cold applications is 15 to 20 minutes, every 4 hours, for 24 to 48 hours
For a problem involving a central venous catheter:
• Do not remove the catheter. Clamp and cap the
catheter hub.
• Follow your facility’s procedure for flushing the
catheter when infiltration or extravasation is suspected.
• When there is an implanted port, remove the port
access needle after aspiration and apply a dressing.
• Consult the physician about the need for a radiographic
study of the catheter to determine the cause
of the infiltration or extravasation. Assess the need for
continuing IV therapy and plans for another central
venous catheter.
Cold application is recommended for extravasation of DNA-binding vesicants (with the exception of mechlorethamine [nitrogen mustard]), 30 contrast media,3,34 and hyperosmolar fluids.2,35
Yucha et al., 1994

18. Injury Claims
Closed Claims Project database, which summarizes data from professional liability carriers, showed that 2.1% of injury claims from 1970 to 2001 were related to peripheral catheters
28% were related to skin slough or necrosis
17% were related to swelling, inflammation, or infection
17% were related to nerve damage (with 22% of these caused by acute limb compartment syndrome or ALCS)
16% were related to fasciotomy scars resulting from ALCS
3% were related to heat compresses used to treat IV infiltrations
Approximately 54% of peripheral catheter claims resulted in successful litigation for the plaintiffs, with compensation ranging from $275 to $10,050,000
Liau, 2006

19. Questions?
Thanks!

20. Harmening, D. (2005). Modern Blood Banking and Transfusion Practices
Harmening, D. (2005). Modern Blood Banking and Transfusion Practices Retrieved January 12, 2017
Fung, Mark et al., AABB Technical Manual, 2014, 18th ed.
Liau DW. Injuries and liability related to peripheral catheters: a Closed Claims analysis. Newsl Am Soc Anesthesiol. 2006;70(6).
Hadaway, L. Infiltration and Extravasation. AJN t August 2007 Vol. 107, No. 8
Yucha CB, Hastings-Tolsma M, Szeverenyi NM. Effect of elevation on intravenous extravasations. J Intraven Nurs. 1994;17(5):
Hosoi, E. Biological and clinical aspects of ABO blood group system. J. Med. Invest :