Nancy Gilchrist MD, Children’s National Medical Center

Case: 4 month old male, recent immigrant, with no past medical history other than bruising with immunizations who presented with sudden onset of ecchymosis that was worsening. Labs revealed leukocytosis, anemia, thrombocytosis, transaminitis, and abnormal PT/PTT. Other than obvious scattered bruising on exam, the patient was hemodynamically stable with hepatomegaly.

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Discussion:

This case was a great one touching on disposition and knowing institutional resources in a busy time of the year. As a tertiary care center, outside hospital transfers are the norm and as ED physicians, we are usually the gatekeepers! Creating an illness script without seeing the patient is always a tough but necessary task many of us to hope to perfect. In the groups mind, coagulopathy and oncologic were highest on the differential but non-accidental trauma with intra-abdominal bleeding is still a potential. Thus, many of us felt to involve a variety of consults early in the course that would help management, i.e. trauma surgery and critical care.

In my mind, as I think about the potential resources that would be needed for this child, FFP and PRBCs are in the near future for this child. I proposed having FFP thawed and ready, given it takes potentially an hour to have available. However, much of the group stated they would not get products ahead of time given the reported stability of the child from the outside hospital.

Much of the group preferred to get the entire set of labs that were proposed, but Dr. Donnelly pushed the group to ask what a serum asa level would do to help management. Drs. Prieto and Zhao agreed it would likely not change management but given the history in order to be thorough should be done. The largest point of contention is in a situation where an already anemic patient needs several milliliters of additional blood to be withdrawn in order to fulfill the lab requests from hematology/oncology. Transfusing first will negate many of the studies needed, however, further withdrawing an excessive amount of blood from this child could tip them over from stable anemia to unstable anemia. That line to walk is a very tight line to walk and ultimately the group discussed the best solution would be to have the blood products bedside so that there would be very little time between blood draw and transfusion.

Salisbury et al, in 2011, studied 17,676 patients with acute myocardial infarction across 57 centers and found a correlation between the volume of blood taken and the development of anemia. On average, for every 50 mL of blood drawn, the risk of moderate to severe iatrogenic anemia increased by 18%. Kurniali et al reported that during an average admission, 65% of patients experienced a drop in hemoglobin of 1.0  g/dL or more, and 49% developed anemia.

Since these studies were done, several hospitals have attempted QI interventions to help decrease phlebotomy induced anemia. In 2011, Stuebing and Miner described an intervention in which the house staff and attending physicians on non-intensive care surgical services were given weekly reports of the cost of the laboratory services for the previous week. They found that simply making providers aware of the cost of their tests reduced the number of tests ordered and resulted in significant hospital savings.

https://www.mdedge.com/ccjm/article/109827/geriatrics/are-we-causing-anemia-ordering-unnecessary-blood-tests

Denouement:

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