Laboratory Investigations – Laboratory Investigations – all that a blood banker all that a blood banker
needs to Knowneeds to Know
Department of Clinical Pathology & Blood BankDepartment of Clinical Pathology & Blood Bank
C M C VelloreC M C VelloreIndiaIndia
Tests for Appropriate use of :-Tests for Appropriate use of :-
Red CellsRed CellsPlateletsPlateletsPlasmaPlasmaCryoCryoFactor ConcentrateFactor ConcentrateBy pass agents – rFVIIa/ FEIBABy pass agents – rFVIIa/ FEIBA
Others – Tranexamic acid, DDAVPOthers – Tranexamic acid, DDAVP
Red Cells and PlateletsRed Cells and Platelets
Hb/ PCV/ RCCHb/ PCV/ RCC
Platelet countPlatelet count
The Coulter Principle
Sensing Zone
Red Blood Cell
A red cell passes through RBC apertureA red cell passes through RBC aperture
OscilloscopeOscilloscopeOhm’s law: Voltage = Current X resistance
Oscilloscope
Sensing Zone
Neutrophil
A White cell passes through WBC apertureA White cell passes through WBC aperture
OscilloscopeThresholds for sensing the voltage can be adjusted
Applying Thresholds to separate Plt from RBCApplying Thresholds to separate Plt from RBC
20 fl
2 fl
Base line
RBC of various sizes
Platelets
TOPIC: Basic Size and Frequency HistogramsBasic Parameter Derivation
A B C
ChannelNo.
No. ofCells
Avg Vol(fL)
Total Vol(fL)
1 0 25.5 0.0
2 1 26.5 26.5
3 2 27.5 55.0
4 3 28.5 85.5
5 4 29.5 118.0
6 5 30.5 152.5
7 6 31.5 189.0
8 5 32.5 162.5
9 4 33.5 134.0
10 2 34.5 69.0
11 1 35.5 35.5
Total 33 31.1 1027.5
TABLE
23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38
Femtolitres
Rel
ativ
e N
umbe
r
Channel 11
Channel 1
How we get from pulses to histograms:
TOPIC: Basic Size and Frequency HistogramsBasic Parameter Derivation
23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38
Femtolitres
Rel
ativ
e N
umbe
r
Histogram
How we get from pulses to histograms:
TOPIC: Basic Size and Frequency HistogramsBasic Parameter Derivation
RBC Histogram
Normal RBC Histogram
RDW = standard deviation x 100Mean Size
MCV = average size of all the cells in the histogram.
TOPIC: Basic Size and Frequency HistogramsBasic Parameter Derivation
Smoothed and Fitted Curves for Platelets
Smoothed (from the raw). Shown between
2 - 20 fL - only where data is collected for platelets.
Platelet count and Platelet Platelet count and Platelet morphology and numbers on morphology and numbers on
smearsmearManual or MachineManual or Machine
Platelet HistogramPlatelet Histogram
Laboratory Evaluation of Laboratory Evaluation of HaemostasisHaemostasis
Screening Tests for HemostasisScreening Tests for Hemostasis
Platelet countPlatelet countBleeding timeBleeding time ( (BTBT) - ) - Plt adh-vWF,Gp1b/ Plt aggr- Plt adh-vWF,Gp1b/ Plt aggr- GpIIb-IIIa/ Plt secretionGpIIb-IIIa/ Plt secretion
Prothrombin timeProthrombin time ( (PTPT) - ) - Extrinsic pathway Extrinsic pathway
factors-VII,V,X,II and Fibrinogenfactors-VII,V,X,II and Fibrinogen Activated Partial thromboplastin timeActivated Partial thromboplastin time ((aPTTaPTT) – ) – Intrinsic pathway factors Intrinsic pathway factors XII,XI,IX,VIII,V,X,II,FibrinogenXII,XI,IX,VIII,V,X,II,Fibrinogen
Most important is - HistoryMost important is - History
Value of history in DiagnosisValue of history in Diagnosis
An abnormal coagulation parameter has no An abnormal coagulation parameter has no major diagnostic value if the patientmajor diagnostic value if the patient
is not bleeding is not bleeding
has not been a bleeder ( no past history has not been a bleeder ( no past history of bleeding) of bleeding)
not likely to be a bleeder –( no family or not likely to be a bleeder –( no family or medication history) medication history)
HistoryHistory
Key to understanding and diagnosing Key to understanding and diagnosing hemorrhagic disordershemorrhagic disorders
* * Without any symptoms an abnormal coagulation test Without any symptoms an abnormal coagulation test
result has no valueresult has no value
* * With a good history you may just need basic tests of With a good history you may just need basic tests of haemostasis in the laboratory for diagnosishaemostasis in the laboratory for diagnosis
Bleeding TimeBleeding Time
Time taken by a Time taken by a standardized skin standardized skin wound to stop wound to stop bleedingbleedingStandard Skin wound Standard Skin wound – 2.5 to 3 mm deep – 2.5 to 3 mm deep and 1.0 to 1.5 mm and 1.0 to 1.5 mm wide (Ivy’s Method)wide (Ivy’s Method)Lancet tip is 3 mm Lancet tip is 3 mm long and 1.5 mm wide long and 1.5 mm wide at the baseat the base
Bleeding Time Bleeding Time (Modified Ivy’s Method)(Modified Ivy’s Method)
BP cuff to 40 mm HgBP cuff to 40 mm Hg
Select an area avoiding Select an area avoiding any vein or angiomasany vein or angiomas
Clean the Volar aspectClean the Volar aspect
Stab confidently three Stab confidently three times and start Stop times and start Stop watch at the end of the watch at the end of the third wound.third wound.
At least one wound is At least one wound is STANDARD STANDARD
Results of Bleeding TimeResults of Bleeding TimeStop the Stopwatch when all the wounds stops Stop the Stopwatch when all the wounds stops bleedingbleedingNormal – 2 to 6 minutesNormal – 2 to 6 minutesIdeal to establish your own rangeIdeal to establish your own rangeProlongation – Prolongation – a) Vascular defecta) Vascular defect
b) Adhesion Defect – VWF (b) Adhesion Defect – VWF (Von Willebrand diseaseVon Willebrand disease) or ) or Platelet adhesion molecule Gp1b (Platelet adhesion molecule Gp1b (Bernard Soulier Bernard Soulier SyndromeSyndrome))c) Aggregation defect – Platelet aggregation receptors c) Aggregation defect – Platelet aggregation receptors GpIIbIIIa (GpIIbIIIa (Glanzmann ThrombastheniaGlanzmann Thrombasthenia))d) Platelet Secretion Defect – Platelet Granule deficiency d) Platelet Secretion Defect – Platelet Granule deficiency ((Gray plateletGray platelet) or ) or AspirinAspirin
Interpretation and furtherInterpretation and further
Specific TestsSpecific Tests
- Von Willebrand Factor assays- Von Willebrand Factor assays
- Platelet Aggregometry studies- Platelet Aggregometry studies
- Clot Retraction – absent in aggregation - Clot Retraction – absent in aggregation defectsdefects
Tests for Secondary haemostatic Tests for Secondary haemostatic Factor defects -Factor defects -
All these Factors are present in the All these Factors are present in the plasmaplasma
Tests for Clotting factors - plasma based Tests for Clotting factors - plasma based teststests
Important – care in preparing plasmaImportant – care in preparing plasma
Starts at Blood sampling Starts at Blood sampling
Avoid contamination by Tissue and avoid Avoid contamination by Tissue and avoid activationactivation
Preparing plasmaPreparing plasma
Anticoagulate blood in Trisodium Citrate to Anticoagulate blood in Trisodium Citrate to prevent clotting of blood to be tested by prevent clotting of blood to be tested by chelating Calcium. chelating Calcium. One part Citrate and nine part Blood from veinsOne part Citrate and nine part Blood from veinsCarefully collected to prevent activation of Carefully collected to prevent activation of factorsfactorsTwo syringe method- 1Two syringe method- 1stst for blood counts and 2 for blood counts and 2ndnd for Coagulation studiesfor Coagulation studies
Preparing PlasmaPreparing Plasma
Centrifuge at high speed (1500 – 2000g Centrifuge at high speed (1500 – 2000g for 10 min) - To separatefor 10 min) - To separate
Plasma as Platelet Poor Plasma Plasma as Platelet Poor Plasma
Test immediately before less stable factors Test immediately before less stable factors are lost. are lost.
If not keep in ice bathIf not keep in ice bath
Plasma Based TestsPlasma Based Tests
All clotting tests to be All clotting tests to be done in a 37done in a 3700C water C water bath. A circulating bath. A circulating water bath is ideal.water bath is ideal.
Keep test plasma or Keep test plasma or control plasma and control plasma and reagents at 37reagents at 3700C at C at least 5 min before least 5 min before doing the testsdoing the tests
ActivatorsActivators
Plasma Based Tests – Adding the Plasma Based Tests – Adding the activatoractivator
TimingTiming
Automated CoagulometersAutomated Coagulometers
CMC-EQASCMC-EQAS
Total No. of ParticipantsTotal No. of Participants 400400
Total No. of Participants in 2010Total No. of Participants in 2010 231231
Information availableInformation available 158158
Prothrombin TimeProthrombin TimeTime taken by a Time taken by a recalcified recalcified citrated plasma to clot in citrated plasma to clot in presence of presence of Tissue FactorTissue Factor..Tests the Tests the Extrinsic PathwayExtrinsic Pathway – Tissue Factor will activate – Tissue Factor will activate the extrinsic pathway by the extrinsic pathway by activating FVII onwardsactivating FVII onwardsTissue FactorTissue Factor - - ThromboplastinThromboplastin with its with its bound negatively charged bound negatively charged phospholipidphospholipid
Reactions involved in the PT-assay
XIIa
XI XIa
IX IXa
X Xa
ProthrombinThrombin
Fibrinogen Fibrin
TFVIIa
TFVII
Va
VIIIa
Extrinsic pathway
XII
Intrinsic pathway
HMWKPrekallikrein
ResultsResults Normal Range – 9 to Normal Range – 9 to 12 seconds or 12-15 12 seconds or 12-15 seconds (Depending seconds (Depending on the Reagent)on the Reagent)
RESULTINGRESULTING
Raw Data- Patient Raw Data- Patient time and Reference time and Reference range.range.
Prothrombin ratio Prothrombin ratio (PR) = (PR) = Patient timePatient time
Control Control timetime
>1.2 (3 Seconds >1.2 (3 Seconds more than Control)more than Control)
Reactions involved in the PT-assay
XIIa
XI XIa
IX IXa
X Xa
ProthrombinThrombin
Fibrinogen Fibrin
TFVIIa
TFVII
Va
VIIIa
Extrinsic pathway
XII
Intrinsic pathway
HMWKPrekallikrein
Prolonged PT indicates deficiency of FVII, FX, FV, FII and FibrinogenProlonged PT indicates deficiency of FVII, FX, FV, FII and Fibrinogen
Factors affecting - PT ResultFactors affecting - PT Result
Variety of reagents (containing different Variety of reagents (containing different thromboplastin) are available in the market thromboplastin) are available in the market some are good and some are bad giving some are good and some are bad giving different PR (Prothrombin Ratio) on the different PR (Prothrombin Ratio) on the same sample. same sample. Ideally a good screening test reagent Ideally a good screening test reagent should be very sensitive so that all levels should be very sensitive so that all levels of low factors can be picked up when a PT of low factors can be picked up when a PT is done.is done.
Sensitivity of a PT reagentSensitivity of a PT reagent
Most sensitive PT reagent – picks up the mildest Most sensitive PT reagent – picks up the mildest of deficiency and exaggerates the difference of deficiency and exaggerates the difference between ranges of deficiency.( PT is abnormal between ranges of deficiency.( PT is abnormal even if FVII is 40% and there is a significant even if FVII is 40% and there is a significant difference in PT time when levels are 13% and difference in PT time when levels are 13% and 17%)17%)Least sensitive PT reagent- misses deficiency Least sensitive PT reagent- misses deficiency and will not show the difference between ranges and will not show the difference between ranges of deficiency .( PT is normal even if FVII is 23% of deficiency .( PT is normal even if FVII is 23% and there is no significant difference in PT time and there is no significant difference in PT time when levels are 11% and 17%)- BAD Reagentwhen levels are 11% and 17%)- BAD Reagent
PT Result - ISI and INRPT Result - ISI and INR
International sensitivity index (ISI)- value that is International sensitivity index (ISI)- value that is assigned indicating the sensitivity of the reagent.assigned indicating the sensitivity of the reagent.Most sensitive reagent has ISI close to a value Most sensitive reagent has ISI close to a value of 1of 1Less sensitive reagents will be more than 1.4 Less sensitive reagents will be more than 1.4 onwardsonwardsInternational normalized ratio (INR) is International normalized ratio (INR) is normalizingnormalizing a PT expressed as PR by a PT expressed as PR by incorporating the allocated sensitivity (ISI) of the incorporating the allocated sensitivity (ISI) of the PT reagent used = PRPT reagent used = PRISIISI
aPTTaPTTTimeTime taken by a taken by a recalcifiedrecalcified citrated plasma citrated plasma to clot in presence of to clot in presence of negatively charged negatively charged - - contactcontact activatoractivator ((Silica, Kaolin, Ellagic Silica, Kaolin, Ellagic acidacid) ) - - phospholipidphospholipid ( (Partial Partial ThromboplastinThromboplastin))
Tests the Tests the Intrinsic Intrinsic PathwayPathway - Contact - Contact activator will activate activator will activate the intrinsic pathway by the intrinsic pathway by activating FXII onwards activating FXII onwards with the help of with the help of phospholipidsphospholipids
Reactions involved in the APT-time
XIIa
XI XIa
IX IXa
X Xa
ProthrombinThrombin
Fibrinogen Fibrin
TFVIIa
TFVII
Va
VIIIa
Extrinsic pathway
XII
Intrinsic pathway
HMWKPrekallikrein
ResultsResults Normal range – 27 Normal range – 27 – 37 Seconds – 37 Seconds
(Different for different (Different for different Reagents)Reagents)
ResultingResulting
Raw Data- Patient time Raw Data- Patient time and Reference rangeand Reference range
Ratio ->1.2 (more than Ratio ->1.2 (more than 6 secs difference from 6 secs difference from the Control time)the Control time)
Reactions involved in the APT-time
XIIa
XI XIa
IX IXa
X Xa
ProthrombinThrombin
Fibrinogen Fibrin
TFVIIa
TFVII
Va
VIIIa
Extrinsic pathway
XII
Intrinsic pathway
HMWKPrekallikrein
Prolonged aPTT indicates deficiency of FXII, FXI, FIX, FVIII, FX, FV, FII and Prolonged aPTT indicates deficiency of FXII, FXI, FIX, FVIII, FX, FV, FII and FibrinogenFibrinogen
ResultsResultsWhat next If results are abnormal (Prolonged What next If results are abnormal (Prolonged time)time)Prolonged aPTT indicates deficiency of FXII, FXI, FIX, Prolonged aPTT indicates deficiency of FXII, FXI, FIX, FVIII, FX, FV, FII and FibrinogenFVIII, FX, FV, FII and Fibrinogen
Prolonged PT indicates deficiency of FVII, FX, FV, FII Prolonged PT indicates deficiency of FVII, FX, FV, FII and Fibrinogenand Fibrinogen
A A Thrombin timeThrombin time is done since it picks Fibrinogen is done since it picks Fibrinogen deficiency. Time taken by plasma to clot when deficiency. Time taken by plasma to clot when thrombin is added – this is the time taken by thrombin is added – this is the time taken by thrombin to convert F’gen to Fibrin.thrombin to convert F’gen to Fibrin.
Mixing/Correction StudiesMixing/Correction StudiesDone when PT/APTT are prolongedDone when PT/APTT are prolongedMixing studies :- Mix equal volumes of test Mixing studies :- Mix equal volumes of test (abnormal) plasma and control pool plasma (abnormal) plasma and control pool plasma (where all factors are present in normal (where all factors are present in normal quantity) and repeat the test.quantity) and repeat the test.Rationale: Rationale:
- if the prolongation in time is due to deficiency of factor (s) - if the prolongation in time is due to deficiency of factor (s) in the test plasma, normal plasma will provide the deficient in the test plasma, normal plasma will provide the deficient factor when they are mixed correcting the prolonged timefactor when they are mixed correcting the prolonged time
- if the prolongation in time is due to an inhibitor (antibody to - if the prolongation in time is due to an inhibitor (antibody to factor or heparin) the normal plasma will also be inhibited factor or heparin) the normal plasma will also be inhibited and the prolonged time will remain prolongedand the prolonged time will remain prolonged
Correction of time: Deficiency of factorCorrection of time: Deficiency of factorNo correction: InhibitorNo correction: Inhibitor
No correctionNo correction
Whatever caused the abnormal (prolonged) Whatever caused the abnormal (prolonged) timing is also causing an abnormality to normal timing is also causing an abnormality to normal plasma after the patients plasma was mixed in it.plasma after the patients plasma was mixed in it.
- Heparin- Heparin
- Lupus anticoagulant (antiphospholipid - Lupus anticoagulant (antiphospholipid antibody)antibody)
- Factor Inhibitor ( antibodies to Clotting - Factor Inhibitor ( antibodies to Clotting factors)factors)
- FDP/D-Dimer- FDP/D-Dimer
Correction StudiesCorrection StudiesDirect interpretation to therapyDirect interpretation to therapyPatient who is bleeding with a prolongation in Patient who is bleeding with a prolongation in plasma clotting testsplasma clotting testsCorrection of the time by mixing studies in which Correction of the time by mixing studies in which the the normal plasmanormal plasma suppliedsupplied the deficient factor the deficient factor will directly mean that if you give (transfuse) the will directly mean that if you give (transfuse) the patient - patient - normal plasma (FFP)normal plasma (FFP) his his clotting clotting defectdefect, that lead to the , that lead to the prolongationprolongation of the time, of the time, will get will get correctedcorrected and the bleeding will stop. and the bleeding will stop.Non Correction of time – No benefit of Non Correction of time – No benefit of transfusing FFP. Use safer productstransfusing FFP. Use safer products– Heparin – use ProtaminHeparin – use Protamin– Inhibitor – other agents Inhibitor – other agents
Standard Mixing studies – will miss a FVIII Standard Mixing studies – will miss a FVIII inhibitorinhibitor
FVIII inhibitorFVIII inhibitor
Late actingLate acting
Picked only on incubation , for e.g,Picked only on incubation , for e.g,
Patient – aPTT Patient – aPTT = 120 sec = 120 sec Control Control = 30 = 30 secsec
MixingMixing = 40 sec = 40 sec
(Keep the “Mix” and individual plasmas 2 hours in water bath)(Keep the “Mix” and individual plasmas 2 hours in water bath)
aPTT of Incubated MixaPTT of Incubated Mix = = 102102 sec sec
Definitive (Specific) Tests Definitive (Specific) Tests
Specific Factor assaysSpecific Factor assays
Inhibitor assayInhibitor assay
Quantify Inhibitors – Bethesda Quantify Inhibitors – Bethesda AssayAssay
Quantify the amount of inhibitorsQuantify the amount of inhibitors
Principle of the assay - Ability of a patients Principle of the assay - Ability of a patients plasma to neutralize FVIII in normal plasma to neutralize FVIII in normal plasma (Plasma plasma (Plasma ≈≈ 100% FVIII) 100% FVIII)– on mixing and incubating for 2 hrson mixing and incubating for 2 hrs
Bethesda UnitsBethesda Units
<5 BU low responder<5 BU low responder
Treatment Treatment
Urea clot solubilityUrea clot solubility(Qualitative assay for FXIII)(Qualitative assay for FXIII)
Fibrin is held by weak forces till FXIII introduces Fibrin is held by weak forces till FXIII introduces bonds between them. Weak forces will dissolve bonds between them. Weak forces will dissolve in in low ionic strength solutionlow ionic strength solution but not the but not the strong bonds.strong bonds.Weak ionic strength solution is – Weak ionic strength solution is – 5 Molar Urea5 Molar UreaIncubate clot in 5M Urea overnight.Incubate clot in 5M Urea overnight.FXIII deficiency- FXIII deficiency- no clotno clot seen the next day (the seen the next day (the clot dissolves) but the clot in a normal plasma clot dissolves) but the clot in a normal plasma appears the same.appears the same.
Are these tests Useful ?Are these tests Useful ?
Issues:-Issues:-
- - AvailabilityAvailability
- - ReliabilityReliability
- - FasterFaster tturn urn aaround round ttime (ime (TATTAT))
Limitation exists for FFP/Cryo Limitation exists for FFP/Cryo
((These tests are necessary in blood banks with These tests are necessary in blood banks with components for use in ensuring quality control of components for use in ensuring quality control of
these products – Coag Factor assays etcthese products – Coag Factor assays etc))
Any AlternativeAny Alternative
At least start with Red cells and Platelets At least start with Red cells and Platelets - Hb/Hct - Hb/Hct - Platelet count- Platelet count
- - ReliabilityReliability- - Faster TATFaster TAT
- Quality Assurance as per ISO-15189- Quality Assurance as per ISO-15189NABLNABL
Look at alternative POC/ NPT (Point of Look at alternative POC/ NPT (Point of Care/ Near Patient Testing) devices –Care/ Near Patient Testing) devices –ROTEM/TEG - ThromboelastographyROTEM/TEG - Thromboelastography
Thromboelastography Thromboelastography (ROTEM/TEG)---------(ROTEM/TEG)---------
Clot activation by Clot activation by TF TF (at (at PhysiologicalPhysiological level)level)
CT/R- Clot time CT/R- Clot time
Rate of Clotting – CFT/k and Rate of Clotting – CFT/k and αα angle – angle – rate of thrombin generationrate of thrombin generation
MA/MCF – Clot strength (Plt/Fib) MA/MCF – Clot strength (Plt/Fib)
Stationary cup with blood - oscillated ( 4o to45’ -10 secs)
Pin is suspended - torsion wire - monitored for motion.
Measure the torque of rotation - transmitted from the immersed pin – after fibrin platelet bonding has linked the cup and pin together
Normal TEGNormal TEG
Thromboelastogram TEG (Whole Blood)Thromboelastogram TEG (Whole Blood)
30%
20%
10%
5%
2% 1%
0.5%
0.2%
FVIII deficient blood spiked with Recombinate
HypocoagulableHypocoagulable
HypofibrinogenemiaHypofibrinogenemia
GlanzmannThrombastheniaGlanzmannThrombasthenia
FXIII deficiencyFXIII deficiency
Primary FibrinolysisPrimary Fibrinolysis
Mr.S – with DU perforationMr.S – with DU perforationPost –op in SICU shifted to MICU Post –op in SICU shifted to MICU due to frank sepsisdue to frank sepsisCoagulogram only mildly abnormal.Coagulogram only mildly abnormal.Over days he uses either red cell Over days he uses either red cell or FFP if to undergo a procedure.or FFP if to undergo a procedure.14 days later - significant ooze 14 days later - significant ooze from all puncture sites. from all puncture sites. Coagulogram still mildly abnormal Coagulogram still mildly abnormal – given 4 FFP and 8 cryo. No – given 4 FFP and 8 cryo. No change – in bleeding but improved change – in bleeding but improved coagulogram coagulogram 12.2/34/275/7.7/45,000 -? 12.2/34/275/7.7/45,000 -? microvascular bleedingmicrovascular bleedingTEG – since they still wanted to TEG – since they still wanted to give FFPgive FFPInformed that nothing in the Informed that nothing in the repertoire of the blood bank to turn repertoire of the blood bank to turn the situation aroundthe situation aroundAdvised rFVIIaAdvised rFVIIa
Mr.HKP – post Subtotal colectomy in SICUMr.HKP – post Subtotal colectomy in SICU
Persistant collection in the drain. Dark coloured.Persistant collection in the drain. Dark coloured.
Monitoring coagulation and Hb and using Blood and Blood products.Monitoring coagulation and Hb and using Blood and Blood products.
Persistantly coagulopathic with fibrinogen at 75 – risk of Dilutional Persistantly coagulopathic with fibrinogen at 75 – risk of Dilutional CoagulopathyCoagulopathy
But best was later in the evening when 16/40/242/7.5/48,000 but But best was later in the evening when 16/40/242/7.5/48,000 but collections were samecollections were same
TEG – still significantly hypocoagulableTEG – still significantly hypocoagulable
rFVIIarFVIIa
Re-explored the next day and a open vessel was ligated.Re-explored the next day and a open vessel was ligated.
PRE & POST FEIBA/rFVIIa TEG – PRE & POST FEIBA/rFVIIa TEG – 798938B798938B
Pre – 4.9.10
Pre – 1.9.10P0st – 4.9.10
Pre – 7.9.10
Pre–2.9.10
Post –1.9.10
Post – 2.9.10
Post – 7.9.10
Ms.M refered with atonic PPH and 11 Red cell Ms.M refered with atonic PPH and 11 Red cell unit transfusedunit transfused
Coags – 32/93/43/3.1/120,000Coags – 32/93/43/3.1/120,000
Cryoprecipatate – 10 rushedCryoprecipatate – 10 rushed
Continued to ooze in ICU after hysterectomy Continued to ooze in ICU after hysterectomy and another 5 units of Red cells and another 5 units of Red cells but still mildly but still mildly coagulopathic 17/42/124/10.5/35,000coagulopathic 17/42/124/10.5/35,000
Did not give rFVIIaDid not give rFVIIa
Given 3 PRC and 4 cryoGiven 3 PRC and 4 cryo
