50-yo, esophageal bleed, hypovolemic, high PT/PTT, what to do next?

[DrMetal]

Hi all, was doing a popular qbank, question (#4386), vignette was: 50-yo with a bad variceal bleed, COAGS up, hypovolemic BP 90/60, what do you give next?

a) whole blood
b) FFP
c) cryoprecipitate
d) pooled platelets
e) plasmaphoresis
f) hemodialysis

correct answer is FFP, b/c he needs factors (his PT and PTT were way up).

My question is: Wouldn't you rather give whole blood, so that you could also replenish his volume? In other words, can't you use whole blood to provide factors and bring up his volume??? (NOTE: 0.9% normal saline was not an answer choice).

Thoughts? Thanks,

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[ASAPRocky]

Hi all, was doing a popular qbank, question (#4386), vignette was: 50-yo with a bad variceal bleed, COAGS up, hypovolemic BP 90/60, what do you give next?

a) whole blood
b) FFP
c) cryoprecipitate
d) pooled platelets
e) plasmaphoresis
f) hemodialysis

correct answer is FFP, b/c he needs factors (his PT and PTT were way up).

My question is: Wouldn't you rather give whole blood, so that you could also replenish his volume? In other words, can't you use whole blood to provide factors and bring up his volume??? (NOTE: 0.9% normal saline was not an answer choice).

Thoughts? Thanks,

Whole blood is never an answer.

FFP is the choice

 

[DrMetal]

Whole blood is never an answer.

FFP is the choice

Ok . . . I get it.

BTW, theres are scenarios where you do give whole blood, but (according to UptoDate), that involve massive transfusions (50% blood loss), secondary to some serious trauma (limbs blown off, etc). Here's some of the verbage I looked up in UTD:

■Whole blood – Whole blood is rarely indicated and seldom is available. Its use should be considered only in the context of massive blood transfusion. The rationale is that massive transfusion of only one blood component (eg, red blood cells) will lead to dilutional deficiencies of the other components (eg, platelets, coagulation factors). This can be avoided by transfusing whole blood. (See "Massive blood transfusion".)

Whole blood should be considered only when dealing with an adult who has bled acutely and massively and then only after the patient has received approximately five to seven units of red cells plus crystalloids.

In any case, that's clearly not the scenario described in the vignette, so FFP it is.

 

[septoplasty]

UpToDate is correct in clinical practice. But sometimes the answers on NBME/USMLE are not really what's done in clinical practice.

Ex. Admin of N Acetylcysteine to prev. contrast toxicity.

USMLE Rule: Wrong answers = Consulting (99% of the time), Whole Blood.

 

[toayoztan]

If whole blood is ever mentioned, it's usually already been given to the patient stated in the vignette, for massive emergency transfusions. It's never really an anwer to choose.

Given that, you need to keep in the back of your mind that EDTA, a calcium chelator, can have adverse effects on the patient, so a quesiton is usually related to that.

Bryan