What is the likely cause of bleeding from multiple sites, including nasogastric tube (NGT), surgical incision, and intravenous (IV) cannula site, in a patient who received 15 units of blood in the intensive care unit (ICU)?

Bleeding from Multiple Sites in an ICU Patient After Massive Transfusion

Thrombocytopenia is the most likely cause of bleeding from multiple sites (NGT, incision, and cannula site) in a patient who received 15 units of blood in the ICU.

Pathophysiology of Bleeding After Massive Transfusion

Massive transfusion (defined as transfusion of ≥10 units of blood within 24 hours) commonly leads to coagulation abnormalities, with thrombocytopenia being a primary concern for the following reasons:

• Dilutional thrombocytopenia: When large volumes of blood products lacking platelets are transfused, the patient's platelets become diluted 1
• Consumption of platelets: During massive hemorrhage, platelets are consumed in the formation of clots 1
• Storage-related platelet dysfunction: Even when platelet counts appear adequate, stored blood products may cause functional platelet defects 1

Evidence Supporting Thrombocytopenia as the Diagnosis

The European guideline on management of bleeding following major trauma states that platelet counts can decrease critically during massive blood loss replacement 1. The clinical presentation of bleeding from multiple sites (NGT, surgical incision, and IV cannula site) is characteristic of thrombocytopenia, particularly when platelet counts fall below 50 × 10^9/L 2.

The Association of Anaesthetists of Great Britain and Ireland recommends maintaining platelet counts at a minimum of 75 × 10^9/L in the context of massive hemorrhage 1. This is higher than the typical threshold for spontaneous bleeding (10-20 × 10^9/L) because surgical patients have additional risk factors for bleeding.

Why Other Options Are Less Likely

1. Transfusion reaction (Option A): While transfusion reactions can occur, they typically present with fever, urticaria, hypotension, or respiratory distress rather than diffuse bleeding from multiple sites 3.

2. Hypocalcemia (Option C): Although hypocalcemia can occur during massive transfusion due to citrate in stored blood products, it typically causes cardiac arrhythmias and neuromuscular symptoms rather than bleeding 1.

3. Von Willebrand disease (Option D): This is an inherited bleeding disorder that would be known from the patient's history and would not suddenly manifest after transfusion unless there was a pre-existing condition 1.

Management Approach

1. Immediate assessment:

   • Check platelet count (target >75 × 10^9/L for patients with active bleeding) 1
   • Assess coagulation parameters (PT/INR, aPTT, fibrinogen)
   • Monitor for signs of ongoing bleeding

2. Platelet transfusion:

   • For active bleeding with suspected thrombocytopenia, administer platelet transfusion immediately 1
   • A pool of 4-8 platelet concentrates or a single-donor apheresis unit is usually sufficient 1

3. Additional blood component therapy:

   • Fresh frozen plasma (FFP): At least 30 mL/kg if coagulation tests are abnormal 1
   • Fibrinogen concentrate or cryoprecipitate: If fibrinogen <1.5-2.0 g/L 1

4. Monitoring response:

   • Reassess platelet count after transfusion
   • Monitor clinical bleeding
   • Repeat coagulation tests as needed

Prevention of Future Episodes

To prevent recurrence in patients requiring ongoing transfusion:

• Consider earlier platelet transfusion during massive transfusion protocols
• Implement a balanced transfusion approach (1:1:1 ratio of RBCs:FFP:platelets) for trauma patients with massive bleeding 1
• Monitor platelet counts regularly during ongoing transfusion

Common Pitfalls to Avoid

1. Delayed recognition: Failing to recognize thrombocytopenia early can lead to worsening bleeding
2. Inadequate replacement: Providing insufficient platelets to correct the deficiency
3. Overlooking other causes: Not checking for concurrent coagulopathy, hyperfibrinolysis, or surgical bleeding
4. Inappropriate transfusion thresholds: Using the same platelet transfusion threshold for all clinical scenarios rather than adjusting based on bleeding risk

In conclusion, the clinical picture of bleeding from multiple sites after receiving 15 units of blood is most consistent with thrombocytopenia, which requires prompt platelet transfusion and comprehensive management of coagulation status.