Paediatric Posting (phase IIIb)

Blood Transfusion Report

Name
: WONG YOKE FUI
Matrix card no : MEM000137
NRIC
: 790630-14-5650
Group
:5
Date
: 7 1- 2005
PATIENTS PROFILE
Name of patient
Age
Sex
Ethnic
R/N
Date of admission

:
:
:
:
:
:

Foong Joe Wai

10 months old
Male
Chinese
1881071-3
15th January 2005

PATIENTS HISTORY
Presenting Complaint
Patient presented with yellowish discoloration of the sclerae for the past 1 week prior to
admission.
History of Presenting Complaint
Parents claimed that they noted yellowish of the sclerae about 1 week ago. Progressive
abdominal distension noted. Loss of appetite noted with reduced feeding from about 3.4oz to 1.0oz with 3
to 4 hourly. Patient looks lethargic. Loose yellow stools several times a day noted. No fever, no vomiting
and urine output is normal in respect of frequency and color. No rashes noted.
Joe Wai was borned prematurely with 36 weeks of gestation. Birth weight is 1.49kg. He is noted
to be a low birth weight baby. He had been admitted to Subang Jaya Medical Centre (SJMC) for 1 month,
but no ventilation done on him. He did not present with jaundice while in the hospital. He was discharged
well with the weight of 1.8kg. Readmission to SJMC for 4 times with the chief complained of respiratory
distress. Currently, he is referred from SJMC and this is the 6 th admission of patient to hospital. Enquiry
about other systems noted unremarkable.
Paediatric history
Birth was done with emergency lower segment Caesarian Section, because maternal pregnancy
induced hypertension. Still on bottle feeding, not yet weaning. Immunisation is up to date. Developmental
milestone is reduced for gross motor because of weakness noted secondary to frequent medical
problems.

Past Medical And Surgical History

As mentioned above.
Drug History
Currently, he did not take any medications. No traditional medications taken. There was no
known allergy to any drugs or food.
Family History
He has an elder sister at the age of 3 years old. She is healthy without any medical or surgical
problems. Parents and other family members were healthy without any congenital problems.

PHYSICAL EXAMINATION
Vital signs
Respiratory rate : 30 breaths per minute
Pulse rate
: 100 beats per minute, regular rhythm, good volume
Blood pressure : 100/60 mmHg
Temperature
: 37.0C
Weight
: 5.76kg
General inspection
He appeared thin and wasted. Active and alert, no dysmorphic features noted. Jaundice noted at
the sclerae, pallor conjunctivae and pedal oedema noted, no cyanosis and no clubbing. No bruises, no
petechiae and no abnormal movement or posture.
Gastrointestinal tract examination
Inspection: Abdomen was distended with dilated vein at the upper abdomen.
Palpation: Hepatosplenomegaly noted. No ballotable kidneys. No enlargement of lymph nodes especially
inguinal, para-aortic and Virchows nodes noted.
Percussion: Tense ascites noted.
Auscultation: Bowel sounds were normal with no increase in intensity.
Examination on the other systems
Examination of the respiratory system noted mildly tachypnaenic, Harrisons sulcus, breath sounds equal
and vesicular in nature. Cardiovascular and neurological system revealed no significant findings.

Differential Diagnosis :
1. Inborn error of metabolism
2. Storage disease
3. Portal hypertension

INVESTIGATIONS
1)

Full Blood Count

Complete Blood Count
HB
HCT
RBC
MCV
MCH
MCHC
RDW
WBC
Platelet
Differential Count
% Neutrophil
% Lymphocyte
% Monocyte

15/1/05
7.59
0.22
4.00
55
18.6
339
24.6
31.2
clumping
56
30
11

Comments :
On the day of admission (15/1/05), the full blood count result noted Joe Wai has hypochromic
microcytic anaemia. Patient has a low haemoglobin level with 7.59g/dL. This level was low compared to
normal value that is 10.0-12.5g/dL for infant age 6 months to 1 year. Full blood count also showed that he
has low haemotocrit. The hypochromic microcytic anaemia may due to iron deficiency, any chronic
diseases, any malignancies or chronic blood loss. A raised in the white blood cells might be secondary to
infection or inflammatory process.
Peripheral blood film showed hypochromic, microcytic, anisocytosis with few polychromatic cells
and basophilic stippling.
With this result of full blood count and peripheral blood film, doctor decided to transfuse packed
cells for him.
2)
Investigation of blood noted Joe Wai has conjugated hyperbilirubinaemia and markedly raised liver
enzymes. Ultrasound and CT scan of the abdomen came to an impression of hepatomegaly suggest
either regenerating nodules or malignancy. Serum result showed normal level of lactate and high level of
ammonia. Low level of serum IgG and IgA also noted. Urine aminoacids, organic acid and succinyl
acetate and serum aminoacids levels are pending. Biopsy liver is indicated after the remission of ascites.

PROGRESSION
After the admission to UMMC, Joe Wai is managed conservatively and investigations done for the
underlying etiology of jaundice, hepatomegaly, anaemia and failure to thrive. After the transfusion of
packed cells, patient general condition did improved. After the serial result of investigations, the
differential diagnoses are inborn error of metabolism, storage disease and hepatoblastoma. The
provisional diagnosis, can only be confirmed with the result of urine aminoacids, organic acid and succinyl
ammonia and liver biopsy.

BLOOD TRANSFUSION
Indications for blood transfusion need to be established before any infusion of blood. For Joe Wai,
the indication is that he has a low haemoglobin level with less than 8.0g/dL. He was given packed cell
transfusion, which contains red cells with minimal white blood cells or plasma. Whole blood transfusion is
not given because the overall aim is to give red blood cells to improve the oxygen carrying capacity
without overloading the intravascular volume. Besides, leucocyte contained inside the packed cell blood
should be filtered to reduce to allo-immunization and febrile transfusion reactions.
Determining the blood group, rhesus status, antibody screening and cross match is
important before blood transfusion in order to prevent the potential adverse reaction. Urine output and
vital signs e.g. blood pressure, heart rate, temperature were monitored hourly. The possible side effects
should be monitor regularly throughout the transfusion process, especially the vital signs, and other
clinical signs e.g. urticaria, cyanosis, dyspnoea, shivering, basal crepitations, raised JVP etc.

Possible Adverse Effects Associated With Transfusion

1. Immediate reaction is the most serious complication of blood transfusion and is usually due to
ABO incompatibility. Complement activation by the antigen-antibody reaction, leads to rigors,
lumbar pain, dyspnoea, hypotension, haemoglobinuria and renal failure. The initial symptoms
may occur a few minutes after starting the transfusion.
2. Non-haemolytic (febrile) transfusion reactions
3. Urticaria and anaphylaxis
4. Long-term adverse effects as a consequence of alloimmunisation e.g. delayed reaction, rejection
of tissue transplant.
5. Transmission of infection e.g. hepatitis, HIV, CMV, EBV etc.