Background:
The incidence of Multiple Myeloma (MM) is about 15% of all hematologic malignancies (1). There are several difficulties during surgery including malignant hematological disorders and thrombosis. As immunomodulation may occur with allogeneic transfusion the use of cellsaver is a source of major controversy.
Case report: A 69 year old male patient had been diagnosed with MM 1 year ago and received chemo-radiotherapy as primary radical treatment. The patient had a history of hypertension, inguinal hernia repair and vertebroplasty. The patient's functional capacity was poor (4 MET) with stable angina pectoris. The electrocardiogram showed ST-segment depression in leads D2, D3, and AVF. He had normal global left ventricular function with an EF of 57%. He had also an ascending aortic aneurysm measuring 4.8 cm. In myocardial perfusion SPECT there was a mild perfusion defect in the inferolateral wall. The left anterior descending coronary artery (LAD) had a 30% stenosis in the mid portion. His Htc level was 29.6%, Hg was 11.2 g/dL and  Platelet count was 76000/mL. Thrombocytopenia occured due to bone marrow infiltration in preoperative period. He had a vertebral compression fracture because of the MM mass at the level of thoracic spine T2-T3. He had posterior laminectomy and instrumentation T1-T10. His all hemodynamic variables were stable during the surgical procedure. Isolyte S was administered at 6 mL/kg/h iv for the fluid maintenance. 1 g tranexamic acid was administered by slow iv injection and then iv infusion was started with a dose of 1 mg/kg/h. When the bleeding amount reached to 1800 cc 2 packed RBCs and 1000 cc gelatin were given. Then the Htc was 23.8%, Platelet was 60000/mL, fibrinogen was 122 mg/dL and INR was 1.65. The thromboelastogram analysis showed a high R (10.4 min) and K levels (3.7 min) with a normal angle degree and MA (58.5 min). At the end of surgery the duration was 8 hours, total bleeding reached to 6 L. We transfused 10U of RBCs, 8P of FFPs and 2 apheresis of platelet. Final Htc was 26.5%, PT:14.7 s, PTT:39.7 s, INR:1.24, Platelet:90000/mL, fibrinogen:164 mg/dL and CVP:5 in supine position.
Discussion: Preoperative thrombocytopenia was one the main factors that could increase bleeding. We administered tranexamic acid at the beginning of the surgery to reduce heavy bleeding. Therefore we restricted the loss of coagulation factors. We couldn’t avoid massive transfusion however disseminated intravascular coagulopathy didn’t occur. 
In the reported case we have demonstrated that optimizing coagulation through goal directed use of blood products can reduce bleeding and using unnecessary blood products.

References:
1. Leebeek FW. Update of thrombosis in multiple myeloma. Thromb Res 2016;140 Suppl 1:S76-80. 



05 / How I couldn’t avoid intraoperative massive transfusion in a patient with Multiple Myeloma?