38 year old presents for pubovaginal sling at our ASC. Unremarkable history except for arthritic neck (C1-3), which was cleared (with no risk for surgery) by ortho-spine. No allergies. No pre-admission blood work.

Case booked for 3.5 hours. Took about five hours. Blood loss began dripping much faster than anticipated at about the 3 hour mark. 700 ml reached rather quickly. Surgeon says "I think you're gonna need blood".

It takes an hour or so to get blood to the surgery center once T&C gets to them.

This wasn't gonna do.

Put in a second line, sent the T&C and rec for two units PRBCs, opened up the third liter of IVF, gave 5% Albumin and started a neo gtt.

Pressures were quickly (but only for short time) in the 40s systolic. After about five minutes, systolic was never below 80. Vascular paged/called stat to ASC from main. Got there in about 10-15 minutes. Bleeding controlled (blood loss now at about 1300 ml). Sats never an issue, mild tachycardia during event.

iStat sent before transfusion, which showed H&H of 10.2/30. Gave one unit, and another half liter LR (total IVF 3400 ml and 250 ml 5% albumin).

Get to PACU, and decide to get another H&H before giving second PRBC, which came back at 10/31. Decided to hold second PRBC, sent it back to main campus, and admit patient to ASC overnight ward.

Last check around 1730 was an H&H of 9/28.

Just got an update around 2200 that patient was being transferred to main campus. Not sure why, but presuming continued fall in blood count.

Question is, is would y'all have transferred to main from the get go? Granted, our overnight staff is less than desirable. And to them, anyone with a systolic pressure above 150 is thought of as critical.

Also, would you have transfused second unit PRBCs in an otherwise "stable"-appearing clinical picture?

Just looking for consensus thought here.