Having survived septic shock, ARDS, acute liver injury and ICU delirium, we are now asked to consider the management of acute bleeding and coagulopathy in an elderly man admitted to the ICU with severe sepsis.
A 77-year-old man whose medical history includes treated hypertension and hypercholesterolemia, previous heavy alcohol intake, and mild cognitive impairment is admitted to the ICU after a Hartmann’s procedure for fecal peritonitis due to a perforated sigmoid colon. He is ventilated and in septic shock. His blood pressure is supported with fluid resuscitation and a norepinephrine infusion. In addition to intravenous antibiotics, his treatment included subcutaneous unfractionated heparin (5000 U twice daily). On the day after admission to the ICU, his blood pressure is stable and supported by a reducing dose of norepinephrine. Analgesia is being provided by a continuous morphine infusion. However, despite adequate analgesia, he intermittently requires sedation in the form of low-dose propofol by infusion to tolerate the endotracheal tube (as reviewed in last months case).
The patient’s nurse notes slight bleeding from his abdominal wound and from around his arterial and central venous catheters.
Laboratory test results from that morning include normal liver-function tests, a hemoglobin level of 8.9 g per deciliter, a platelet count of 54,000 per cubic millimeter, an international normalized ratio of 1.6, an activated partial-thromboplastin time (APTT) of 52 seconds, and a fibrinogen level of 1.7 g per liter
How would you assess and manage his bleeding? Which of the following strategies would you use in this patient?
1. Cease heparin and transfuse packed red cells, platelets, cryoprecipitate, and fresh-frozen plasma or prothrombin complex concentrate.
2. Cease heparin and transfuse cryoprecipitate and fresh-frozen plasma or prothrombin complex concentrate.
3. Cease heparin, transfuse platelets, administer an antifibrinolytic agent (e.g., epsilon-aminocaproic acid or tranexamic acid).
4. Cease heparin and repeat laboratory tests in 8 to 12 hours.
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