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An important factor in preoperative screening
Author(s) -
Olson Andrew P.J.,
Fogarty Patrick F.,
Dhaliwal Gurpreet
Publication year - 2010
Publication title -
journal of hospital medicine
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.128
H-Index - 65
eISSN - 1553-5606
pISSN - 1553-5592
DOI - 10.1002/jhm.595
Subject(s) - medicine , veterans affairs , university hospital , medical laboratory , family medicine , general hospital , gerontology , library science , pathology , computer science
A previously healthy 25-year-old Guatemalan man presented to the emergency department with 1 day of fever, nausea, vomiting, and right lower quadrant abdominal pain. A computed tomography (CT) scan revealed acute appendicitis. The patient underwent an uncomplicated laparoscopic appendectomy and was discharged in stable condition after 48 hours. Five days after the operation he returned to the emergency department with abdominal pain, nausea, vomiting, and lightheadedness. He was tachycardic, and his hemoglobin was 9.5 g/dL (normal, 13.3-17.7 g/dL), decreased from 14.4 g/dL prior to his appendectomy. A CT scan showed intraperitoneal blood with active extravasation of contrast at the site of the appendectomy. Additional laboratory testing revealed an activated partial thromboplastin time (aPTT) of 52 seconds (normal, <37 seconds) and protime (also prothrombin time [PT]) of 14 seconds (normal, <14.1 seconds). The platelet count was 449,000/lL (normal, 150-400,000/lL) and the fibrinogen level was 337 mg/dL (normal, 170-440 mg/dL). Crystalloid and packed red blood cells were administered. Since further laboratory evaluation of the prolonged aPTT was not immediately available, the patient was empirically treated with fresh frozen plasma (FFP), cryoprecipitate, and Factor VIII/ von Willebrand factor concentrate. At laparotomy, bleeding was observed at the previous operative site, and 2 L of intraperitoneal blood was evacuated. The next morning, Factor VIII and Factor IX (FIX) activities and the ristocetin cofactor study performed on specimens obtained immediately prior to the second operation were normal, but the FIX activity was 5% of normal. The diagnosis of FXI deficiency was made and 2 to 3 units of FFP (the amount necessary to maintain the patient’s measured FXI activity near 20% of normal) were transfused daily. Nine days of FFP infusions were required to achieve complete wound hemostasis. The patient had no further bleeding episodes after discharge. Upon further interviewing, the patient revealed that 2 months prior he sustained a small laceration on his arm that ‘‘bled for a long time’’ and that his brother had experienced prolonged bleeding after a dental extraction.