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- Sep 22, 2004
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So I was on call Saturday night, it was crazy busy. When our second emergent AAA rolled in it came to me. Here's the skinny
83 M who presented to an outside facility with new onset of abdominal pain. Workup revealed a 5.3 cm dissecting infrarenal AAA, down to left iliac. Transferred to us for management. Significant PMHx significant for A-fib and porcine AVR. On warfarin. Labs when he hits our ED: INR 6.8 H&H 13/39. Gets FFP and vitamin K in the ED and show up with stable vitals, and our massive transfusion protocol activated. Second INR, a little over half an hour later. 2.0. So maybe the first one was spurious, we'll never know. We say hi, get quick history, and go to room. Surgeons scrub, prep, put up drapes, I tube, the second I say "In," they go. So, hcts constantly drifting, INR won't get below 1.9 despite despite, 9 more units of FFP, also 10 units PRBCs, 11 liters of of crystaloid, one unit of platelets and cryo. But he remains stable despite. After the second iliac is unclamped still stable, but INR stil 1.9, and oozing is significant. So, in our institution, he meets criteria for recombinant factor 7 (nonacidotic, failure of massive transfusion protocol, and fibrinogen >100). We give it. In less than a minute, clots start forming. The next INR, in the ICU 0.9. He was actually extubated the next day, but reintubated Monday night for respiratory failure.
After that I had an appy in a 25 year old guy.
83 M who presented to an outside facility with new onset of abdominal pain. Workup revealed a 5.3 cm dissecting infrarenal AAA, down to left iliac. Transferred to us for management. Significant PMHx significant for A-fib and porcine AVR. On warfarin. Labs when he hits our ED: INR 6.8 H&H 13/39. Gets FFP and vitamin K in the ED and show up with stable vitals, and our massive transfusion protocol activated. Second INR, a little over half an hour later. 2.0. So maybe the first one was spurious, we'll never know. We say hi, get quick history, and go to room. Surgeons scrub, prep, put up drapes, I tube, the second I say "In," they go. So, hcts constantly drifting, INR won't get below 1.9 despite despite, 9 more units of FFP, also 10 units PRBCs, 11 liters of of crystaloid, one unit of platelets and cryo. But he remains stable despite. After the second iliac is unclamped still stable, but INR stil 1.9, and oozing is significant. So, in our institution, he meets criteria for recombinant factor 7 (nonacidotic, failure of massive transfusion protocol, and fibrinogen >100). We give it. In less than a minute, clots start forming. The next INR, in the ICU 0.9. He was actually extubated the next day, but reintubated Monday night for respiratory failure.
After that I had an appy in a 25 year old guy.
