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A 74-year-old man with severe chronic obstructive pulmonary disease, type 2 diabetes mellitus, and chronic kidney disease presents to the emergency department (ED) 36 hours after developing sudden-onset right upper quadrant abdominal pain, radiating to the back, after eating his favorite meal of fried chicken. Since then the pain has persisted and has been accompanied by vomiting, fever to 38.9°C (102°F), and mild yellowing of his eyes. His family calls 911 after noticing that he is confused. On arrival at the ED his temperature is 39.4°C (103°F), pulse is 115/min, blood pressure is 88/40 mm Hg, respiratory rate is 32/min, and oxygen saturation is 96% on room air. ECG reveals sinus tachycardia with no diagnostic abnormality. Physical examination is notable for a remarkably ill-appearing man in acute distress with diffuse abdominal tenderness that localizes to the epigastrium and right upper quadrant. Despite multiple fluid boluses, the patient remains hypotensive, and norepinephrine is started while laboratory tests are still pending because of technical issues. The patient is referred for emergent endoscopic retrograde cholangiopancreatography (ERCP) on the basis of imaging consistent with gallstone pancreatitis. The patient has bleeding from all of his venous access sites when laboratory tests finally return and show profound leukocytosis, anemia, and thrombocytopenia. Coagulation studies and a peripheral smear sent stat are still pending but a fibrinogen level returns at 87 mg/dL. Liver function studies are remarkable for transaminitis and elevated indirect and direct bilirubinemia.
In addition to receiving broad-spectrum antibiotics and continuing aggressive volume resuscitation, the patient should receive what additional therapy?
A.Cryoprecipitate
B.Cryosupernatant
C.Fresh frozen plasma
D.Plasma exchange
E.Platelet transfusion
F.Platelet-poor plasma
G.RBC transfusion
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Posts: 3,675,937
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Posts: 3,675,937
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Posts: 3,675,937
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Posts: 3,675,937
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Posts: 3,675,937
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The correct answer is D. 43% chose this.
The patient has end-stage renal disease with profound uremia as suggested by his symptoms including confusion, suppressed appetite, pruritus, and platelet dysfunction, accounting for his epistaxis, not to mention serologic evidence of a substantially elevated creatinine level, electrolyte dyscrasias, and hypocarbia. Uremic bleeding is due to a multifactorial process that includes decreased platelet adhesion, defective binding of von Willebrand factor (vWF) to platelet glycoproteins, and decreased platelet release of procoagulant granules. The long-term control of uremic bleeding is by adequate hemodialysis to remove the as-yet-unidentified molecules that inhibit platelet function.
A is not correct. 6% chose this.
Cryoprecipitate is enriched in factor VIII and fibrinogen. As the patient has normal coagulation studies, it is unlikely that his fibrinogen level would be decreased in such a way as to induce spontaneous bleeding. Bleeding secondary to a low platelet count is characterized by petechiae, epistaxis, and gum bleeding, whereas bleeding secondary to low factor levels is typically characterized by hemarthroses and ecchymoses.
B is not correct. 22% chose this.
Short-term control of the bleeding as a consequence of coagulopathy can be obtained with desmopressin (DDAVP) as often used in patients with hemophilia. It acts by increasing release of vWF from endothelial cells, thereby partially correcting one aspect of the abnormal clotting. However, DDAVP offers only temporary correction of the abnormality, as the endothelial cell stimulation has a limit. Tachyphylaxis can occur with prolonged use of DDAVP.
C is not correct. 26% chose this.
This patient has uremic bleeding resulting in platelet dysfunction, which results in excessive bleeding and typically presents with superficial and mucosal bleeding. Although factor replacement may be tempting given a clinical history suggesting poor nutrition implying vitamin K deficiency, he has essentially normal coagulation study results.
E is not correct. 3% chose this.
Uremic bleeding results in extensive platelet dysfunction as mentioned previously. Thus, the introduction of additional platelets would yield little efficacy with hemostasis and is not indicated given a normal platelet count.
Bottom Line:
Uremic bleeding is due largely to as-yet-unknown toxins that inhibit platelet function. In the short term DDAVP can be helpful in controlling bleeding by its effects on vWF release, but ultimately initiating and maintaining adequate dialysis is the most durable therapy to control bleeding.
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answer is A...
sorry to put up wrong explanation
B is not correct. 2% chose this.
Cryosupernant is the plasma remaining after removal of the pelleted cryoprecipitate. This is a source of all coagulation and plasma proteins, except for factor VIII, fibrinogen, von Willebrand factor, and fibronectin. Cryosupernant is stable for 5 years if stored in a dedicated freezer at or below -20°C.
C is not correct. 46% chose this.
Although fresh frozen plasma would begin to replace the consumed clotting factors, it is a relatively poor source of fibrinogen, which would be the major factor being consumed. The presumably elevated PT and PTT would be corrected by the fresh frozen plasma, but the dropping fibrinogen level would require cryoprecipitate.
D is not correct. 10% chose this.
Plasma exchange would replace the consumed clotting factors and show a beneficial effect on PT and PTT. However, the added time and expense of plasma exchange are unlikely to be of efficacious as administering cryoprecipitate.
E is not correct. 6% chose this.
Platelet transfusions can be indicated in the supportive management of DIC; however, most clinically significant bleeding complications secondary to thrombocytopenia occur with much lower platelet counts (
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The correct answer is A. 30% chose this.
The patient is in septic shock as a result of acute cholangitis with a clinical scenario consistent with disseminated intravascular coagulation (DIC). While an elevated prothrombin time/partial thromboplastin time (PT/PTT) would have been helpful in establishing the diagnosis, his serologic results inclusive of anemia with indirect bilirubinemia suggesting hemolysis and thrombocytopenia in the setting of decreased fibrinogen are adequate in suggesting DIC. Additionally, another laboratory feature of DIC is elevated fibrin degradation products. The disorder is characterized by consumptive coagulopathy with microvascular fibrin strands that activate platelets and shear RBCs resulting in schistocytes on peripheral smear. The diffuse coagulopathy results in simultaneous microvascular thrombi and increased risk of spontaneous hemorrhage. The mainstay of treatment is correcting the underlying inflammatory disorder that drives the process and supportive therapy with appropriate clotting factors as needed. The falling fibrinogen level, or a level
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resi_hope
nice q's
but brings out a lot of gap in my knowledge
how many points to keep in mind while reading the q's... 
thanks for taking the time
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