Mt Sinai Medical Center, Chicago, IL, USA.
Am J Ther. 2012 Nov;19(6):e182-5. doi: 10.1097/MJT.0b013e3182459a79.
Patient presented with passage of fresh blood mixed with clots per rectum. In the ER, she was found to have bright red blood per rectum with clots, with frank blood on nasogastric tube. She was on dabigatran for atrial fibrillation and aspirin, with intermittent intake of ibuprofen. Vitals were positive for orthostatic hypotension. The pertinent findings in the physical examination were altered mental status with orientation*1, weak peripheral pulses, irregularly irregular heart rate, and bilateral pitting edema 2+ in bilateral lower extremities. Patient was intubated and put on mechanical ventilation. A massive transfusion protocol was followed. Laboratories and imaging: hemoglobin/hematocrit, 7.2/22.1; white blood cells, 7.7, platelet, 210; international normalized ratio, 2.5; prothrombin time, 19.2; activated partial thromboplastin time, 88.2; CMP was WNL; BNP, 621; fibrinogen, 500 mg/dL. Electrocardiogram showed atrial fibrillation with inferolateral ischemia. Ultrasonography of the liver and gallbladder showed no acute pathology. Echocardiogram showed an EF of 70% with hyperdynamic LV. Patient was transferred to the intensive care unit. Dabigatran, aspirin, and nonsteroidal anti-inflammatory drugs were discontinued, and antihypertensives were held. She was given blood and FFPs. Hemoglobin, hematocrit, and coagulation profile was monitored every 6 hours. Gastroenterology, general surgery, interventional radiology, and hematology services were called stat. IR placed a double-lumen, power central venous catheter. In gastroenterology, EGD and colonoscopy was performed, which showed active bleed at distal esophagus, stopped with local epinephrine. No active bleed seen on colonoscopy. The patient was put on Nexium drip. Hematology service recommended thrombin time (>200) and factors 2, 5, 7, 9, 10-41(l), 80, 68, 48(l), 61. Prothrombin time and activated partial thromboplastin time mixing studies were done, which indicated the presence of thrombin inhibition. Prothrombin complex concentrate at 50 U/kg was started to reverse the effect of dabigatran, and platelets were transfused to reverse the effect of aspirin. They also discussed that the half-life of dabigatran being 17 hours, and the drug would not be toxic at this point, as the patient was already 24-hour inpatient by now. The hemoglobin trend: 7.4→6.4→8.2→7.5→6.6. At this point, the need for further intervention in form of hemodialysis or plasmapheresis was considered. The patient was given plasmapheresis and hemoglobin and hematocrit stabilized. The patient was kept on continued mechanical ventilator support for the night and extubated next day. The hemodynamics stabilized and the patient was transferred to the general medical floors after 1 day of observation, after extubation.
患者出现新鲜血液与血块混合经直肠排出。在急诊室，发现患者有新鲜血液与血块经直肠排出，鼻胃管中有鲜血。她因心房颤动服用达比加群和阿司匹林，并间歇性服用布洛芬。生命体征表现为直立性低血压。体格检查的相关发现为神志改变伴定向力障碍*1、外周脉搏微弱、心率不规则不齐、双侧下肢双侧凹陷性水肿 2+。患者行气管插管并接受机械通气。随后遵循大出血方案进行治疗。实验室和影像学检查结果：血红蛋白/血细胞比容，7.2/22.1；白细胞，7.7，血小板，210；国际标准化比值，2.5；凝血酶原时间，19.2；活化部分凝血活酶时间，88.2；CMP 在正常范围内；BNP，621；纤维蛋白原，500mg/dL。心电图显示心房颤动伴下外侧壁缺血。肝胆超声未见急性病变。超声心动图显示 EF 为 70%，左心室高动力。患者转入重症监护病房。停用达比加群、阿司匹林和非甾体抗炎药，并停止使用降压药。给予输血和新鲜冰冻血浆。每 6 小时监测血红蛋白、血细胞比容和凝血谱。胃肠病学、普通外科、介入放射科和血液科均被召集。介入放射科放置了双腔、动力中央静脉导管。在胃肠病学中，进行了内镜检查和结肠镜检查，显示远端食管有活动性出血，局部给予肾上腺素后停止出血。结肠镜检查未见活动性出血。患者开始接受 Nexium 滴注。血液科建议进行凝血酶时间 (>200) 和因子 2、5、7、9、10-41(l)、80、68、48(l)、61 检测。进行凝血酶原时间和活化部分凝血活酶时间混合研究，表明存在凝血酶抑制。给予 50U/kg 的凝血酶原复合物浓缩物以逆转达比加群的作用，并输注血小板以逆转阿司匹林的作用。他们还讨论了达比加群的半衰期为 17 小时，并且由于患者现在已经是 24 小时住院患者，因此此时药物不会有毒性。血红蛋白趋势：7.4→6.4→8.2→7.5→6.6。此时，考虑进一步进行血液透析或血浆置换等干预。给予患者血浆置换，血红蛋白和血细胞比容稳定。患者在夜间继续接受持续机械通气支持，并于次日拔管。血流动力学稳定，患者在拔管后观察 1 天后转入普通内科病房。
