Case 2

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CC: แพทย'น�ดมิา F&C เน)"องจ้ากตรัวจ้พบเซลำลำ'มิดลำ�กผู้ดป่กต 2เด)อน PTA

PI: U/D rheumatic heart disease s/p AVR,MVR (prosthetic valve) 10 yr on warfarin 16.5 mg/wk, last f/u ธั�นวาคู่มิ 52 INR 3.0, FC I

Present illness

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ฮอรั'โมิน ป่รัะจ้�าเด)อนมิาเป่3นรัอบ แต�ออกมิากแลำะนาน จ้4งหย$ดกน

1 ป่� เว�ยนศี�รัษะบ�อย ต�องให�เลำ)อด6 เด)อน ส่�งป่รั4กษาแผู้นกนรั�เวชี PAP

smear: atypical cell

TVS : normal

น�ดมิา admit workup plan F&C

Past history

Hb E trait Iron deficiency anemia

Baseline Hb 8-10 g/dl,

HCT 27-32,MCV 68,RDW 18.6

Current medication

furosemide (40) 1 tab o pc

digoxin(0.25)1/2 tab o pc

warfarin(3)1 tab ส่ลำ�บ 11/2 tab

24/11/52(~ 1mo PTA)

Consult med preop evaluation for F&C

Intermediate risk surgery

no active clinical risk predictors

FC >4 METs

Advice

off warfarin ก�อน OR 5-7 days

admit for bridging heparin ชี�วงท�"หย$ด warfarin

notify med at ward

CBC

Hb 10.3

HCT 32.7

MCV 68

MCH 21.4

MCHC

RDW 18.6

WBC 8420

N% 72

L% 16

Plt 319,000

BUN 9Cr 0.53

PT

PTT

INR

EKG

CXR

13/1/53

No bleeding Plan TAH

พรุ่��งนี้�� Consult med

ยั�งไม่�ต้�องให้� heparin

PTPTT INR

Admit 7/1/53 consult med Set OR for conization,F&C 12/1/53

8/1/53

Off warfarin

Unfractionated

heparin

12/1/53

Off heparin before

operation 6 hr

PT14,INR1.2,PTT30

F&C with conization

No complication Blood loss 20 cc

16/1/53

Notify med Plan INR

next 3 day keep 2.5-

3.5

14/1/53

TAHOp time 90 min

Blood loss 600 cc

( or 100 ml ?)

I/

O2000/700

15/1/53

No bleeding per vagina

Start heparin 12.00Start

warfarin 17.00

I/O1600/3200

15/1

16/1

17/1

18/1

19/1

PTT

19/1/530.00

Notify med ห้ลั�งให้�NSS 1000 ml

ห้ายัใจห้อบเห้นี้��อยั HCT 31-- >24

ให้� PRC 1u,FFP 2 u

18/1/5323.00

เวี�ยันี้ศี�รุ่ษะ ห้นี้�าม่�ด ไม่�ปวีดท้�อง เลั�อดออกจาก

ช่�องคลัอดเลั$กนี้�อยั ป%สสาวีะออกด�

BP 80/50 PR 88 full RR 20

Heart &lung clearAbd mild distension

No bleeding per vagina

HCT stat 31% Rx load NSS 1000 mlDopamine2:1 iv 10ud/minU/S abdomen no free fluid

19/1/53 00.30

Lungs: fine crepitation both

O2 sat 80

IMP: 1 shock -- > cardiogenic

hypovolemia

plan treat CHF ก�อนแลำ�วคู่�อย correct anemia

2 acute anemia

from hematoma at abdominal wall+/-intraabdominal bleeding

risk: prolonged PTT

Lab 18/1/53 23.30

CBC Hb 7.8 HCT 24.3 PLT 225,000

PT 26.7,INR2.4,PTT75

Management

01.30 น.

Vit K 2 mg oral

Protamine sulfate 12 mg iv

On ETT

Hold PRC

lasix 40 mg iv stat

Off dopamine เดมิ, dopamine (4:1) 15 μd/min

Morphine 2 mg iv stat

BP maintainได�

19/1/53

03.00

BP 85/37 , PR 110/min

HCT 29%

Dobutamine(4:1)

5-- >10-- >15 ml/hr

Urine ออกน�อย -- > lasix 160 mg iv at 4.40

-- >urine 100 ml/hr

8.40

Renotify medBP 100/50,HR 130 AF c RVRTape off dopamine, dobutamine

6.30

CBC Hb 8.5,HCT 26.5INR 1.8,PT19.8, PTT31.9

19/1/53

10.00

BP 92/46 , PR 124/min

Start levophed (1:10) 5 ml/hr

13.00

Consult cardio

19/1/53

16.35

BP 87/43

PR 146/min irregular

17.05

AF 160-180Cardioversion CordaroneEchocardiogram -- > AV regurgitation suspected valve dysfunction ย�าย CCU 19.50

Echocardiogram

LVEF 70%, severe AR,severe AS

aortic peak gradient 98.3mm Hg

peak mitral valve gradient 20.64

Fluoroscope

aortic closed angle 37.3o ,opened 72.9

mitral closed angle 22o ,opened 83.1

Imp: aortic prosthetic valve thrombosis

Consult CVT

Streptokinase

20/1/53 bradycardia then asystole

CPR not success--- > death

How to manage pt with mechanical valve

prosthesis who have major bleeding

Pt who received heparin

in emergency situation

Should we reverse heparin effect by protamine sulfate?

Bridging Therapy in Patients With Mechanical Valves Who Require Interruption of Warfarin Therapy for Noncardiac Surgery, Invasive Procedures, or Dental Care

Class I

1. In patients at low risk of thrombosis, defined as those with a bileaflet mechanical AVR with no risk factors,* it is recommended that warfarin be stopped 48 to 72 h before the procedure (so the INR falls to less than 1.5) and restarted within 24 h after the procedure. Heparin is usually unnecessary. (Level of Evidence: B)

ACC/AHA Practice Guidelines

Class I

2. In patients at high risk of thrombosis, defined as those with any mechanical MV replacement or a mechanical AVR with any risk factor, therapeutic doses of intravenous UFH should be started when the INR falls below 2.0 (typically 48 h before surgery), stopped 4 to 6 h before the procedure, restarted as early after surgery as bleeding stability allows, and continued until the INR is again therapeutic with warfarin therapy. (Level of Evidence: B)

Class IIa

It is reasonable to give fresh frozen plasma to patients with mechanical valves who require interruption of warfarin therapy for emergency noncardiac surgery, invasive procedures, or dental care.

Fresh frozen plasma is preferable to high-dose vitamin K1.

(Level of Evidence: B)

Class IIb

In patients at high risk of thrombosis ,therapeutic doses of subcutaneous UFH (15 000 U every 12 h) or LMWH (100 U per kg every 12 h) may be considered during the period of a subtherapeutic INR. (Level of Evidence: B)

Class III

In patients with mechanical valves who require interruption of warfarin therapy for noncardiac surgery, invasive procedures, or dental care, high-dose vitamin K1 should not be given routinely, because this may create a hypercoagulable condition. (Level of Evidence: B)

*Risk factors: atrial fibrillation, previous thromboembolism,LV dysfunction, hypercoagulable conditions, older-generation thrombogenic valves, mechanical tricuspid valves, or more than 1 mechanical valve.