Life-threatening bleeding in patients anticoagulated with warfarin are rare but often requires rapid surgical interventions. Fresh frozen plasma (FFP) and vitamin K have been the standard treatment for warfarin reversal, but it carries risks. Guidelines now recommend the use of prothrombin complex concentrate (PCC) in life-threatening bleeding. However, PCC is expensive and not readily available within the Emergency Department (ED). We present a case whereby early use of PCC resulted in excellent outcomes.
A 52-year-old lady with atrial fibrillation, hypertension and ischemic heart disease presented to ED with sudden severe right abdominal pain. There was no significant prior history and denied any injuries. Examination revealed an obese lady who appeared pale and in severe pain. The blood pressure was 110/49, pulse rate of 76 and afebrile. The right hypochondrium was tender and there was a vague but large mass over the right upper quadrant. Bedside ultrasound showed multiple cysts over the right kidney a large hyperechoic mass and no intra-abdominal free fluid. A formal ultrasound confirmed the finding of a right renal mass with non-liquefied abscess and she was subsequently treated with intravenous antibiotics. However, her pain persisted and became more tachycardic. Her investigations revealed a significant drop of hemoglobin from 11 g/dl (taken one day prior at the primary care clinic) to 7.6 g/dl. Her INR was 2.9. An urgent CT revealed active arterial bleeding into a large cyst in the right kidney forming a huge complex intraparenchymal renal hematoma. As this was a life-threatening bleeding and required immediate intervention, PCC was administered. Her INR stabilized to 1.1 within 2 hours and successful angioembolization was performed thereafter.
This case illustrates that the early use of PCC results in rapid reversal of bleeding secondary to warfarin. Furthermore, bleeding should be suspected in all warfarinised patients irrespective of the INR levels.
prothrombin complex concentrate, bleeding renal cyst
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