Re: Episode 30

After posting our first case study episode, we realized that time constraints resulted in glossing over certain aspects of each scenario. One listener, in particular, reached out to us with legitimate questions regarding the first scenario. We wanted to take this opportunity to address those concerns formally via our blog.

James writes:

“Hello.  In regards to the first case presented here, two items that came up that I would like to ask a question to the group on.  Numerous items already going on with this patient.  To me, it sounded like a “hot” abdomen with a decent chance of emergent surgical event going on in addition to the hyperkalemia.  His INR is way up, and his platelets are low.  Does it make sense to ask the sending facility for Vitamin K or FFP in order to start reversing the abnormal INR/coagulation studies?  Second item that I want to mention was this is a hypotensive patient with a presumed source of infection in his abdomen.  No mention was made about initiating some type of antibiotic coverage.  “Lot of fish to fry in this case”, and may not have enough time in transit to accomplish this.  However, for those of us doing ground based transports, we “may” have enough time to consider/accomplish this?  Thoughts?  Any hints on recommended antibiotics for intra-abdominal infections?” 

At face value, it seems intuitive to administer FFP or Vitamin K. In reality, most surgeons would be hesitant to accept this type of patient to the OR while things are still “hot” with the exception of an obvious life or death situation. What about PCC’s? If you consider cost versus benefit, it would not be worth it in the absence of life-threatening hemorrhage. This is particularly true in the case of an INR that low. In regard to your question, Vitamin K takes approximately 12-24 hours to be effective. Additionally, FFP has an intrinsic INR of 1.5, so there isn’t a lot of ground to gain. I think it’s worthy of consideration, if the patient is being emergently transferred to the OR. I would only reverse them with an abundance of caution, though.

With respect to antibiotics, they are absolutely indicated. We mentioned sepsis being a part of the differential. Some may recommend antibiotigram, but it is only helpful if you are reasonably certain of the pathogen. In intra-abdominal infections, there are so many gram-negatives that could be growing, that it wouldn’t be helpful unless you had a culture. I would urge you to give something that has good gram-negative coverage as well as anaerobes. Zosyn, Cefepime or Meropenem are all appropriate choices. They cover just about everything with the exception of something like VRE. After resuscitation, antibiotics are probably the most important step.

Great questions. Keep them coming!

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