Commentary

Think before reversing anticoagulants


 

Medicolegal review has the opportunity to become the morbidity and mortality conference of the modern era. Each month, this column presents a case vignette that explores some aspect of medicine and the applicable standard of care. I hope to bring a critical emphasis on how physicians think and make decisions, with the ultimate goal of highlighting the lesson to be learned by all.

The more we share in our collective failures, the less likely we are to repeat those same mistakes.

Mr. B was a 76-year-old man with a 2- to 3-year history of umbilical hernia. He presented to the emergency department at 10 p.m. on a Sunday night with periumbilical abdominal pain. The pain began the prior evening when he was lifting something heavy. The pain was rated at a 5/10 intensity and had been fairly constant ever since. There was some nausea with emesis. Mr. B denied bowel motions for the past 2 days.

Mr. B had a past medical history significant for hypertension, hyperlipidemia, asthma, and chronic atrial fibrillation. His medications included simvastatin, Coumadin, verapamil, and as needed albuterol.

On examination, Mr. B had normal vital signs but he looked uncomfortable. He had an umbilical hernia that was red and tender. A complete blood count was normal. A complete metabolic profile was normal except for a potassium of 3.3 mEq/dL. An acute abdominal series was normal.

Mr. B was treated with an intravenous opiate and reported feeling a little better, but he was still having pain. The emergency department physician handed off Mr. B to Dr. Weekend-Nocturnist with a diagnosis of "incarcerated hernia." Dr. Weekend-Nocturnist admitted Mr. B to telemetry and initiated IV fluids, potassium replacement, and IV analgesia. An amylase/lipase, coagulation studies, and a CT of the abdomen and pelvis were included in the admission orders. At 3 a.m., the amylase/lipase were reported as normal and the INR was 1.97. The CT was complete shortly thereafter, and the result is transcribed:

"Impression: small bowel obstruction of the ileum due to an anterior wall hernia; there is distal small bowel decompression. Luminal contrast is only seen within the proximal small bowel. There is no evidence of bowel incarceration, abscess, perforation, or fluid collection."

At 7 a.m., Dr. Weekend-Nocturnist transferred care of Mr. B to Dr. Daytime-Hospitalist. At 9:30 on Monday morning, Dr. Daytime-Hospitalist saw Mr. B on rounds. Mr. B complained of some nausea, but his vital signs remained normal. The abdominal exam confirmed an 8-cm, tender, nonreducible umbilical mass. Dr. Daytime-Hospitalist ordered a routine surgical consult, along with 5 mg of subcutaneous vitamin K, 4 units of fresh frozen plasma, and an unfractionated heparin drip according to a weight-based dosing nomogram. Dr. Daytime-Hospitalist documented informed consent for blood products as "risks, benefits, and alternatives discussed."

The first unit of fresh frozen plasma arrived at the floor at noon. After 50 cc of FFP was transfused, Mr. B turned bright red and complained of difficulty breathing. Within 30 seconds, he was unconscious with no spontaneous respirations. A code blue was called. He was intubated and resuscitated for 17 minutes until he was pronounced dead at 12:50 p.m. No autopsy was performed. Cross-match testing on Mr. B’s blood and the FFP did not reveal ABO incompatibility.

Complaint

Approximately 1 year later, Dr. Daytime-Hospitalist was sued by the widow of Mr. B for wrongful death. The estate of Mr. B asserted that Dr. Daytime-Hospitalist did not have a reasonable indication for the use of FFP in this case, and thus the informed consent was nullified. The plaintiff further asserted that the FFP caused transfusion-related lung injury and was the proximate cause of Mr. B’s death.

The plaintiff concluded that were it not for the negligent actions of Dr. Daytime-Hospitalist, Mr. B would be alive today.

Scientific principles

FFP is indicated for "bleeding conditions." This includes but is not limited to liver disease or failure, dilutional coagulopathy from massive red blood cell transfusion, severe disseminated intravascular coagulation (DIC) refractory to prothrombinase complex concentrates or cryoprecipitate, warfarin overdose, and vitamin K deficiency.

FFP is also indicated to reverse the effects of warfarin in the setting of urgent or emergent surgery. The risks of FFP include but are not limited to blood-borne infection (hepatitis B and C, HTLV, and HIV), volume overload, febrile reactions, anaphylaxis (IgA individuals, ABO incompatibility), and transfusion-related lung injury (TRALI).

Complaint rebuttal and discussion

Dr. Daytime-Hospitalist argued that the FFP was indicated for urgent or emergent surgery in the setting of incarcerated umbilical hernia, and that this benefit outweighed the potential risks. Dr. Daytime-Hospitalist further argued that Mr. B was aware of the risk and wished to proceed. Finally, the defendant also argued that the cause of death was speculative and was unlikely to be related to the administration of FFP. However, in this case Dr. Daytime-Hospitalist ordered the surgical consult as routine, not stat. The CT of the abdomen and pelvis did not support an incarcerated hernia, nor did the physical examination support an urgent or emergent surgical need. Also, FFP has a time-limited clinical benefit due to the half-lives of the coagulation factors in the blood product.

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