to delaying operations with stage 2 hypertension and accompanying target organ damage, or stage 3 hypertension (BP >180/110) without organ damage. In this scenario, the risk of delaying an operation (bowel incarceration, strangulation, or perforation, etc.) likely outweighs the risks of suffering a perioperative adverse outcome due to chronic hypertension. Sudden reduction in BP (as in choice B and D) can decrease perfusion pressure and are not recommended.Answer: CSear JW. Perioperative control of hypertension: when will it adversely affect perioperative outcome? Curr Hypertens Rep. 2008; 10(6):480–487. doi: 10.1007/s11906‐008‐0090‐2. PMID: 18959836.Vázquez‐Narváez KG, Ulibarri‐Vidales M. The patient with hypertension and new guidelines for therapy. Curr Opin Anaesthesiol. 2019; 32(3):421–426. doi: 10.1097/ACO.0000000000000736. PMID: 31048597.10 A 51‐year‐old man with alcoholic cirrhosis (MELD 19, weight = 50 kg) and a history of failed ventral hernia repair 7 years ago presents to the ED with severe abdominal pain, tachycardia, and acidosis. CT scan demonstrates incarcerated ventral hernia with surrounding air and fluid, consistent with perforated viscus. Laboratory studies are significant for a WBC of 17 000/mm3, Hgb of 12 g/dL, INR 3.1, and CO2 of 15 mEq/L. Your chief resident asks what you would like to do prior to proceeding to the operating room to lower his bleeding risk. You respond:Administer 2u fresh frozen plasma (FFP).While the data are preliminary, prothrombin complex concentrate (KCentra) has shown encouraging results and may be of benefit.Administer 10 mg IV Vitamin K. Administer 15 mcg DDAVP.Proceed directly to the operating room as the emergent nature of his operation prohibits the time required to reverse his mildly elevated INR.Clearly, this patient requires an emergent operation, but requires reduction in his bleeding risk by treatment of his coagulopathy; accomplishing this is far from simple, however. Historically, reversal of coagulopathy of chronic liver disease (CCLD) was accomplished with FFP, with a dose of 10–15 mL/kg (which in this patient equates to 750 mL, and since there are 250 mL/unit of FFP, this would be 3 units). However, the data have fairly consistently shown that reversal of coagulopathy with FFP in this patient population is unreliable at best, with only transient changes in bleeding risk. Supratherapeutic doses of FFP can be given with slightly improved reversal; however, this exposes the patient to significant risk of volume overload, and should be avoided. IV vitamin K can be used to augment this reversal, but would be less effective in an emergent situation than FFP. DDAVP would be given at a rate of 3 mg/kg for treatment of uremic platelet dysfunction, but would be ineffective in correcting the INR in the above patient. A small study did demonstrate equivalence between DDAVP and FFP in bleeding reduction in patients with CCLD undergoing dental extraction, but there is currently no evidence to support DDAVP for acute reversal in this situation; furthermore, as previously mentioned, FFP is an unreliable reversal agent and so should not be the gold standard to which DDAVP is compared. PCC (KCentra) has more recently come to the market, and while there are no large‐scale trials evaluating its role in coagulopathy of CCLD, several case reports and small studies have shown promising results. However, more research into its efficacy is needed.Answer: BHarrison MF. The misunderstood coagulopathy of liver disease: a review for the acute setting. West J Emerg Med. 2018; 19(5):863–871. doi: 10.5811/westjem.2018.7.37893. Epub 2018 Aug 8. PMID: 30202500; PMCID: PMC6123093.Kujovich JL. Coagulopathy in liver disease: a balancing act. Hematology Am Soc Hematol Educ Program. 2015;2015:243–249. doi: 10.1182/asheducation‐2015.1.243. PMID: 26637729.Pereira D, Liotta E, Mahmoud AA. The use of Kcentra® in the reversal of coagulopathy of chronic liver disease. J Pharm Pract. 2018; 31(1):120–125. doi: 10.1177/0897190017696952. Epub 2017 Mar 15. PMID: 29278982.Lesmana CR, Cahyadinata L, Pakasi LS, Lesmana LA. Efficacy of prothrombin complex concentrate treatment in patients with liver coagulopathy who underwent various invasive hepatobiliary and gastrointestinal procedures. Case Rep Gastroenterol. 2016; 10(2):315–322. doi: 10.1159/000447290. PMID: 27482190; PMCID: PMC4945807.
11 A 43‐year‐old woman presents to your trauma bay following an MVC. She is evaluated by standard ATLS protocol and is found to be hypotensive, tachycardic, and diaphoretic with a GCS of 14. FAST exam reveals fluid in Morrison's pouch. While preparing to bring the patient to the OR for exploration, the patient's husband alerts you that the patient takes rivaroxaban (Xarelto) for a provoked deep vein thrombosis 2 months ago. How should you proceed with her care?Administer prothrombin complex concentrate (PCC) and proceed to the operating room for exploration.Administer 15 mL/kg of FFP and proceed to the operating room for exploration.Proceed to the operating room immediately as hemodialysis is the only effective method of rivaroxaban (Xarelto) reversal.Administer platelets and proceed to the operating room for exploration.Administer protamine and proceed to the operating room for exploration.This patient requires an immediate operation to address her hemorrhagic shock. While proceeding to the operating room should not be delayed, her medication‐induced coagulopathy should obviously be addressed. First‐line reversal of direct factor Xa inhibitors (such rivarobaxan) is accomplished with prothrombin complex concentrate (PCC). Vitamin K antagonists (warfarin) is reversed with PCC first‐line, and FFP as second‐line therapy. Oral direct‐thrombin inhibitors such as dabigatran are reversed with PCC first‐line, with hemodialysis as second‐line therapy. Heparin and LMWH can be temporarily and partially reversed with protamine. Aspirin and Plavix are treated with platelet transfusion, with desmopressin as a second‐line option.Answer: AMcCoy CC, Lawson JH, Shapiro ML. Management of anticoagulation agents in trauma patients. Clin Lab Med. 2014; 34(3):563–574. doi: 10.1016/j.cll.2014.06.013. Epub 2014 Jul 19. PMID: 25168942.
12 You evaluate a 74‐year‐old woman with a history of asthma and COPD who is brought to the trauma bay by EMS following a fall down a flight of stairs. Per EMS report, the patient had a GCS of 13 upon arrival for confused speech and localizing to pain only, and was initially hemodynamically normal. However, during transport, the patient became hypotensive and tachycardic. FAST exam in the trauma bay reveals fluid in the bilateral upper quadrants, as well as the pelvis, and she is taken immediately to the OR for exploration. During the operation, you are alerted that her thromboelastography (TEG) results are as follows:R (reaction time): ElevatedK (kinetics): Increasedα Angle: DecreasedMA (maximum amplitude): DecreasedLY30 (clot lysis): NormalBased on these results, what intervention (if any) should be given?Platelets onlyFFP and plateletsTXA onlyCryoprecipitate, platelets, and FFPCryoprecipitate, FFP, and TXAThis patient has an elevated reaction time (indicating that clot is taking longer than normal to form – which is a problem with coagulation factors, and as such should be treated with FFP), as well as an increased K (indicating the clot takes longer to reach a fixed strength – which indicates a fibrinogen deficiency and is thus treated with cryoprecipitate), and a decreased Alpha angle (indicating an elevated time of fibrin accumulation – which is a function of fibrinogen and platelet number, and is thus treated with cryoprecipitate and platelet transfusion). Additionally, the MA is decreased, indicating a decreased clot strength owing to platelet dysfunction, which can be addressed with platelet transfusion. An elevated LY30 indicates hyperfibrinolysis, which is reversed with TXA; however, the LY30 is normal in this patient.Answer: DSchmidt AE, Israel AK, Refaai MA. The utility of thromboelastography to guide blood product transfusion. Am J Clin Pathol. 2019; 152(4):407–422. doi: 10.1093/ajcp/aqz074. PMID: 31263903.13
13 You are called to the intensive care unit to assist with a difficult airway in a patient with a sudden decline in mental status. The anesthesia resident has attempted intubation twice without success, and states he was unable to visualize the vocal cords on direct laryngoscopy. He is currently providing oxygenation and ventilation with bag‐valve mask, and the SpO2 is 91% and slowly rising. Which of the following should be performed?Consider placing a rescue device, such as laryngeal mask airway.Reattempt direct laryngoscopy with a different blade.Attempt to intubate over a blindly placed bougie.Continue with bag‐mask ventilation until fully preoxygenated.All of the above.Establishment of an
