WBR0823

Author	PageAuthor::Vendhan Ramanujam
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Emergency Room
Sub Category	SubCategory::Gastrointestinal, SubCategory::Hepatology
Prompt	[[Prompt::A 65 year old male comes to the ER with complaints of acute sharp and cramping right upper abdominal pain, 8/10 in severity, spreading to his right shoulder blade and worsening over the past six hours. The pain is accompanied by nausea and vomiting. He is a known alcoholic cirrhotic patient. His vital signs are heart rate 112 beats/min, respiratory rate 20/minute, blood pressure 100/60 mm Hg and oral temperature 39.2 C. On physical examination yellowing of his skin and sclera are obvious, and abdominal examination elicits guarding and tenderness without rigidity. Emergency serum biochemistry tests were ordered and it revealed the following results RBC count: 4.2 million/mm3 WBC count: 16,000/ mm3 Platelet count: 140,000/mL Aspartate aminotrasferace (AST): 100 IU/L Alanine aminotrasferace (ALT): 70 IU/L Total bilirubin: >4 mg/dL Serum albumin: 2 g/dL Prothrombin time: 22 seconds Partial thromboplastin time: 80 seconds An emergency ultrasound was also performed and it revealed a calculous cholecystitis. The patient requires an emergency laparoscopic cholecystectomy. A transfusion of fresh frozen plasma is planned to minimize the risk of bleeding due to surgery. The transfusion should be started]]
Answer A	AnswerA::The day before surgery
Answer A Explanation	AnswerAExp::'''Incorrect'''-Transfusion of FFP with a half-life 4 to 6 hours on the day before the surgery will not be effective in maintaining the hemostasis in this patient who is at increased risk of bleeding during the surgery.
Answer B	AnswerB::The night before surgery
Answer B Explanation	AnswerBExp::'''Incorrect'''-Transfusion of FFP with a half-life 4 to 6 hours on the night before the surgery will not be effective in maintaining the hemostasis in this patient who is at increased risk of bleeding during the surgery.
Answer C	AnswerC::Four hours before the surgery
Answer C Explanation	AnswerCExp::'''Correct'''-This will be the most effective method to achieve adequate hemostasis during the surgery, since the half-life of most of the stable clotting factors is 4 to 6 hours.
Answer D	AnswerD::During the surgery
Answer D Explanation	[[AnswerDExp::Incorrect-Since it takes 4 to 6 hours for the clotting factors to achieve their half-life to become effective, transfusion of FFP during the surgery will not be effective in maintaining the hemostasis in this patient who is at increased risk of bleeding during the surgery.]]
Answer E	AnswerE::Post-operatively in the recovery room
Answer E Explanation	AnswerEExp::'''Incorrect'''-Post-operative transfusion is of no use in maintaining the hemostasis in this patient since they are at increased risk of bleeding during the surgery.
Right Answer	RightAnswer::C
Explanation	[[Explanation::A transfusion with fresh frozen plasma (FFP) is necessary in this patient to replenish his clotting factors. The effectiveness of the transfusion in maintaining hemostasis is dependent on the quantity of each factor delivered and its half-life. The half-life of the most stable clotting factor, factor VII, is 4 to 6 hours. Clotting factors are effective only after reaching their half-life. A reasonable transfusion scheme would be to give FFP on call to surgery or 4 to 6 hours before the surgery. This way the transfusion is complete prior to the incision with circulating factors to cover the operative and immediate postoperative period. Educational Objective: Cirrhotic patients with poor coagulation profile and acute cholecystitis that needs urgent surgical intervention have to be transfused with fresh frozen plasma (FFP) on call to surgery or 4 to 6 hours before the surgery. This will be the most effective method to achieve adequate hemostasis during the surgery, since most of the stable clotting factors half-life is 4 to 6 hours. Educational Objective: References: ]]
Approved	Approved::Yes
Keyword	WBRKeyword::Cholelithiasis, WBRKeyword::Acute cholecystitis, WBRKeyword::Cholecystectomy, WBRKeyword::Fresh frozen plasma
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