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
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| 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. |
| Approved | Approved::Yes |
| Keyword | WBRKeyword::Cholelithiasis, WBRKeyword::Acute cholecystitis, WBRKeyword::Cholecystectomy, WBRKeyword::Fresh frozen plasma |
| Linked Question | Linked:: |
| Order in Linked Questions | LinkedOrder:: |