CICM SAQ 2011.1 Q8

Questions

8.1. A 40 year old previously well male presents with a ruptured appendix and associated peritonitis (Day 0). He returns to theatre 3 days later with ischaemic colitis and requires a right hemicolectomy. At laparotomy, he is noted to have extensive thrombosis in his superior mesenteric vein and portal vein. Attempts to anticoagulate him postoperatively (day 5 onwards) with intravenous heparin have been unsuccessful.

His post op haematology results are as follows:

a) What are the possible factors preventing therapeutic anticoagulation in this patient?
b) List 2 strategies to effect anticoagulation with intravenous heparin.

8.2. A 28 year old man presented with a persistent epistaxis to the emergency department.

The coagulation profile was as follows:

a) What is the most likely diagnosis?
b) What would you confirm your diagnosis

8.3. A 50 year old female presents with a right deep vein thrombosis and haemoptysis.

These blood results are from her admission:

a) What is the APTT mixing test and what is its significance in this patient?


Answers

Answer and interpretation

8.1. a) What are the possible factors preventing therapeutic anticoagulation in this patient?

  • Disseminated intravascular coagulation
  • High clot burden
  • Antithrombin III deficiency
  • High Factor VIII levels

8.1 b) List 2 strategies to effect anticoagulation with intravenous heparin.

  • Change to low molecular heparin, instead of unfractionated heparin
  • Give cryoprecipitate and/or fresh frozen plasma (if there is confirmed ATIII
  • deficiency )
  • Give antithrombin III concentrate

8.2.a) What is the most likely diagnosis?

  • Von Willebrand’s disease

8.2. b) What would you confirm your diagnosis

  • History – easy bruising, mucosal bleeding
  • Family history
  • Plasma vWF levels
  • Factor VIII levels /activity

8.3. a) What is the APTT mixing test and what is its significance in this patient?

  • It involves mixing patient’s plasma with normal pooled platelet free plasma. If it normalized then the elevated APTT is due to factor deficiency. Partial correction suggests an inhibitor.
  • These results suggest antiphospholipid syndrome in this patient

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Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

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