Wednesday, December 08, 2004

Way to go.
This patient came in last weekend in a-fib with RVR. Started her on heparin and took her for a transesophageal echocardiogram followed by cardioversion.
She converted successfully after just one shock of 20 Joules. So we started transitioning her heparin to coumadin.
My staff wanted to load her higher so that she would be ready for discharge by this weekend (she had a wedding to go to).
"Let's load her, 10mg, 10mg then 5mg."
Not a good idea, I said. Naturally, the consultant staff overules my opinion. After all, they pay him over $200,000 a year (US dollars). And I'm just a measly SMuRf.
Day one, INR 1.1
Day two, INR 3.3
Uh oh. Maybe we should back down on her load.
Day two night; she complains of abdominal pain. Stat CBC shows a hemoglobin of 6.6, INR 5.9. CT abdomen: large rectus sheath hematoma
We had to give her 2 mg of vitamin K and fresh frozen plasma, and obviously, blood.
So much for getting her home by the weekend.
Way to go.
Lesson: Stick to 5mg po daily loads. Even consultants can make bad calls.
Found out one of the patients I admitted on my last call 2 nights ago coded on the way to CT. The lady with PEs. As it turns out, she had a massive thrombus seen on the echo, running from the IVC into the right atrium. It was flapping wildly. That was almost certainly the source of her bilateral emboli. They were wanting to image the thrombus before deciding on intervention. But she suffered a v-fib arrest in radiology. 30 mins of CPR. Defibrillator. I bet the room smelt of burnt flesh by the time they were done, if they had tried for so long. They couldn't bring her back. I bet she clotted off a large portion of her IVC. My hunch is she had an occult malignancy.
Just had to leave all this behind when I came home. So, curled up in front of the fireplace, fired up the X'mas tree lights. Started wrapping my presents. Was almost tempted to wrap up my present to myself, a leather Kenneth Cole briefcase, but I thought that would be too corny.
17 days to Christmas...


Blogger Palmdoc said...

Well you are right. The practice of loading with warfarin is no longer recommended. If patients need to be discharged early, better to do so with LMWH on board.

3:36 PM  
Blogger vagus said...

Well, we still load them but with 5mg po qd; that's the standard US dosing.
We do frequently send patients out on LMWH, but it's bloody expensive here and this elderly lady's insurance didn't cover the price (I hate this about the US).
However LMWH not yet FDA approved for use in patients with prosthetic heart valves, so in those situations we can't use them.
Thanks for visiting. Where are you based?

5:40 PM  

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