Examkin

Soru

Zorluk: KolaySurgical and Procedural Interventions

An 82-year-old woman is admitted to the hospital after a mechanical fall at home resulting in a displaced right femoral neck fracture. She is evaluated by the orthopedic surgery team, who recommend urgent hemiarthroplasty to minimize morbidity. Her past medical history is significant for hypertension and atrial fibrillation, for which she takes warfarin. Her vital signs are within normal limits. Laboratory evaluation reveals an International Normalized Ratio (INR) of 3.8. The surgical team wishes to proceed with the operation as soon as it is safe. Which of the following procedural preparation steps are indicated for this patient? (Select all that apply)

  1. Administration of 4-factor prothrombin complex concentrateCevap
  2. Administration of intravenous vitamin KCevap
  3. C
    Immediate progression to the operating room without anticoagulant reversal
  4. D
    Postponement of the surgical intervention for 5 to 7 days to allow spontaneous INR normalization
  5. E
    Ordering magnetic resonance imaging of the right hip to further characterize the fracture

Cevap

The indicated preparation steps for this patient are the administration of 4-factor prothrombin complex concentrate and the administration of intravenous vitamin K.
This patient requires urgent surgical repair of a hip fracture. Current guidelines recommend operating on hip fractures within 48 hours of presentation to significantly reduce mortality and morbidity. However, the patient is therapeutically anticoagulated with warfarin and has an INR of 3.8, which poses an unacceptable risk of severe intraoperative hemorrhage. Therefore, rapid reversal of her anticoagulation is required. The standard of care for rapid, urgent reversal of warfarin is the administration of 4-factor prothrombin complex concentrate (PCC) alongside intravenous vitamin K. PCC provides immediate, direct replacement of vitamin K-dependent clotting factors (II, VII, IX, and X). Because the half-life of the factors in PCC is relatively short, concurrent administration of intravenous vitamin K is required to promote endogenous synthesis of these factors, ensuring sustained normalization of the INR throughout the perioperative period.

Adım Adım Çözüm

1
Identify the need for urgent surgery.
The patient has a displaced femoral neck fracture, which requires surgical repair ideally within 48 hours to minimize mortality and complications.
Prolonged immobilization in elderly patients leads to severe complications such as pneumonia, deep vein thrombosis, and decubitus ulcers.
2
Assess the patient's bleeding risk.
The patient is on warfarin with a supratherapeutic INR of 3.8.
Performing major orthopedic surgery with an elevated INR is contraindicated due to the risk of massive intraoperative hemorrhage.
3
Determine the appropriate reversal strategy.
Select 4-factor prothrombin complex concentrate and intravenous vitamin K.
PCC provides rapid replenishment of clotting factors, while vitamin K ensures sustained factor production.

Anahtar Kavram

Patients on warfarin requiring urgent surgical intervention must undergo rapid anticoagulant reversal using 4-factor prothrombin complex concentrate (PCC) and intravenous vitamin K to prevent life-threatening hemorrhage while avoiding unnecessary surgical delays.
Tahmini Süre:1m 0s
Bu soruyu puanla

Konular

Surgical and Procedural Interventions

Bu konudan daha fazla soru