Rat Poison
Well. Where, indeed, did that last post come from? Maybe I was channeling Che Guevara or something. I get a little passionate when it comes to exploitation of the proletariat in America.
Back to the ICU.
It was Sunday. Bright and sunny and absolutely freezing in the way of Minnesota in January. I was on call for the weekend, slogging through morning rounds when I got the "5141" page. I thought "So it begins." The ER doc was somewhat frantic. The patient was a 60 year old woman who fell at home and couldn't get up. EMS was called and noted a blood pressure of 60 systolic. They put in an IV, started some saline and transported her to Red Room 1 in the ER.
Once there the ER doc noted a rigid, distended abdomen. The labs showed a hemoglobin of about 5 (normal is around 14), meaning she didn't have much blood perfusing her vessels, probably because most of her blood volume was in her belly. She was also on coumadin.
Coumadin is rat poison. The rats eat it. It thins their blood, preventing the blood from clotting. The poor rodents bleed into their heads, get dizzy and crawl outside to die. Ok, I made up that last part, but you get the point. People are put on coumadin for a variety of problems such as blood clots, cardiac arrhythmias, artificial valves- situations where you need to prevent blood from clotting. The problem lies in the fact that coumadin has what we doctors call a narrow therapuetic window. That's doctor speak for a drug where beneficial treatment levels are very close to lethally toxic levels.
In order to monitor therapy in patients on coumadin we monitor a lab test called the INR, which stands for International Normalized Ratio. Whatever that means. The goal is for the INR to be between 2 and 3. Less than 2 means risk of clotting and when you get greater than 4 or so it means increased risk of bleeding. Monitoring the INR and adjusting the dose of coumadin is a major headache with the dose being adjusted just about every week. This patient had an INR of 7.5. When the ER doc relayed that to me I responded with something really intelligent, on the order of "Yikes!"
She arrived in the ICU and, along with 3 nurses, I set about stablizing her. We basically poured the blood bank into her, to correct her anemia. We also gave her a lot of fresh frozen plasma and vitamin K to try and reverse the coumadin-induced anticoagulation.I put in a femoral arterial line for real time monitoring of blood pressure. Her blood pressure came up and her heart rate came down and we got a chance to sit back and catch our breath.
The first thing I did was have the HUC stat page the surgeon on call. Wherever she was bleeding from she was going to need someone to go in and fix it. The surgeon came by and had a look but felt we should temporize and focus on correcting her high INR and transfusing her. I had to agree that at the moment she looked relatively good, although deep down I wondered if now was the time to operate, when she was indeed quasi-stable.
Well, you fight the Angel of Death with surgeon you have.
Needless to say, about an hour later, when I was just finishing my orders and dictation she crashed. I ordered more blood, but our peripheral IVs weren't up to the task, so I went for the big guns. In a patient who needs massive infusions of blood and fluids you want a central line that's short and fat, and therefore has less resistance to flow. I favor a Cordis introducer in these cases, so I had the nurse set up for the line. Not only was the INR still elevated making line placement risky, but this patient weighed in at 100 kg, meaning no landmarks were available to guide my needle home into the internal jugular vein. Once more I rolled out the Site-Rite portable ultrasound and, fortunately, with only a minimum of flailing about had an introducer in place in short order.
By now the surgeon was back, but he opted to turf the patient to Interventional Radiology. The goal was to have the radiologist do a mesenteric angiogram, locate the bleeding artery and, if possible, embolize or otherwise clot it off. The Flying Squad came and trundled her off to Radiology and I went off to try and see some of my other patients. For the next few hours at least, she would be a SEP (Someone Elses Problem).
Back to the ICU.
It was Sunday. Bright and sunny and absolutely freezing in the way of Minnesota in January. I was on call for the weekend, slogging through morning rounds when I got the "5141" page. I thought "So it begins." The ER doc was somewhat frantic. The patient was a 60 year old woman who fell at home and couldn't get up. EMS was called and noted a blood pressure of 60 systolic. They put in an IV, started some saline and transported her to Red Room 1 in the ER.
Once there the ER doc noted a rigid, distended abdomen. The labs showed a hemoglobin of about 5 (normal is around 14), meaning she didn't have much blood perfusing her vessels, probably because most of her blood volume was in her belly. She was also on coumadin.
Coumadin is rat poison. The rats eat it. It thins their blood, preventing the blood from clotting. The poor rodents bleed into their heads, get dizzy and crawl outside to die. Ok, I made up that last part, but you get the point. People are put on coumadin for a variety of problems such as blood clots, cardiac arrhythmias, artificial valves- situations where you need to prevent blood from clotting. The problem lies in the fact that coumadin has what we doctors call a narrow therapuetic window. That's doctor speak for a drug where beneficial treatment levels are very close to lethally toxic levels.
In order to monitor therapy in patients on coumadin we monitor a lab test called the INR, which stands for International Normalized Ratio. Whatever that means. The goal is for the INR to be between 2 and 3. Less than 2 means risk of clotting and when you get greater than 4 or so it means increased risk of bleeding. Monitoring the INR and adjusting the dose of coumadin is a major headache with the dose being adjusted just about every week. This patient had an INR of 7.5. When the ER doc relayed that to me I responded with something really intelligent, on the order of "Yikes!"
She arrived in the ICU and, along with 3 nurses, I set about stablizing her. We basically poured the blood bank into her, to correct her anemia. We also gave her a lot of fresh frozen plasma and vitamin K to try and reverse the coumadin-induced anticoagulation.I put in a femoral arterial line for real time monitoring of blood pressure. Her blood pressure came up and her heart rate came down and we got a chance to sit back and catch our breath.
The first thing I did was have the HUC stat page the surgeon on call. Wherever she was bleeding from she was going to need someone to go in and fix it. The surgeon came by and had a look but felt we should temporize and focus on correcting her high INR and transfusing her. I had to agree that at the moment she looked relatively good, although deep down I wondered if now was the time to operate, when she was indeed quasi-stable.
Well, you fight the Angel of Death with surgeon you have.
Needless to say, about an hour later, when I was just finishing my orders and dictation she crashed. I ordered more blood, but our peripheral IVs weren't up to the task, so I went for the big guns. In a patient who needs massive infusions of blood and fluids you want a central line that's short and fat, and therefore has less resistance to flow. I favor a Cordis introducer in these cases, so I had the nurse set up for the line. Not only was the INR still elevated making line placement risky, but this patient weighed in at 100 kg, meaning no landmarks were available to guide my needle home into the internal jugular vein. Once more I rolled out the Site-Rite portable ultrasound and, fortunately, with only a minimum of flailing about had an introducer in place in short order.
By now the surgeon was back, but he opted to turf the patient to Interventional Radiology. The goal was to have the radiologist do a mesenteric angiogram, locate the bleeding artery and, if possible, embolize or otherwise clot it off. The Flying Squad came and trundled her off to Radiology and I went off to try and see some of my other patients. For the next few hours at least, she would be a SEP (Someone Elses Problem).
posted by ICUDOC at 8:09 PM
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