A 63-year-old man comes to the emergency department due to 8 hours of constant epigastric pain, which has become more severe and diffuse over the past 2 hours. He also has nausea and has had one episode of vomiting containing bile but no blood. The patient has been having episodic upper abdominal discomfort that occasionally awakens him from sleep but is relieved by antacids. Other medical conditions include hypertension, hyperlipidemia, type 2 diabetes mellitus, persistent atrial fibrillation, and chronic kidney disease. Medications include atorvastatin, lisinopril, metoprolol, warfarin, insulin lispro, and glargine. Temperature is 38.2 C (100.9 F), blood pressure is 110/70 mm Hg, and pulse is 100/min and irregular. BMI is 36 kg/m². The patient is in moderate distress due to pain. The abdomen is diffusely tender to palpation with rigidity, guarding, and rebound tenderness. Bowel sounds are absent. Laboratory findings are as follows: An upright chest x-ray shows a small amount of free air under the right diaphragm. Nasogastric suction, intravenous crystalloid, and antibiotics are started, and an urgent surgery is planned. Which of the following additional interventions is most appropriate at present?

Question

Quizplus · Accepted Answer

Explanation: This patient has an acute abdomen (guarding, rebound tenderness) with subdiaphragmatic (intraperitoneal) free air. This presentation suggests perforation of a hollow abdominal viscus, likely due to a duodenal or gastric ulcer (given the patient's history of intermittent upper abdominal pain relieved with antacids), which requires nasogastric tube decompression, intravenous fluids, antibiotics, and urgent surgical evaluation. In addition, this patient takes warfarin for atrial fibrillation, and his warfarin-induced anticoagulation should be reversed. Indeed, therapeutic anticoagulation with an international normalized ratio (INR) between 2 and 3 (eg, 2.1 in this patient) is appropriate for the chronic management of atrial fibrillation; however, if not corrected preoperatively, therapeutic anticoagulation can predispose patients to intra- and postoperative bleeding complications. Patients taking warfarin who require anticoagulation reversal (eg, urgent surgery with a high risk of bleeding, significant hemorrhage) should be managed as follows: Warfarin should be discontinued immediately. Patients (particularly those with an INR >2) should receive prothrombin complex concentrate (PCC), a concentrate of vitamin K-dependent cofactors. Three-factor PCC contains factors II, IX, and X with small amounts of protein C and S, whereas 4-factor PCC, the preferred agent, also contains therapeutic quantities of factor VII. PCC rapidly normalizes the INR, typically in ≤10 minutes; however, the effects are transient (hours). Intravenous vitamin K should also be administered to provide substrate for synthesis of new vitamin K-dependent clotting factors by the liver (particularly given the transient effects of PCC). If PCC is unavailable, fresh frozen plasma (FFP) can be administered; however, it is less effective and typically requires transfusion of multiple units, increasing the risk of volume overload. (Choice A) Colloids include FFP and albumin. FFP can be used if PCC is unavailable, whereas albumin is indicated in the treatment of hepatorenal syndrome or spontaneous bacterial peritonitis. (Choice B) Desmopressin is given preoperatively to patients with mild hemophilia A to prevent excessive bleeding. It indirectly increases factor VIII levels by causing von Willebrand factor release from endothelial cells. (Choice C) The decision to transfuse patients preoperatively is based on underlying risk factors for ischemic heart disease and anticipated blood loss during surgery. In general, tissue oxygen delivery does not become deficient until the hemoglobin drops below 7 g/dL. Although preparations for blood transfusion (eg, consent, type and screen) should be made, reversal of this patient's anticoagulation is more appropriate at this time. (Choice E) Platelet counts greater than 50,000/mm³ provide adequate hemostasis for most invasive procedures. ³ Educational objective: Patients on warfarin who require urgent surgery with a high risk of bleeding, or those who are experiencing significant hemorrhage, should receive prothrombin complex concentrate (PCC) and intravenous vitamin K. If PCC is unavailable, fresh frozen plasma can be given.

A 63-Year-Old Man Comes to the Emergency Department Due to 8