Beta adrenergic receptor antagonists/warfarin
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Delayed haemorrhage: case report A 52-year-old man developed delayed haemorrhage during treatment with warfarin and unspecified beta adrenergic receptor antagonists for hypertension and as anticoagulant therapy. The man presented to the emergency department with progressive pain in the left upper abdomen for last 15 days and transient haematuria for 5 days, which followed catheterisation. Anamnesis revealed that he had been in a road traffic accident one month prior to the current presentation. At that time, he had been diagnosed with a grade III splenic injury, haemoperitoneum and cholelithiasis. He had been admitted to a hospital for 5 days, kept on conservative non operative management and then discharged. His medical history was significant for hypertension, atrial fibrillations and a prosthetic mitral valve replacement 12 years prior. Since the surgery, he had been receiving regular warfarin and unspecified beta adrenergic receptor antagonists [beta blockers; routes and dosages not stated]. He sustained head injury and had repeated seizures post injury in past 1 month. He was receiving unspecified antiepileptics. He also had subdural haematoma, bilateral minimal pleural effusions and basal atelectasis and dilated cardiomyopathy. Upon current presentation, examination revealed heart rate of 57 /min, BP of 140/80mm Hg, respiratory rate of 18 /min and 96% SpO2. Foley’s catheter was in place with a mild haematuria. He was hospitalised. On the night of admission, he developed sudden fall in heart rate, BP and saturation. He was immediately shifted to the ICU. He was treated for arrhythmias and haemodynamic instability. Investigations showed a INR of 3.49 due to warfarin and haemoglobin of 6 g/dL. The man was treated with blood and fresh frozen plasma transfusion. After stabilisation, a grade IV splenic injury was diagnosed. CT scan confirmed bilateral pleural effusion with underlying segmental and subsegmental collapse and cardiomegaly. He showed severe anaemia due to active bleed from pseudoaneurysm of the splenic artery. The delayed haemorrhage was considered to be secondary to warfarin and unspecified beta adrenergic receptor antagonists therapy [duration of treatment to reactions onsets not stated]. After cardiology reference, warfarin was stopped. He started receiving heparin with a serial monitoring of haematocrit, aPTT and PT/INR. Vitamin K was initiated. Further blood and fresh frozen plasma were transfused accordingly. Pseudoa-neurysm embolisation was done under fluoroscopic guidance after INR had decreased to 1.35. The procedure was successful. His laboratoryparameters and haemodynamic status became normal. He was discharged. His treatment was shifted back to unspecified oral anticoagulants and unspecified beta adrenergic receptor antagonists. On follow-up, he remained asymptomatic. Kumari M, et al. Management of a delayed, post-traumatic rupture of splenic artery pseudoaneurysm in a patient with life threatening co-morbidities: A treatment challenge. 803519505 International Journal of Surgery Case R
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