A 65-year-old man with end-stage renal disease on hemodialysis is transferred to the ICU with new onset hematemesis. After adequate IV access is established, he is transfused four units of packed red blood cells, four units of fresh frozen plasma, and one apheresis unit of platelets. His vital signs improve though he still is having episodes of hematemesis. As you await the GI consult for possible endoscopy, what is the next best step in management?
A. Prothrombin complex concentrate (PCC)Correct Answer: B
Patients with renal dysfunction often have impaired platelet function and abnormal platelet-endothelial interaction that can lead to increased bleeding. Uremic bleeding can present as ecchymoses, purpura, epistaxis, and GI bleeding and intracranial bleeding. Treatment options include administration of desmopressin, which is thought to reduce bleeding by increasing the release of factor VIII:von Willebrand factor multimers. Bleeding time is reduced in an hour and its effects typically last 4 to 8 hours. Dosing of desmopressin is 0.3 µg/kg IV or subcutaneously.
PCC and Fresh frozen plasma would be indicated in the setting of an elevated INR, while tranexamic acid would be indicated in the setting of hyperfibrinolysis.
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