A 56-year-old female is scheduled to undergo a total thyroidectomy
for papillary carcinoma. She is currently taking warfarin (Coumadin)
5 mg daily due to a femoral DVT 4 months ago. Her current INR is
2.9. Regarding her anticoagulation regimen, what is the most
appropriate course of action before surgery?
Give this one a try later!
, Decrease Coumadin dose to 1 mg Decrease Coumadin dose to 1 mg
daily 7 days before surgery. daily 5 days before surgery.
Stop Coumadin 7 days before Stop Coumadin 5 days before
surgery. surgery.
Stop Coumadin 3 days before
surgery.
Don't know?
2 of 20
Term
A 62-year-old man becomes hypotensive 18 hours following repair
of an incarcerated ventral hernia that required resection of 30 cm of
infarcted small bowel with reanastomosis. The defect was closed
with a biologic mesh and the skin was closed. Past medical history
includes hypertension treated with metoprolol, COPD treated with
prednisone and diabetes mellitus type 2 treated with metformin. He
is NPO and postoperative medications include an IV
hydromorphone PCA and IV antibiotics. He had no intraoperative
hypotension and was stable until recently when vital signs were: BP
80/50 mmHg, P 110/bpm and RR 22 breaths/min, T 38.5°C. O2
saturations have ranged from 88-94% on 2 liters nasal O2. Despite
aggressive fluid administration and vasopressors his blood pressure
remains below 90mmHg. Lab value changes are as follows:
, Pre-op Now
Sodium 142 mEq/dL 124 mEq/dL
Potassium 3.9 mEq/dL 5.7 mEq/dL
Hct 46% 37%
Glucose 146 mg/dL 74 mg/dL
BUN 18 mg/dL 34 mg/dL
Which of the following is the most likely cause of his shock?
A. Sepsis
B. Intraabdominal bleeding
C. Metformin toxicity
D. Adrenal insufficiency
E. Allergy to antibiotic
Give this one a try later!
D
Patients who take steroids for chronic diseases are at risk for acute adrenal
insufficiency in the postoperative period if their steroid medications are
not continued. The distributive shock of adrenal insufficiency is
characterized by hypotension that is refractory to fluid resuscitation as well
as high-dose vasopressors. Biochemical manifestations include
hyponatremia, hyperkalemia, hypoglycemia and azotemia. Therefore, if
steroid withdrawal was the source of the patient's hypotension, he would
not be expected to respond to low-dose norepinephrine. Patients with
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