A 61-year-old woman with compensated hepatitis C cirrhosis was seen at the emergency department for a painful umbilical hernia. The hernia was reduced without incident, although given her painful presentation and the risk of an incarcerated hernia developing, surgical correction was recommended. Her baseline serum creatinine level was 1.1 mg/dL (to convert to micromoles per liter, multiply by 88.4), with a Model for End-Stage Liver Disease score of 15, but given her cirrhosis and the concern for bleeding risk, she was admitted to the hospital the day prior to surgery for medical optimization. The morning of her surgery, routine laboratory tests revealed an international normalized ratio (INR) for prothrombin time of 1.8, which was not significantly different from values over the past year. She was ordered 1 unit of fresh frozen plasma (FFP) to bring her INR down to 1.5 or less prior to the operation. Within 30 minutes of starting FFP infusion, the patient developed a diffuse urticarial cutaneous eruption. Transfusion was stopped, diphenhydramine and methylprednisolone were administered, and the patient had complete resolution of her symptoms. However, because of this reaction, hernia repair was cancelled and she was discharged the next day with instructions to follow up with a hematologist for consultation regarding coagulopathy management.
Roberts JR, Bambha K. Balanced Coagulopathy in Cirrhosis—Clinical Implications: A Teachable Moment. JAMA Intern Med. 2014;174(11):1723–1724. doi:10.1001/jamainternmed.2014.4023
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