A 68-year-old man presents to the emergency department with melena and lightheadedness for the past 2 days. His medical history is significant for atrial fibrillation treated with warfarin. Physical examination reveals conjunctival pallor and mild orthostatic hypotension. Laboratory studies show the following:
Hemoglobin: 8.9 g/dL
Platelet count: 240,000/mm³
Prothrombin time (PT): 38 seconds
International normalized ratio (INR): 5.8
Upper endoscopy is planned after stabilization. In addition to administration of intravenous vitamin K, which of the following is the most appropriate next step in management?
The correct answer is:
D) Transfuse fresh frozen plasma
Fresh frozen plasma (FFP) contains all coagulation factors and is indicated for patients with significant bleeding due to coagulation factor deficiencies, including warfarin-associated coagulopathy. This patient has active gastrointestinal bleeding and a markedly elevated INR due to warfarin therapy. Although vitamin K will eventually restore synthesis of vitamin K-dependent clotting factors, its onset of action is delayed. FFP provides immediate replacement of deficient clotting factors and is appropriate for urgent reversal of coagulopathy in a bleeding patient.
Answer choice A: Administer desmopressin, is incorrect. Desmopressin is used to improve platelet function in patients with uremic platelet dysfunction, mild hemophilia A, or some forms of von Willebrand disease. It does not replace coagulation factors depleted by warfarin therapy.
Answer choice B: Observe and repeat coagulation studies in 12 hours, is incorrect. This patient has active bleeding and severe coagulopathy. Immediate correction of clotting factor deficiency is required rather than observation.
Answer choice C: Transfuse cryoprecipitate, is incorrect. Cryoprecipitate contains concentrated fibrinogen, factor VIII, factor XIII, and von Willebrand factor. It is primarily used for hypofibrinogenemia and certain factor deficiencies, not for broad replacement of clotting factors in warfarin-associated bleeding.
Answer choice E: Transfuse platelets, is incorrect. Platelet transfusion is indicated for thrombocytopenia or platelet dysfunction associated with bleeding. This patient's platelet count is normal, and his bleeding is due to a coagulation factor deficiency.
Key Learning Point
Fresh frozen plasma (FFP) contains all coagulation factors and is indicated for patients with active bleeding or urgent procedures in the setting of coagulation factor deficiencies, such as warfarin-associated coagulopathy with an elevated INR. FFP provides immediate clotting factor replacement while definitive therapies, such as vitamin K, take effect.
