J D Adams1, S Jones, B C Brost. 1. Department of Obstetrics and Gynecology, Keesler United States Air Force Medical Center, Keesler Air Force Base, MS 39534, USA.
Abstract
BACKGROUND: Topical thrombin spray is frequently used as a hemostatic agent in surgery, particularly following cardiovascular, orthopedic and neurologic surgery. Acquired coagulation factor inhibitors to thrombin and factor V may develop following gynecologic surgery with repeat topical thrombin use. CASE: A 45-year-old woman underwent total abdominal hysterectomy/bilateral salpingo-oophorectomy. Her past medical history included idiopathic thrombocytopenic purpura and Marfan's syndrome and past surgery included splenectomy and aortic valve replacement with a three-vessel coronary artery bypass graft. She was converted from Coumadin (DuPont Pharmaceuticals, Wilmington, Delaware) to heparin preoperatively, and heparin was stopped six hours before surgery, with normalization of her prothrombin time (PT) and partial thromboplastin time (PTT). Topical bovine thrombin spray was applied to the surgical field in anticipation of early resumption of heparin anticoagulation. Seven days after surgery, after recovering from some acute bleeding problems, the patient began to have elevation of her PT in spite of being off Coumadin for 10 days. Her PT and international normalized ratio (INR) continued to rise, reaching peak values of 31.4 and 6.99, respectively. A mixing study did not correct the problem, confirming the presence of coagulation inhibitors. The patient was given intravenous immunoglobulins and corticosteroids, and her PT/PTT and INR values slowly normalized. CONCLUSION: Acquired coagulation factor may develop following gynecologic surgery with topical thrombin use. This potential complication should be strongly considered in any patient prior to using topical bovine thrombin, especially those with a prior exposure or history of surgical procedures in which bovine thrombin is commonly used.
BACKGROUND: Topical thrombin spray is frequently used as a hemostatic agent in surgery, particularly following cardiovascular, orthopedic and neurologic surgery. Acquired coagulation factor inhibitors to thrombin and factor V may develop following gynecologic surgery with repeat topical thrombin use. CASE: A 45-year-old woman underwent total abdominal hysterectomy/bilateral salpingo-oophorectomy. Her past medical history included idiopathic thrombocytopenic purpura and Marfan's syndrome and past surgery included splenectomy and aortic valve replacement with a three-vessel coronary artery bypass graft. She was converted from Coumadin (DuPont Pharmaceuticals, Wilmington, Delaware) to heparin preoperatively, and heparin was stopped six hours before surgery, with normalization of her prothrombin time (PT) and partial thromboplastin time (PTT). Topical bovinethrombin spray was applied to the surgical field in anticipation of early resumption of heparin anticoagulation. Seven days after surgery, after recovering from some acute bleeding problems, the patient began to have elevation of her PT in spite of being off Coumadin for 10 days. Her PT and international normalized ratio (INR) continued to rise, reaching peak values of 31.4 and 6.99, respectively. A mixing study did not correct the problem, confirming the presence of coagulation inhibitors. The patient was given intravenous immunoglobulins and corticosteroids, and her PT/PTT and INR values slowly normalized. CONCLUSION: Acquired coagulation factor may develop following gynecologic surgery with topical thrombin use. This potential complication should be strongly considered in any patient prior to using topical bovinethrombin, especially those with a prior exposure or history of surgical procedures in which bovinethrombin is commonly used.
Authors: Paul Ness; Michael Creer; George M Rodgers; Joseph J Naoum; Kenneth Renkens; Stacy A Voils; W Allan Alexander Journal: Patient Saf Surg Date: 2009-05-22