Acquired absolute vitamin K deficiency in a patient undergoing warfarin therapy.

We report a case of absolute vitamin K deficiency (VKD) diagnosed by measuring serum VK levels in an elderly woman undergoing warfarin therapy. A 78-year-old woman was admitted to our hospital because of dyspnea and sore throat diagnosed as pharyngitis 1 week before admission. On admission, the sore throat had exacerbated and dyspnea developed. She had history of atrial fibrillation, for which warfarin 1.5 mg/d was started approximately 10 years prior and her international normalized ratio (INR) had been maintained at an acceptable therapeutic level. Blood results revealed unmeasurable INR and abnormally prolonged activated partial thromboplastin time (APTT). She was diagnosed with adenoiditis and warfarin-related coagulopathy and administered intravenous VK (20 mg) and fresh frozen plasma (FFP; 4 U), which improved INR and APTT. Since the coagulopathy responded to intravenous VK administration, the patient was clinically diagnosed with warfarin-related relative VKD. Approximately 1 month later, she returned with complaints of sore throat. Blood results indicated abnormal INR (7.22) and APTT (N80.0 s). She was diagnosed with recurrent adenoiditis and VK deficient coagulopathy. The patient's serum VK levels were low (VK1 level, 0.13 ng/mL; VK2 levels, 0.85 ng/mL). Initial treatment of VK (20 mg) and FFP followed by intravenous VK (20 mg/d) for 6 days, her symptoms dissipated. Warfarin was suspected to have caused absolute VKD. Severe coagulopathy in patients undergoing warfarin therapy is primarily caused by, relative VKD. However, the possibility of warfarin-related absolute VKD should be suspected when INRis not sufficiently improved by intravenous VK administration.

Comparison of sedation using propofol vs. midazolam in patients admitted to the intensive care unit after extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: a multicentre observational study.

AIMS: Optimal sedation regimens for patients after extracorporeal cardiopulmonary resuscitation (ECPR) remain unclear. This study compared the outcomes of patients who received propofol and midazolam for sedation post-ECPR for out-of-hospital cardiac arrest (OHCA). METHODS AND RESULTS: A retrospective cohort study analysed data from the Study of Advanced Life Support for Ventricular Fibrillation with Extracorporeal Circulation in Japan, including patients admitted to 36 intensive care units (ICUs) in Japan post-ECPR for OHCA of cardiac aetiology between 2013 and 2018. One-to-one propensity score-matched analysis compared outcomes between patients post-ECPR for OHCA who received exclusive treatment with a continuous propofol infusion (propofol users) and those who received exclusive treatment with a continuous midazolam infusion (midazolam users). The cumulative incidence and competing risk methodology were used to compare the time to liberation from mechanical ventilation and ICU discharge. Propensity score matching created 109 matched pairs of propofol and midazolam users with balanced baseline characteristics. Competing risk analysis for the 30-day ICU period showed no significant difference in the probability of liberation from mechanical ventilation (0.431 vs. 0.422, P = 0.882) and ICU discharge (0.477 vs. 0.440, P = 0.634). Furthermore, there was no significant difference in the proportion of 30-day survival (0.399 vs. 0.398, P = 0.999), 30-day favourable neurological outcome (0.176 vs. 0.185, P = 0.999), and vasopressor requirement within 24-h post-ICU admission (0.651 vs. 0.670, P = 0.784). CONCLUSION: This multicentre cohort study revealed no significant differences in mechanical ventilation duration, ICU stay length, survival, neurological outcomes, and vasopressor requirement between propofol and midazolam users admitted to the ICU after ECPR for OHCA.

A minimally invasive multiple percutaneous drainage technique for acute necrotizing pancreatitis.

BACKGROUND: In approximately 20% of patients, necrotizing pancreatitis is complicated with severe acute pancreatitis, with high morbidity and mortality rates. Minimally invasive step-up approach is both safe and effective, but sometimes requires multiple access sites. METHODS: A 62-year-old woman was admitted with diabetic ketoacidosis, and initial computed tomography (CT) revealed no evidence of acute pancreatitis. She was clinically improved with insulin therapy, fluid administration, and electrolyte replacement. However, on the 14(th) day of admission, she developed a high-grade fever, and CT demonstrated evidence of acute necrotizing pancreatitis with a large collection of peripancreatic fluid. Percutaneous transgastric drainage was performed and a 14 French gauge (Fr) pigtail catheter was placed 1 week later, which drained copious pus. Because of persistent high-grade fever and poor clinical improvement, multiple 8 and 10 Fr pigtail catheters were placed via the initial drainage route, allowing the safe and effective drainage of the extensive necrotic tissue that was occupying the bilateral anterior pararenal space. RESULTS: After drainage, the patient recovered well and the last catheter was removed on day 123 of admission. CONCLUSIONS: Multiple percutaneous drainage requires both careful judgment and specialist skills. The perforation of the colon and small bowel as well as the injury of the kidney and major vessels can occur. The current technique appears to be safe and minimally invasive compared with other drainage methods in patients with extended, infected necrotic pancreatic pseudocysts.