2018 FSA Posters
P017: NON PHARMACOLOGIC ELEVATED PTT FOR ELECTIVE HAND SURGERYâ¦DELAY, TRANSFUSE OR PROCEED?
Matthew D Warrick, MD1, Tyler Wickas2; 1University of Florida Jacksonville, 2Florida State University
INTRODUCTION: An aPTT is a test that is frequently ordered prior to surgery to examine the intrinsic and common pathways of the coagulation cascade
Although frequently ordered, this test is rarely required for surgery and management of isolated unexpectedly elevated values posses a real challenge even for experts in hematology
Once the factors are appreciated the abnormal value must be framed in a clinical context in order to facilitate efficient and cost effective tests which will allow our pre-operative patient to receive her surgery in a timely fashion despite an isolated elevated aPTT only
See Figure 1 below for a diagram of the work up for an isolated elevated PTT
CASE: Pt is a 31 y/o AA female with a PMH significant for fibromyalgia, obesity, iron deficiency anemia and improved but continued menorrhagia despite uterine fibroid embolization who developed a left ulnar nerve palsy
Specifically, the pt showed an impaired ability to abduct or adduct the 2,3,4 and 5th digits, when asked to extend the fingers the 4th and 5th MCP joints were extended while the PIP and DIP joints remained flexed
The patient also illustrated impaired pain, temperature and light touch sensation over the medial aspect of the hand
Other relevant findings included some degree of thenar wasting and weakness of the abductor pollicis brevis
Presumably, due to the pts menorrhagia coagulation studies were completed prior to surgery by the pts PCP which illustrated a PTT value of 58
The pts PT/INR remained normal
Surgery was delayed and a hematology work-up revealed normal factor VIII, IX, XI activity without inhibitors, no evidence of Von Willebrand’s disease, negative lupus anticoagulant
On the morning of surgery a PTT was drawn that illustrated a value of 183s
A discussion was had between the peri operative team occured and the decision was made to transfuse 2 units of FFP and repeat the PTT
With 2 units of FFP the PTT corrected to 33 seconds
The patient received a carpal tunnel release (median nerve), cubital tunnel and Guyon’s canal release
Follow up with the patient did not reveal any bleeding related complications
CONCLUSIONS: Namely, we describe the case of an adult outpatient with a longstanding isolated elevated aPTT, no history of thrombosis and no active bleeding
What makes this case particularly challenging is that she may or may not have a history of bleeding given her menorrhagia
Although the work-up of the patient is incomplete the only remaining cascade members to explore are prekallikrin, HMWK and factor XII deficiencies
A deficiency of any three of the above factors is not associated with excessive clinical bleeding despite an elevated aPTT, but might be associated with some degree of thrombotic disease due to their role in turning plasminogen to plasmin which is a consideration in an immobile pt after surgery
This case illustrates the challenges for all anesthesiologists, surgeons, hematologists and patients who present for surgery with rare diseases
REFERENCES:
Tcherniantchouk, O, et al. The isolated prolonged PTT. American Journal of Hematology V. 88 issue issue 1 Jan 2013.