Case Presentation: Introduction: In a hospital medicine service, how often do we come across the conundrum of a high risk bleeder who has a high risk for clot? This is one of the more common clinical scenarios that plague us as providers. A double edged sword, we talk about the dire consequences on either side of choices we make, the patient makes and the family makes.
Case: We describe an 82 year old female with a complicated past medical history including Stage 4 adenocarcinoma of right lung post chemotherapy and radiation therapy, Protein C deficiency on chronic warfarin, chronic atrial fibrillation, systolic heart failure, mitral regurgitation, End Stage Renal Disease on hemodialysis, who was admitted for hematemesis.
Her vitals on presentation were in the stable range and on lab work was found to have chronic but stable anemia and International Normalized Ratio (INR) of 2.87. Along with fluid resuscitation and blood transfusion, her warfarin was held and she was kept on a pantoprazole drip and the non-emergent endoscopy that followed showed her to be bleeding from esophagitis which was managed conservatively. Incidentally, in the CT scan done to screen for a recurrence of her lung cancer, she was found to have a pericardial effusion that was approaching tamponade physiology on further echocardiogram assessment, for which a pericardial window with pleural drainage catheter was placed.
On day 9 of admission, her dialysis was cut short due to visible clots in the machine and she was found to have clots in her AV Fistula as well. She was started on a Heparin drip, resumed on warfarin and Vascular Surgery performed a thromboembolectomy but unfortunately the patient threw an embolus into her brachial artery, for which she had an emergent embolus retrieval.
She was doing well for a while thereafter but had an acute drop in her hematocrit, concerning for another bleed. Her heparin drip and warfarin were again held, she was transfused a unit of blood and the help of hematology and gastroenterology was sought. There was no large retroperitoneal bleed and she was not scoped again given her age, recent endoscopy and risk of both bleeding and clotting.
As we stopped the anticoagulation, her dialysis catheter, freshly placed after the fistula dysfunction, clotted as well. Extensive talks were done with the patient and the family of the risks on either side of the treatment scale. The patient decided that she had had enough and did not want any further treatment and wanted to go home on comfort measures. The team offered to send her home on Heparin subcutaneous injections in the prophylactic doses for deep vein thrombi in hopes to do least harm of bleeding while still minimally preventing clotting events but she declined and was sent home on sublingual morphine.
Discussion: Discussion: This case posed the classic dilemma of a patient with good indications for anticoagulation and a contraindication secondary to bleeding. It is a common conundrum faced by doctors and each case has to be dealt with individually taking into account wishes of family and patient along with opinion from experts.
Conclusions: There is no right or wrong answer when this kind of case presents itself. It should be, in our view, a combined decision made on patient and family preference, supplemented by expert opinion and any harm must be first avoided. Any complications faced along the way should be dealt with as they arise,