病歷號碼：
5090509
床號：
679-A 姓名：王´
玉
年齡：
72歲 性別：男
入院日期：
2001年2月13日
Chief complaints:
Change in bowel habits and felt abdominal distension for months.
Present Illness:
The 72 y/o man has history of (1)arrhythmia with pacemaker for 20 +years , received CATH for 5~6 times at 臺大 or北榮 since 1975 and just discharged from our CV ward due to CAD1 with unstable angina;(2)essential hypertension;(3)DM.
He felt abdominal discomfort and received colonscope which revealed polyp . Polypectomy was performed. Then, he followed up at our OPD. In recent months, he suffered from change in bowel habits and felt abdominal distension. So, he went to our OPD for help, where colonofibroscope was performed on 2000.11.18 and biopsy revealed rectal malignant mass. He was suggested to accept C/T and R/T to reduce the size of tumor during 2000.11.27~2001.1.4.. This January, he suffered from acute cholecystitis with GB stone and received pig-tail drainage. Now, he was admitted for surgical intervention of rectal cancer and further management.
Laboratory data:
|
HE |
2/13 |
2/15 |
2/16 |
2/17 |
2/19 |
2/21 |
|
WBC 103/uL
RBC 106/uL
HGB g/dl
HCT %
MCV fL
MCH pg
MCHC %
Platelet 103/uL |
5.5
3.80
12.1
35.8
94.2
31.8
33.7
146 |
15.7
2.91
9.1
26.1
90.6
31.1
34.7
99 |
11.9
3.17
9.3
27.1
85.5
29.2
34.1
93 |
10.0
3.60
10.4
30.8
85.5
28.8
33.7
137 |
5.7
3.45
10.0
29.5
85.7
29.1
33.9
186 |
7.0
3.59
10.4
31.1
86.7
29.1
33.5
211 |
|
Pro. Time sec
N.C. sec
I.N.R.
ISI
APTT sec |
11.6
10.4
1.12
1.02
35.8 |
|
|
|
|
|
Impression:
Rectal adenocarcinoma s/p C/T and R/T
Hospital course:
|
2/14 op day: radical proctectomy with end-colostomy J-B
Hb :8.5 1605:BT PRBC 2u
G5W 1500cc+HR 6u HM 22u 12u KCl :40meq qd
Zantac 1 amp q8h |
|
2/15 Ismo(20)1/2 #bid Aspirin EML(100)1# qd
Hb:9.1 Plt:99000/uL
0615:BT PRBC 2u
1525:BT PRBC 2u J-B:220
2/16 Hb:9.3 Plt:93000/uL
Stop Aspirin EML(100)1# qd
Hold Transamin 1amp q8h + VitK1 1amp qd
1040:BT PRBC 2u
1335:BT FFP 6u
2350:BT plt 12u J-B :966
2/17 Hb:10.4 Plt:137000
0950:BT FFP 6u J-B:601
(2/15~2/17: Heart rate:100~140 bpm) |
|
2/18 1000:BT FFP 6u
1300:BT plt 12u J-B:470ml
2/19 J-B :405ml
2/20 N/S 1000cc qd Ismo(20)1/2# bid APAP 1# qid
(2/18~2/21 Heart rate: 90~120 bpm)
|
|
(2/22~2/23 Heart rate : 80~110 bpm)
|
Aspirin
(Antiplatelet drugs)
- Aspirin acetyles cyclooxygenase , blocking the formation of TXA2, can inhibit the function of platelet.
- Aspirin can increase release of PGI2.
- Administration:
- Low dose(600mg /day), t1/2=3 hrs; high dose(4g/day), t1/2=15 hrs
B. Complications:
- Drugs interaction should be considered.
- A single low dose of aspirin(80mg PO)irreversibly inhibits the entire circulating platelet pool. This effect generally diminishes over 10 days, the time required for biosynthesis of a new cohort of platelets.
- Patients on aspirin who are undergoing elective procedures should avoid taking the drug for 5 days before surgery.
- For rare patient with significant bleeding, platelet transfusion will compensate completely for aspirin-induced platelet dysfunction.
- Complications include GI discomfort, bleeding,respiration inhibit(acidemia), fever, hypersensitivity and Reye's syndrome( fulminant hepatisis and brain edema)
- Bleeding time was measured safely under direct colonoscopic visualization. Aspirin prolonged the colon bleeding time. Therefore, endoscopists should be aware of a risk of abnormal bleeding after endoscopic biopsy and polypectomy in patients with aspirin use. Two days were necessary for colon bleeding time to become normalized in patients with aspirin use. (Nakajima H, Takami H, Yamagata K, Kariya K, Tamai Y, Nara H. Aspirin effects on colonic mucosal bleeding: implications for colonic biopsy and polypectomy. Volume 40, Number 12, December 1997. Department of Medicine, Kuroishi City Hospital, and the First Department of Medicine, Hirosaki University School of Medicine, Aomori, Japan)
Heparin
(Thrombin inhibitors)
- Heparin is a natural inhibitor of coagulation derived from mast cells.
- It catalyzes the inactivation of thrombin and factors Xa and IX a by antithrombin III.
- Heparin administration at usual doses prolongs the thrombin time and aPTT, but generally not the PT.
- Treatment DVT and pulmonary embolism.
- Therapeutic range: aPTT 55~80 sec; normal range:24~40 sec
Administration:
- Its onset of action is immediated by the IV route and within 20~60 minutes by the SC route.
- It is cleared largely by the reticuloendothelial system, with a half-life of perhaps 1 hour after a bolus.
- Clearance is prolonged in liver or renal failure.
Complications:
- Bleeding occurs in 5~10 % of patients.
- Concomitant use of antiplatelet agents increases the risk of bleeding and should be avoided if possible.
- Stools should be monitored for signs of occult blood loss before and during heparin use.
- GI bleeding is a relative contraindication to heparin administration and warrants investigation for an underlying anatomic abnormality.
- Heparin can be reversed rapidly by infusion of protamine sulfate.
- Osteoporosis is a significant complication of long-term heparin use(>6 months).
- Contraindication: hypersensitivity reaction; bleeding disease; alcoholism; surgery of brain,eye and spinal
Coumadin
(Prothrombin inhibitors)
- Warfarin inhibits conversion of vitamin K to its active from.
- Administration of warfarin leads to depletion of the vitamin K-dependent clotting factors(II, VII, IX, and X)in addition to proteins C and S.
Administration :
- Warfarin is well absorbed orally but requires 4~5 days before a full anticoagulant effect is achieved.
- Warfarin should be started at a level dose(5 mg PO qd)and then adjusted to the target INR.(2.0~3.0 range,patients with mechanical valves require a higher intensity of anticoagulation :INR 2.5~3.5; INR =(patient PT/control PT)ISI)
- Complications:
- Bleeding occurs in 10~20% of patients treated with warfarin.
- Marked elevation of the INR(>5)
- In asymptomatic patients may be corrected partially with low-dose vitamin K.
- More serious bleeding should be managed in the same manner as that for vitamin K deficiency with infusion of FFP or vitamin K, depending on the urgency of the situation.
- Drug interaction should be considered.
- Warfarin is contraindicationted in the first trimester of pregnancy because of teratogenicity.
Transamin
(Fibrinolysis antagonist)
- Tranexamic acid can inhibit activation of plasminogen.
I1陳大隆309819
90.2.24.