How Far Do You Go?

A gentleman with bipolar disorder intentionally walks into traffic and is hit by a high speed vehicle. Rushed to the hospital, he's found to have multiple injuries including an aortic injury, pelvic fracture, lumbar spine fracture, and fractures of one arm and both legs. Because of his aortic injury, he is emergently taken to the cath lab for placement of a thoracic aortic graft. While the procedure goes smoothly, his initial labs from the emergency department give us pause. His INR, a measure of coagulability, is over 4, dramatically elevated. His platelets are bordering on 100,000 the limit where most would do elective surgery. The cardiac anesthesia team starts transfusing fresh frozen plasma, platelets, as well as blood. We don't know why his lab values are so abnormal - whether he is taking warfarin or if he has liver dysfunction or if it's something else - but we treat empirically given his multiple injuries.

His care is then transferred to me from the cardiac anesthesia team. The orthopedic surgeons begin fixing an open fracture. Hemodynamically, requiring only intermittent boluses of low dose pressors. His INR has trended down to 2.4, closer to normal, but the platelets have plummeted to 50,000 with an unclear cause. Ideas of heparin-induced thrombocytopenia or dilutional coagulopathy cross my mind as I pour in more blood products. He's cold at 34.5 degrees Celsius, which doesn't help the bleeding. And most of all, we don't know what other medical problems the patient has, why his liver seems to be failing, what other medications he was on.

As the anesthesiologist, I am consulted by the surgery intensive care team, the spine service, and the orthopedic surgeons about whether they should proceed with further surgeries. Once the open fracture is fixed, they would like to fixate the pelvis, stabilize the lumbar spine burst fracture, and work on the arm. They would like to do these procedures within 48 hours, but they don't have to be done now. How do I weigh the risks and benefits of proceeding or sending him to the ICU for workup and stabilization before further surgeries?

This is a tough question because there are too many unknowns. The patient had already been through about eight hours of anesthesia and undergone a major aortic procedure. Could we get him through one more surgery? In the end, I advised that given his dropping platelets without a clear reason, his elevated INR, his temperature, and his multiple transfusions, that we get him to the ICU. There are a lot of risks with an unstable pelvis and unstable spine, but I felt that a night in the ICU could stabilize him. I was worried that his kidneys took a hit during the cath lab procedure, that his liver may be failing from unrecognized injury or hypotensive episodes, and that we didn't know his mental status. These hard decisions, trying to weigh a lot of unknowns, make intensive care medicine very challenging.