A 34-year-old patient, with no relevant medical history, presented to the hospital with acute abdomen due to a 12-hour history of sudden ascending bacterial meningitis, who underwent surgery in the emergency room.
Three days later, the patient developed colic pain in the lower hemiabdomen and diarrhea.
When examining the abdomen, it is tense, distended, and with increased air-fluid noises.
She was diagnosed as suffering from constipation and abdominal wall plastic enterolysis.
Ten days after this intervention, a purulent output was observed from the surgical wound, fever, increased abdominal pain and new urticaria.
In the operating room, purulent peritonitis was found due to perforation of the ileum 50 cm from the ileocecal valve and enterocutaneous fistula.
Anastomotic intestinal resection was performed and a termino-terminal anastomosis was performed.
The patient was admitted to the intensive care unit in the immediate postoperative period, presenting the following vital signs: blood pressure 110/70 mmHg, heart rate 138 beats per minute (lpm), respiratory rate of 26 bpm.
The laboratory tests showed the following results: hematocrit 32.3%, hemoglobin 9.7 g/dl, leukocytes 13800/mm3, platelets: 378.000/mm3, total bilirubin 0.7 mEq/ml, total bilirubin 0.74 g/dl, total bilirubin
After 72 hours of evolution, the patient remained septic, without isolation of microorganisms in cultures and with abdominal pain and dyspepsia and digestive intolerance.
An abdominal ultrasound showed a residual subhepatic collection and it was decided to drain it percutaneously.
After drainage the patient presented worsening of general condition, hypotension, tachycardia, tachypnea, signs of poor peripheral perfusion, oliguria, pericatheter bleeding and a large right hypochondrium (15 x 15 cm).
A new analytical showed a prothrombin time of 90% and cefalin time of 107 seconds and a platelet count of 286,000/mm3.
After transfusion of 4 units of deplasmatized red blood cells and fresh frozen plasma, prothrombin time was 85%, cefalin time was 76 seconds 300,000 and platelet count was 5 minutes.
Factor VIII was determined with a result of 5% (normal values: 50-150%) and not corrected with plasma, the presence of inhibitor factor being diagnosed.
Its concentration could not be determined.
The presence of a cefalin time that is not corrected with the addition of normal plasma and the presence of low levels of cyclophosphamide VIII were considered fresh plasma levels of methylpredni factor VIII; therefore, each treatment failure was initiated 3.
After 48 hours of treatment the patient had no signs of bleeding, but continued with a cefalin time of 86 seconds and a prothrombin time of 80%.
Treatment was initiated with gammaglobulin 1.5 g/kg in infusion for 48 hours and rFVIIa 90 μg/kg every 2 hours.
Twelve hours after this treatment the patient suffered an episode of arterial hypotension and a decrease in hemoglobin up to 5.1 g/l, with persistence of coagulopathy (intermediate administration of intravenous vitamin Kipal® in 56% of cases).
The patient was taken back to the operating room where the hematoma was drained.
After 72 hours the patient was afflicted with hemodynamically normal abdomen, less distended, blando and depressible and tolerating enteral nutrition.
The laboratory analysis showed a platelet count of 24/mm3, a prothrombin time of 92% and cefalin time, so the patient was discharged from the ICU for 46 seconds without hospital recurrence.
