Bleeding duodenal ulcer on rivaroxaban79-year-old man, 70 kg, for emergency laparotomy to under-run a bleeding duodenal ulcer after failed endoscopy

The patient

The examiner asks

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1. Consider

   What are your concerns?

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   • A 79-year-old on rivaroxaban, bleeding from a duodenal ulcer, for emergency laparotomy after failed endoscopy. Patient
   • At 79 and shocked, his risk is high; I agree goals of care with him and his family.
   • Blood fills his stomach: rapid sequence induction, suction in hand. Airway
   • His rivaroxaban, taken 8 hours ago, is still active; levels are low only after about 3 days. Disease
   • Emergency: we proceed now, with no cardiac testing. Stem trigger

2. Prepare

   How do you prepare in the time you have?

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   • Massive transfusion protocol activated now, with a rapid infuser and warmer. (Disease)
   • Two large-bore lines and an arterial line, ideally before induction.
   • Reverse his rivaroxaban with andexanet: 400 or 800 mg bolus, then a 2-hour infusion.
   • High or low dose depends on his rivaroxaban dose and the 8-hour gap since it.
   • If andexanet isn't available, prothrombin complex concentrate, though evidence for it is thin.
   • Andexanet has its own clot risk; roughly 1 in 10 clotted within a month.
   • Baseline clotting, fibrinogen, ionised calcium and viscoelastic testing if we have it.

3. Plan

   Take me through your induction and resuscitation plan.

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   • Nasogastric tube aspirated, head-up, suction on, preoxygenated. Airway
   • Etomidate reduced to 0.15–0.2 mg/kg for his age and shock.
   • Rocuronium 1.2 mg/kg for rapid sequence.
   • Permissive hypotension until the surgeon controls the ulcer, then full resuscitation. Disease
   • Early blood products; little crystalloid, which dilutes his clotting and loosens clot.
   • Keep him warm and correct acidosis and calcium as we go.

4. Crisis

   The ulcer is opened and bleeding is torrential. BP 64/30, HR 140. What do you do?

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   • Massive haemorrhage: surgical control comes first, so the surgeon presses on the bleeding vessel now. (Crisis)
   • Red cells, plasma and platelets given 1:1:1 through the warmer.
   • Andexanet now if not yet given; his rivaroxaban is feeding this bleed.
   • Viscoelastic results guide his fibrinogen and plasma.

5. Crisis

   After 12 units, BP is 70/40 despite volume. Ionised calcium is 0.78 mmol/L and his QT is long. What now?

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   • Citrate in the blood has bound his calcium; that's causing hypotension and risks arrhythmia. Crisis
   • Calcium chloride 10%, 10 mL over 10 minutes, then a calcium gluconate infusion.
   • Over 1 unit every 10 minutes keeps dropping it, so I recheck every few units.
   • Low calcium also weakens his heart's contraction.
   • Temperature and pH checked too: cold and acidosis worsen his clotting.
   • After surgery: ICU; anticoagulation restarts only when surgeon and cardiology judge the bleed safe. After surgery