Acute arterial thrombosis associated with inadvertent high dose of tranexamic acid
A 27-year-old male with no known co-morbidity sustained penetrating injuries to the perineum, rectum, bladder neck, and bowel following a fall on a sharp object. After initial resuscitation, he underwent surgical repair of his injury with ileostomy and primary repair of bladder neck injury. The perineum was contaminated with rectal content. After debridement and hemostasia, a delayed closure was planned. Patient had a stormy course in the intensive care unit (ICU), with the delayed abdominal closure being followed by wound dehiscence, ventilator-associated pneumonia and adult respiratory distress syndrome (ARDS). He was managed with ventilator support, antibiotics, parenteral nutritional, and thromboprophylasix with low molecular weight heparin (LMWH). Despite his stormy course, he was recovering from ARDS and healing perineal wound; In the 3rd week of his ICU admission, he had sudden bleeding from the bladder neck manifesting as hematuria through Foleys catheter and pericatheter bleeding from the urethra. The bleeding was managed with surgical exploration of perineal wound and direct compression. He was transfused with two unit of packed red blood cell (PRBC), and 1 gm of TA was ordered. But, by mistake, the patient received 10 gm of TA as bolus, followed by 1 gm infusion for 8 hrs. Patient was stabilized and was doing well on a ventilator until the attending nursing staff noticed pallor and coldness of the right lower limb after 6-8 hours of TA administration. Suspecting acute arterial occlusion, an urgent contrast angiography was done, which revealed arterial thrombosis involving right common iliac artery extending from the bifurcation of aorta up to the proximal femoral artery [].\nConsultation of a vascular surgeon was sought; the patient was systemically heparinized as per the hospital protocol to keep activated partial throboplastin time (aPTT) 2-2.5 times the control value. A few hours later, there was increasing pallor of the limb with loss of arterial pulsations in the entire lower limb with associated swelling. Immediate decompressive fasciotomy was done to prevent further ischemic injury. In view of worsening ischemic changes, the patient was planned for aorto-femoral bypass grafting. But, before he was prepared for the operating room, there was return of blood flow, skin color and arterial pulsations to the lower limb. Surgical intervention was postpone. Eventually, the patient recovered well from the arterial thrombosis and also from ARDS and was discharged from the ICU after about 10 days from the arterial thrombosis on LMWH prophylaxis.