Indian Journal of Critical Care Medicine September-October 2013 Vol 17 Issue 5
many developing countries, for example, prothrombin complex concentrates including factor eight inhibitor bypassing activity or are not widely accessible, for example, hemodialysis or continuous venovenous hemofiltration. Data regarding safety of dabigatran in elderly and underweight patients is sparse. In the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial, largest study conducted on dabigatran, average weight of dabigatran treated patients in the 110 and 150 mg group was 82.9 and 82.5 kg, respectively; with only a sixth of patients having weight below 73 kg. It is highly unlikely that RE-LY trial data can be extrapolated and used in an underweight patient like the present case. In a review of 78 bleeding episodes identified during an audit in Australia and New Zealand, advanced age was identified as one of the factors contributing to bleeding risk and this was compounded further by the presence of impaired renal function (common in elderly) and low body weight (<60 kg). Bleeding risk in these frail elderly patient was not completely mitigated by dose reduction. In RE-LY trial, compared to warfarin, dabigatran was associated with a small but significant increase in the rate of myocardial infarction (MI). In a recent meta-analysis of seven randomized control trials (n = 30,514), association of dabigatran with a higher risk of MI or acute coronary syndrome was confirmed further. Till cardiac risk of dabigatran is further investigated, clinicians should apply caution in prescribing the drug to high-risk patients. Current case illustrates the limitations of prescribing dabigatran in resource-limited setting and a need for appropriate prescriber education program to restrict complications of therapy.
Acknowledgment I sincerely acknowledge the clinical contributions of staffs and doctors from Critical Care, Gastroenterology, Nephrology, Fortis-Escorts Hospital, Faridabad.
Department of Critical Care Medicine, Fortis-Escorts Hospital, Neelam Bata Road, NIT, Faridabad, Haryana, India
Correspondence: Dr. Supradip Ghosh, Department of Critical Care Medicine, Fortis-Escorts Hospital, Neelam Bata Road, NIT, Faridabad, Haryana - 121 001, India. E-mail: [email protected]
Schiele F, van Ryn J, Canada K, Newsome C, Sepulveda E, Park J, et al. A specific antidote for Dabigatran: Functional and structural characterization. Blood 2013;121:3554-62.
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Dager WE, Gosselin RC, Roberts AJ. Reversing dabigatran in life-threatening bleeding occurring during cardiac ablation with factor eight inhibitor bypassing activity. Crit Care Med 2013;41:e42-6. Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009;361:1139-51. Harper P, Young L, Merriman E. Bleeding risk with Dabigatran in the frail elderly. N Engl J Med 2012;366:864-6. Uchino K, Hernandez AV. Dabigatran association with higher risk of acute coronary events. Arch Intern Med 2012;172:397-402. Access this article online Quick Response Code: Website: www.ijccm.org
An unusual cause of decrease in GCS in a patient with craniofacial injury Sir, A 40-year-old male with multiple injuries was referred to JPNA trauma centre 12 hours after road traffic accident. He had sustained craniofacial injury with fractured upper limb (LeFort type 2 facial injury and supracondylar fracture of right humerus). On examination, patient had an oxygen saturation Sp02 of 95% on oxygen mask (with a flow rate of 5lts/min), a heart rate of 115/min and blood pressure 90/60 mm Hg. GCS on examination was E1V1M1. He had received initial care at the referring private hospital, where a Foley catheter was inserted in the right nasal cavity to control epistaxis, and a cast was applied for the fractured humerus. At the time of referral from the previous hospital the GCS was 10 (E2V4M4). In the time interval of 3 hours to arrival at our ED, the GCS had deteriorated to 3. A CT head on arrival showed that the tip of the Foley’s catheter lay in the left parietal region intracranially with the inflated balloon located in the left centrum semiovale [Figure 1]. There was cerebral edema with parietal hypodensity, suggestive of an infarct. In view of the low GCS, it was decided to shift the patient to the ICU and manage him conservatively with ICP monitoring, controlled ventilation, and antibiotics. As the coagulation profile of the patient was normal, the
Indian Journal of Critical Care Medicine September-October 2013 Vol 17 Issue 5
• Advancing the catheter parallel to the floor of nasal cavity • Advancing the catheter up to a distance of 11 to 13 cm and confirming the visualization of the catheter tip in the oropharynx • Clinically and radiographically identifying the catheter tip before inflating the balloon.
Figure 1: Plain axial CT head showing tip of Foley catheter in the parietal region
balloon of the Foleys was gradually deflated followed by removal of the catheter. A repeat CT showed no change in the size and extent of the infarct. Despite all efforts, patient expired on the 4th day of admission. The initial management of craniofacial trauma is more challenging than the management of head trauma alone. The use of pressure application to control epistaxis is an age-old, time-tested method. Among many devices, Foley catheter is one of the more frequently used, especially in a resource-limited setting. This is despite the fact that the Foley catheter is not designed for this purpose and can cause various complications such as balloon malposition, bleeding, and pressure necrosis.[1,2] Since it is very difficult to ascertain the correct intranasal length required for successful hemostatis, chances of balloon malpositions are high. There have been earlier case reports where the balloon had been inflated in the intracranial cavity.[3,4] Hence, we recommend that posterior nasal packing with Foley catheter should be discouraged in patients with craniofacial injuries. Endoscopic cauterization should be the preferred method. If at all a Foley catheter has to be used in an emergency, a few principles should be followed: • Use of a large bore catheter as it will have less tendency to migrate intracranially
While the use of a Foley catheter for control of nasal bleeding has been described previously, and indeed the correct ‘off-label’ use of such a device may be a useful first aid, we wished to highlight the potential catastrophic consequences that such an approach can entail.
Department of Anaesthesia and Critical Care, All India Institute of Medical Sciences, Patna, 1Anaesthesia and Critical Care, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, 2Neuroanaesthesia, All India Institute of Medical Sciences, New Delhi, 3Anaesthesia and Critical Care, JPNATC, AIIMS, New Delhi, India Correspondence: Dr. Chandni Sinha, 112, B2, type 4, AIIMS residential complex, Khagaul, Patna, India. E-mail: [email protected]
References 1. 2. 3. 4. 5.
Hartley C, Axon PR. The Foleys catheter in epistaxis management: A scientific appraisal. J Laryngol Otol 1994;108:399-402. Ho EC, Mansell NJ. How we do it: A practical approach to Foley catheter posterior nasal packing. Clin Otolaryngol Allied Sci 2004;29:754-7. Pawar SJ, Sharma RR, Lad SD. Intracranial migration of Foley catheter: An unusual complication. J Clin Neurosci 2003;10:248-9. Woo HJ, Bai CH, Song SY, Kim YD. Intracranial placement of a Foley catheter: A rare complication. Otolaryngol Head Neck Surg 2008;138:115-6. Bhattacharya N, Gopal HV. Examining the safety of nasogastric tube placement after endoscopic sinus surgery. Ann Otol Rhinol Laryngol 1998;107:662-4.
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