A 65-year-old man undergoes a technically difficult abdominal-perineal resection for a rectal cancer during which he receives 3 units of packed red blood cells. Four hours later, in the intensive care unit (ICU), he is bleeding heavily from his perineal wound. Emergency coagulation studies reveal normal prothrombin, paial thromboplastin, and bleeding times. The fibrin degradation products are not elevated, but the serum fibrinogen content is depressed and the platelet count is 70,000/mL. Which of the following is the most likely cause of his bleeding?
A 65-year-old man undergoes a technically difficult abdominal-perineal resection for a rectal cancer during which he receives 3 units of packed red blood cells. Four hours later, in the intensive care unit (ICU), he is bleeding heavily from his perineal wound. Emergency coagulation studies reveal normal prothrombin, paial thromboplastin, and bleeding times. The fibrin degradation products are not elevated, but the serum fibrinogen content is depressed and the platelet count is 70,000/mL. Which of the following is the most likely cause of his bleeding?
💡 Explanation
**Core Concept:** Abdominal-perineal resection is a surgical procedure for rectal cancer treatment. Post-operative bleeding can be due to various coagulation factors deficiencies or abnormalities. Normal coagulation studies suggest the absence of intrinsic or common pathway deficiencies.
**Why the Correct Answer is Right:** The patient received 3 units of packed red blood cells, which may have introduced donor platelets into the patient's circulation. However, the patient's platelet count is significantly depressed to 70,000/mL. The normal platelet count is around 150,000-450,000/mL. Platelet function abnormalities could lead to impaired hemostasis and increased bleeding tendency.
**Why Each Wrong Option is Incorrect:**
A. **Normal coagulation studies**: Prothrombin, partial thromboplastin time (PTT), and bleeding times are all within normal limits. This indicates that the intrinsic and common pathways are not deficient.
B. **Fibrinogen is normal**: Fibrinogen levels are also normal, ruling out fibrinogen deficiency as the cause of bleeding.
C. **Fibrin degradation products are not elevated**: Elevated FDP levels suggest fibrinolysis, which is not observed in this case.
D. **Impaired platelet function**: The patient's platelet count is significantly depressed, indicating impaired platelet function and contributing to the bleeding disorder.
**Clinical Pearl:** In cases of unexplained bleeding after blood transfusion, consider platelet function abnormalities in addition to coagulation factor deficiencies. A depressed platelet count can lead to impaired platelet function and increased bleeding tendency despite normal coagulation studies. This is particularly important when evaluating patients who have received blood products, such as platelets, during surgery or critical illness.
✓ Correct Answer: C. A bleeding blood vessel in the surgical field
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