ワーファリン服用者の呼吸苦

ワーファリン服用者の呼吸苦にはこんなケースもあるのだというカナダはトロントからの報告。

N Engl J Med 2016; 374　January 21, 2016

Spontaneous Retropharyngeal Hematoma

Noah Ditkofsky, M.D., and Tarek Hanna, M.D.

INRが11以上である。INRの値というのは高値だからどうだ・・という話でもないようだが、非循環医としてはやはり「ビビる」のが正しい反応だろう。小生の外来でもワーファリンを投与されている患者殿は山のようにいるが、INRチェックが疎かになっている患者殿がいないかどうか気をつけよう。

どうやら挿管はせずに済んだようだ。ICUに４日。急いで凍結血漿を投与している（なんせINRが11以上で出血である）。気道であるが気管支鏡所見として「patent airway」と記述されている。この右の写真はかなり危なくみえるが、いい度胸だと思うな。

• A 56-year-old man presented to the emergency department with a 5-hour history of throat swelling and pain and difficulty breathing that was exacerbated by supine positioning; he had not had any obvious antecedent trauma. His medical history included prostate cancer, hypertension, hyperlipidemia, deep-vein thrombosis, and stroke. Medications included warfarin (presumably for deep-vein thrombosis), antihypertensive agents, and a statin. He was afebrile, and the physical examination was notable for minor swelling of the posterior oropharynx. Laboratory studies revealed a normal white-cell count, an international normalized ratio of more than 11, a prothrombin time of more than 120 seconds, and an activated partial-thromboplastin time of 127 seconds. Radiography of the neck revealed marked soft-tissue swelling that was causing mass effect on the airway (Panel A); the findings on a subsequent computed tomographic scan of the neck were consistent with a retropharyngeal hematoma, which was probably caused by supratherapeutic anticoagulation (Panel B shows the sagittal view, and Panel C the axial view; the arrow in each panel indicates the hematoma). Transnasal laryngoscopy revealed a bulging posterior pharynx but a patent airway. The patient was administered 6 units of fresh-frozen plasma and was admitted to the intensive care unit for observation. His coagulopathy resolved, as did his symptoms, and he was discharged 4 days after admission.