What is the most appropriate initial fluid therapy for an adult patient with a metallic valve on warfarin (anticoagulant), presenting with symptoms of significant bleeding (bloody stool), hypovolemic shock (hypotension, cold periphery, pallor), severe anemia (low Hemoglobin), and laboratory evidence of over-anticoagulation (elevated International Normalized Ratio (INR), prolonged Prothrombin Time (PT), and prolonged Activated Partial Thromboplastin Time (APTT))?

Management of Life-Threatening Warfarin-Associated Gastrointestinal Bleeding in a Patient with Mechanical Valve

The most appropriate fluid therapy is D. Packed RBC, which must be administered immediately alongside prothrombin complex concentrate (PCC) to address both the hemorrhagic shock and the coagulopathy. 1

Immediate Resuscitation Strategy

This patient is in hemorrhagic shock (hypotension 90/65 mmHg, cold periphery, pallor) with severe anemia (Hb 6 g/dL) and critical over-anticoagulation (INR 7). Crystalloids alone (Ringer's lactate or normal saline) are contraindicated as primary resuscitation in massive hemorrhage with severe anemia because they worsen dilutional coagulopathy and fail to restore oxygen-carrying capacity. 1

Why Packed RBCs Are Essential

• Packed RBCs must be transfused to target hemoglobin >7-8 g/dL and maintain hemodynamic stability in patients with life-threatening bleeding and elevated INR. 1
• The patient's hemoglobin of 6 g/dL with ongoing bleeding and shock mandates immediate blood product replacement, not crystalloid resuscitation 1
• Fresh whole blood or fresh frozen plasma (200-500 mL) can also be used in emergency situations of severe hemorrhage, though packed RBCs are preferred when significant blood loss has occurred 2

Concurrent Coagulopathy Reversal (Beyond the Question Scope, But Critical)

While the question asks specifically about "fluid therapy," this patient requires simultaneous management:

• Prothrombin complex concentrate (PCC) 25-50 U/kg IV plus vitamin K 10 mg by slow IV infusion must be administered immediately alongside packed RBCs. 1
• PCC provides rapid reversal of warfarin effect and is superior to fresh frozen plasma for emergency reversal 1
• Despite the mechanical valve, the immediate bleeding risk outweighs the delayed thrombosis risk, justifying both PCC and vitamin K administration 1
• Vitamin K takes 12-24 hours to work but provides sustained reversal 1

Fresh Frozen Plasma Considerations

• If coagulopathy persists after PCC, fresh frozen plasma (FFP) at 15-30 mL/kg should be administered, with at least 30 mL/kg required for established coagulopathy with PT/aPTT >1.5 times normal. 1
• FFP is reasonable in patients with mechanical valves and uncontrollable bleeding who require reversal of anticoagulation 3
• However, inadequate FFP dosing (1-2 units) is insufficient for established coagulopathy 1

Why Other Options Are Incorrect

A. Ringer's lactate - Crystalloids worsen dilutional coagulopathy in massive hemorrhage and fail to restore oxygen-carrying capacity; they should not be used as primary resuscitation 1

B. Protein purified factor (PCC) - While PCC is absolutely necessary for this patient, it addresses coagulopathy but not the hemorrhagic shock from severe anemia. The question asks about "fluid therapy," and PCC alone without packed RBCs will not restore hemodynamic stability or oxygen-carrying capacity 1

C. Normal saline - Same rationale as Ringer's lactate; crystalloids are contraindicated as primary therapy in this scenario 1

Critical Management Pitfalls to Avoid

• Never delay packed RBC transfusion in favor of crystalloid resuscitation in hemorrhagic shock with severe anemia 1
• Never withhold vitamin K and PCC due to prosthetic valve concerns, as life-threatening bleeding takes precedence over thrombosis risk 1
• Infusions of blood or plasma should be monitored carefully to avoid precipitating pulmonary edema in elderly patients or patients with heart disease 2
• The risk of valve thrombosis during brief anticoagulation interruption is approximately 0.08-0.16% for 3 days, far lower than the immediate mortality risk from uncontrolled hemorrhage 3

Monitoring Requirements

• Serial INR measurements every 6 hours to monitor for rapid changes 4
• Target INR <1.5 for major bleeding control 1
• Daily hemoglobin, electrolytes, and renal function while active bleeding continues 3
• Platelets should be maintained ≥75 × 10⁹/L (note: this patient has thrombocytosis at 550, so platelet transfusion is not needed) 1