 Welcome back to the meds smarter question of the week before we begin Please click that like button and also subscribe and turn the bell on so you'll be notified when we post new content Let's begin on that question As always we start with the last sentence of the question and then we'll read the rest of the vignette What is the most appropriate treatment for this patient's coagulopathy a 50 year old obese female with poorly controlled non-insulin dependent diabetes Melitis presents with fever ten thirty nine point four degrees Celsius or one hundred and two point nine degrees Fahrenheit jaundice Hypotension and an acute onset of right upper quadrant pain Abdominal imaging shows multiple gallstones and cholecystitis an urgent collect me is performed and subsequent gallbladder fluid and blood cultures grow aerobic non-lactose fermenting oxidized positive gram negative rods The blood tests are as follows Hematocrit 25% white blood cell count fifteen thousand three hundred platelet count eighty thousand INR or international normalized ratio of three point two D dimer 8200 Fibrogen levels are low Microscopic inspection of peripheral blood smears shows schistocytes and multiple helmet cells Clinically, there is no evidence of active bleeding What is the most appropriate treatment for this patient's coagulopathy? Well before we look at the answer choices Let's talk about these lab values for a female the normal hematocrit levels are going to be 36 to 46 percent So 25 percent is low white blood cell count typically is going to be in the range of 4500 to 11,000 so Fifteen thousand three hundred is elevated platelet count is typically between 150,000 to 400,000 So a level of 80 means that we are very low our INR levels should be around one so we are High on our INR and our normal D dimer levels should be less than 0.5 So we are very high on our D dimer levels once again if I bring in levels already told us that it is low So now that we know that piece of information, let's go ahead and take a look at our answer choices a Fresh frozen plasma B vancomycin C amoxicillin D as trianam or E vitamin K Take a minute read the question and answer choices again Come up with your answer and then write the answer in the comment box below Well, we know from this question that we're dealing with a Microbacteria because the blood cultures and the gallbladder fluid grow an aerobic non lactose fermenting Oxidase positive gram negative rod What does that describe if you remember back to your microbiology? This is pseudomonas So pseudomonas along with fever jaundice hypotension and right upper quadrant pain This gives us that great picture of cholecystitis, which we've got a diagnosis for already that it a collect me now what we're trying to deal with is this issue of Bleeding and our lab values So we are dealing with what appears to be DIC with our elevated D dimer low platelets But we also have this sepsis Due to pseudomonas that is something that's important to remember here. So what do we need to do for this patient? We don't see any signs of active bleeding. So this is a key point here so with no active bleeding signs of Bacterial growth of pseudomonas. We want to treat that pseudomonas first and foremost because that's our underlying condition causing Us to be in DIC. So how do we treat pseudomonas? Fresh frozen plasma is not that's going to be treating DIC only we want to treat the underlying condition here Vencomycin, Vencomycin is a very good medication to use for things like methicillin resistant staph aureus and C-diff however, we don't use this for pseudomonas. So Vencomycin is not a Option here amoxicillin while amoxicillin is a great Extended spectrum medication. It does not provide any coverage for pseudomonas as Trianam I do know that we use as trianam for Pseudomonas, so I'm gonna keep that as an option and let's continue on E vitamin K that will not help us get rid of the pseudomonas infection So it's marked that out that leaves us with D as our final choice and D is the correct answer as trianam. So what we're seeing with this patient with our fever jaundice High-potension and acute onset right upper quadrant pain. This is classic of the charco's triad And we add that with our leukocytosis, which is our high white blood cell count That gives us that picture of cholecystitis. So we're dealing with the Aerobic non-lactose fermenting oxase positive grand negative rod on top of the signs and symptoms of disseminated intravascular coagulation or DIC So we're going to use as trianam in this case As trianam if you can remember is a beta-lactamase resistant Antibiotic that it will interfere with our cell wall biosynthesis So it's going to bind to the penicillin binding protein 3 and stop the cell wall formation in those bacteria If you are studying for the step 2 or step 3 boards Remember that as trianam does have a low bioavailability when given orally So we will use this either intravenous or nebulized to help with that bioavailability