Surgical hemostasis may be achieved by using a number of physical, chemical, or
biologic methods. One such method is with topical
thrombin; however, one member of that class of drugs, bovine-derived
thrombin, is associated with potentially serious consequences such as development of immune-mediated coagulopathy. This case report describes a 61-year-old man with
peripheral artery disease who presented with a nonhealing
ulcer between his toes. Previous exposure to bovine
thrombin was unknown but was considered likely because of his extensive surgical history that included procedures in which topical
thrombin is commonly used. The patient was admitted and underwent lower extremity revascularization during which he received his first documented exposure to bovine-derived
thrombin. By postoperative day 9, he developed a 2.7-cm retroperitoneal
hematoma that had progressed to 9.6 cm by postoperative day 13. Evacuation of the
hematoma was performed, during which the patient received his second known exposure to topical bovine
thrombin. Based on a plasma mixing study on postoperative day 25, presence of
factor V and
thrombin inhibitors was suspected. A hematology consultation determined that the patient had developed an immune-mediated coagulopathy manifested as exaggerated laboratory coagulation values that continued even after discontinuation of oral anticoagulation, treatment with multiple transfusions of fresh frozen plasma, and intravenous
vitamin K administration. The patient was discharged, after no further
bleeding episodes had occurred, on postoperative day 29. Although determining previous exposure to bovine-derived
thrombin or presence of
antibodies can be difficult, a surgeon's index of suspicion should be raised in patients experiencing coagulopathy if they have previously undergone vascular, cardiac, or spinal procedures in which they were most likely exposed to topical
thrombin.