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October 9, 1987, Vol 258, No. 14 >
ARTICLE | October 9, 1987

Coagulopathy Caused by Vitamin K Deficiency in Critically III, Hospitalized Patients FREE

Jack B. Alperin, MD
[+] Author Affiliations

Reprints not available.


JAMA. 1987;258(14):1916-1919. doi:10.1001/jama.1987.03400140078028
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References

A coagulopathy due to vitamin K deficiency was discovered in 42 hospitalized patients, most of whom had been misdiagnosed as having disseminated intravascular coagulation. Factors contributing to vitamin deficiency included inadequate diet, malabsorption, failure of physicians to prescribe vitamin K supplements, antibiotic therapy, renal insufficiency, hepatic dysfunction, recent major surgery, and possibly pregnancy. Sixteen patients (34%) bled sufficiently to need red blood cell transfusions and ten patients (24%) ultimately died. Of 18 patients who also had thrombocytopenia, three did have disseminated intravascular coagulation. The deficiency, a contributor to morbidity and mortality, can be prevented by prophylactic administration of vitamin K to severely ill patients who are eating inadequately and receiving antibiotics.

(JAMA 1987;258:1916-1919)

REFERENCES

1 +
Warner ED, Brinkhous KM, Smith HP:  Bleeding tendency of obstructive jaundice: Prothrombin deficiency and dietary factors . Proc Soc Exp Biol Med 1939;;37:628-630.
2 +
Waddell WW, Gurerry DP, Bray WE, et al:  Possible effects of vitamin K on prothrombin and clotting time in newly-born infants . Proc Soc Exp Biol Med 1939;;40:432-434.
3 +
Kark R, Lozner EL:  Nutritional deficiency of vitamin K in man . Lancet 1939;;2:1162-1164.
4 +
Olsen RE:  Vitamin K , in Coleman RW, Hirsh J, Marder VJ, et al (eds): Hemostasis and Thrombosis . Philadelphia, JB Lippincott, 1982;, pp 582-592.
5 +
Olsen RE:  The function and metabolism of vitamin K . Ann Rev Nutr 1984;;4:281-337.
6 +
Suttie JW:  Vitamin K-dependent carboxylase . Ann Rev Biochem 1985;;54:459-477.
7 +
Ham JM:  Hypoprothrombinaemia in patients undergoing prolonged intensive care . Med J Aust 1971;;2:716-718.
8 +
Pineo GF, Gallus AS, Hirsh J:  Unexpected vitamin K deficiency in hospitalized patients . Can Med Assoc J 1973;;109:880-883.
9 +
Ansell JE, Kumar R, Deykin D:  The spectrum of vitamin K deficiency . JAMA 1977;;238:40-42.
10 +
Reddy J, Bailey RR:  Vitamin K deficiency developing in patients with renal failure treated with cephalosporin antibiotics . NZ Med J 1980;;92: 378-380.
11 +
Corrigan JJ:  Vitamin K-dependent coagulation factors in gram-negative septicemia . AJDC 1984;; 138:240-242.
12 +
Jones PG, Strother SV, Rolston KVI, et al:  Hypoprothrombinemia in patients with cancer receiving cefoperazone and mezlocillin . Arch Intern Med 1986;;146:1397-1399.
13 +
Triplett DA, Harms CS: Procedures for the Coagulation Laboratory . Chicago, American Society of Clinical Pathology Press, 1981;.
14 +
Bessman JD:  Evaluation of automated whole-blood platelet counts and particle sizing . Am J Clin Pathol 1980;;74:157-162.
15 +
Triplett DA (ed): Laboratory Evaluation of Coagulation . Chicago, American Society of Clinical Pathology Press, 1981;.
16 +
Cohen P, Gardner FH:  Thrombocytopenia: A laboratory sign and complication of gram-negative bacteremic infection . Arch Intern Med 1966;;117: 113-124.
17 +
Mant MJ, King EG:  Severe, acute disseminated intravascular coagulation: A reappraisal of its pathophysiology, clinical significance and therapy based on 47 patients . Am J Med 1979;;67:557-563.
18 +
Mant MJ, Hirsh J, Pineo GF, et al:  Prolonged prothrombin time and partial thromboplastin time in disseminated intravascular coagulation not due to deficiency of factors V and VIII . Br J Haematol 1973;;24:725-734.
19 +
Physicians Desk Reference , ed 41. Oradell, NJ, Medical Economics Books, 1987;.
20 +
Ramotar K, Conly JM, Chubb H, et al:  Production of menaquinones by intestinal anaerobes . J Infect Dis 1984;;150:213-218.
21 +
Udall JA:  Human sources and absorption of vitamin K in relation to anticoagulation stability . JAMA 1965;;194:107-109.
22 +
Frick PG, Riedler G, Brogli H:  Dose response and minimal daily requirement for vitamin K in man . J Appl Physiol 1967;;23:387-389.
23 +
Physicians Desk Reference for Nonprescription Drugs , ed 8. Oradell, NJ, Medical Economics Books, 1987;.
24 +
Covington TR, DiPalma JR (eds):  Blood modifiers , in Facts and Comparisons: Drug Information . Philadelphia, JB Lippincott, 1986;, pp 84-86.
25 +
Ivey M, Elmer G:  Nutritional supplement, mineral, and vitamin products , in Laitin SC (ed): Handbook of Nonprescription Drugs . Washington, DC, American Pharmaceutical Association, 1982;, pp 207-257.
26 +
Conly JM, Ramotar K, Chubb H, et al:  Hypoprothrombinemia in febrile, neutropenic patients with cancer: Association with antimicrobial suppression of intestinal microflora . J Infect Dis 1984;; 150:202-213.
27 +
Sattler FR, Colao DJ, Caputa GM, et al:  Cefoperazone for empiric therapy in patients with impaired renal function . Am J Med 1986;;81: 229-236.
28 +
Brown BB, Klar J, Lemeshow S, et al:  Enhanced bleeding with cefoxitin or moxalactam: Statistical analysis within a defined population of 1493 patients . Arch Intern Med 1986;;146:2159-2164.
29 +
Fainstein V, Bodey GP, McCredie KB, et al:  Coagulation abnormalities induced by β-lactam antibiotics in cancer patients . J Infect Dis 1983;; 148:745-750.
30 +
Lipsky JJ:  N-methyl-thio-tetrazole inhibition of the gamma carboxylation of glutamic acid: Possible mechanism for antibiotic-associated hypoprothrombinaemia . Lancet 1983;;2:192-193.
31 +
Aronoff GR, Cockerell CA, Moorthy R, et al:  Methylthiotetrazole and antibiotic induced hypoprothrombinemia , abstracted. Clin Res 1986;;34: 394A.
32 +
Olson JA:  Recommended dietary intakes (RDI) of vitamin K in humans . Am J Clin Nutr 1987;;45: 687-692.
33 +
Council on Scientific Affairs:  Vitamin preparations as dietary supplements and as therapeutic agents . JAMA 1987;;257:1929-1936.

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1 +
Warner ED, Brinkhous KM, Smith HP:  Bleeding tendency of obstructive jaundice: Prothrombin deficiency and dietary factors . Proc Soc Exp Biol Med 1939;;37:628-630.
2 +
Waddell WW, Gurerry DP, Bray WE, et al:  Possible effects of vitamin K on prothrombin and clotting time in newly-born infants . Proc Soc Exp Biol Med 1939;;40:432-434.
3 +
Kark R, Lozner EL:  Nutritional deficiency of vitamin K in man . Lancet 1939;;2:1162-1164.
4 +
Olsen RE:  Vitamin K , in Coleman RW, Hirsh J, Marder VJ, et al (eds): Hemostasis and Thrombosis . Philadelphia, JB Lippincott, 1982;, pp 582-592.
5 +
Olsen RE:  The function and metabolism of vitamin K . Ann Rev Nutr 1984;;4:281-337.
6 +
Suttie JW:  Vitamin K-dependent carboxylase . Ann Rev Biochem 1985;;54:459-477.
7 +
Ham JM:  Hypoprothrombinaemia in patients undergoing prolonged intensive care . Med J Aust 1971;;2:716-718.
8 +
Pineo GF, Gallus AS, Hirsh J:  Unexpected vitamin K deficiency in hospitalized patients . Can Med Assoc J 1973;;109:880-883.
9 +
Ansell JE, Kumar R, Deykin D:  The spectrum of vitamin K deficiency . JAMA 1977;;238:40-42.
10 +
Reddy J, Bailey RR:  Vitamin K deficiency developing in patients with renal failure treated with cephalosporin antibiotics . NZ Med J 1980;;92: 378-380.
11 +
Corrigan JJ:  Vitamin K-dependent coagulation factors in gram-negative septicemia . AJDC 1984;; 138:240-242.
12 +
Jones PG, Strother SV, Rolston KVI, et al:  Hypoprothrombinemia in patients with cancer receiving cefoperazone and mezlocillin . Arch Intern Med 1986;;146:1397-1399.
13 +
Triplett DA, Harms CS: Procedures for the Coagulation Laboratory . Chicago, American Society of Clinical Pathology Press, 1981;.
14 +
Bessman JD:  Evaluation of automated whole-blood platelet counts and particle sizing . Am J Clin Pathol 1980;;74:157-162.
15 +
Triplett DA (ed): Laboratory Evaluation of Coagulation . Chicago, American Society of Clinical Pathology Press, 1981;.
16 +
Cohen P, Gardner FH:  Thrombocytopenia: A laboratory sign and complication of gram-negative bacteremic infection . Arch Intern Med 1966;;117: 113-124.
17 +
Mant MJ, King EG:  Severe, acute disseminated intravascular coagulation: A reappraisal of its pathophysiology, clinical significance and therapy based on 47 patients . Am J Med 1979;;67:557-563.
18 +
Mant MJ, Hirsh J, Pineo GF, et al:  Prolonged prothrombin time and partial thromboplastin time in disseminated intravascular coagulation not due to deficiency of factors V and VIII . Br J Haematol 1973;;24:725-734.
19 +
Physicians Desk Reference , ed 41. Oradell, NJ, Medical Economics Books, 1987;.
20 +
Ramotar K, Conly JM, Chubb H, et al:  Production of menaquinones by intestinal anaerobes . J Infect Dis 1984;;150:213-218.
21 +
Udall JA:  Human sources and absorption of vitamin K in relation to anticoagulation stability . JAMA 1965;;194:107-109.
22 +
Frick PG, Riedler G, Brogli H:  Dose response and minimal daily requirement for vitamin K in man . J Appl Physiol 1967;;23:387-389.
23 +
Physicians Desk Reference for Nonprescription Drugs , ed 8. Oradell, NJ, Medical Economics Books, 1987;.
24 +
Covington TR, DiPalma JR (eds):  Blood modifiers , in Facts and Comparisons: Drug Information . Philadelphia, JB Lippincott, 1986;, pp 84-86.
25 +
Ivey M, Elmer G:  Nutritional supplement, mineral, and vitamin products , in Laitin SC (ed): Handbook of Nonprescription Drugs . Washington, DC, American Pharmaceutical Association, 1982;, pp 207-257.
26 +
Conly JM, Ramotar K, Chubb H, et al:  Hypoprothrombinemia in febrile, neutropenic patients with cancer: Association with antimicrobial suppression of intestinal microflora . J Infect Dis 1984;; 150:202-213.
27 +
Sattler FR, Colao DJ, Caputa GM, et al:  Cefoperazone for empiric therapy in patients with impaired renal function . Am J Med 1986;;81: 229-236.
28 +
Brown BB, Klar J, Lemeshow S, et al:  Enhanced bleeding with cefoxitin or moxalactam: Statistical analysis within a defined population of 1493 patients . Arch Intern Med 1986;;146:2159-2164.
29 +
Fainstein V, Bodey GP, McCredie KB, et al:  Coagulation abnormalities induced by β-lactam antibiotics in cancer patients . J Infect Dis 1983;; 148:745-750.
30 +
Lipsky JJ:  N-methyl-thio-tetrazole inhibition of the gamma carboxylation of glutamic acid: Possible mechanism for antibiotic-associated hypoprothrombinaemia . Lancet 1983;;2:192-193.
31 +
Aronoff GR, Cockerell CA, Moorthy R, et al:  Methylthiotetrazole and antibiotic induced hypoprothrombinemia , abstracted. Clin Res 1986;;34: 394A.
32 +
Olson JA:  Recommended dietary intakes (RDI) of vitamin K in humans . Am J Clin Nutr 1987;;45: 687-692.
33 +
Council on Scientific Affairs:  Vitamin preparations as dietary supplements and as therapeutic agents . JAMA 1987;;257:1929-1936.

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