Treatment of a life-threatening laryngeal bradykinin angio-oedema precipitated by dipeptidylpeptidase-4 inhibitor and angiotensin-I converting enzyme inhibitor with prothrombin complex concentrates.

(etomidate 20 mg, fentanyl 150 mg, and suc-cinylcholine 75 mg). Once in the operating theatre, TEM study was performed at the beginning of surgery. The fibTEM MCF was 9 mm, and fibrinogen at the same time was 3.19 g litre 21 ; i.v. fibrinogen 30 mg kg 21 and tranexamic acid 25 mg kg 21 were given. Fetal extraction was performed with evacuation of a retroplacental haematoma affecting 30–40% of placental surface. During surgery, bleeding was estimated at about 1500 ml, and Ringer's lactate 1500 ml was given. At the end of surgery, the patient was transferred to post-anaesthesia care unit (PACU) and discharged after 12 h, without symptoms or new episodes of bleedings. In the PACU, she received 1000 ml of Ringer's lactate and one unit of packed red blood cells (PRBCs) as the haemoglobin was 7.2 g dl 21. Four hours after arrival in the PACU, the plasma fibrinogen level was 3.28 g litre 21 and fibTEM MCF reached 18 mm, while immediately before discharge, fibrino-gen plasma level was 3.31 g litre 21 and fibTEM MCF 21 mm. I.V. infusion of hydroxyethyl starch 130/0.4 (6%) may be accompanied by a marked overestimation of fibrinogen concentration measured according to the Clauss method. 5 It also appears to impair clot formation. 6 This impairment is accompanied by an increase in transfusion requirements resulting in a decline in MCF. 6 This effect lasts approximately for up to 2 h, 7 can be reversed with i.v. fibrinogen, and seems to be due to interference with formation of fibrin mesh. 6 Overestimation of fibrinogen concentration and interference with formation of fibrin mesh would explain the initial finding of a lower fibTEM MCF than expected, with a fibrino-genaemia of 3.19 g litre 21. 4 Meanwhile, both the treatment and disappearance of the effects of hydroxyethyl starch would explain the progressive increase in fibTEM MCF in spite of stable fibrinogen levels. In conclusion, hydroxyethyl starch 130/0.4 (6%) seems to be a friend to haemodynamics and a foe for haemostasis. 1 Ducloy-Bouthors AS, Jude B, Duhamel A, et al. High-dose tranex-amic acid reduces blood loss in postpartum haemorrhage. Crit Care 2011; 15: R117 2 Cortet M, Deneux-Tharaux C, Dupont C, et al. Association between fibrinogen level and severity of postpartum haemorrhage: secondary analysis of a prospective trial. The use of fibrinogen concentrate to correct hypofibrinogenaemia rapidly during obstetric haemorrhage. 4 Huissoud C, Carrabin N, Audibert F, …