A 40-year-old male, weighing 65 kg, suffered from flame burns of 45% total body surface area (TBSA) (40% full thickness) combined with inhalation injury, affecting his face, neck, trunk, upper extremities, and right lower extremity. He was rescued by the firemen from the accidental site and directly sent to the local hospital, which provided sufficient fluid resuscitation during hypovolemic stage post-burn. Negative personal medical history and family history were confirmed while the patient was transferred to our hospital for further treatment on the post-burn day (PBD) 3. Topical usage of 1% silver sulfadiazine (1%SD-Ag cream) was served as wound management together with surgical procedures of escharectomy (upper extremities and right lower extremity) and heterograft on PBD 4, consecutively 2 autografting on PBD 10 and 16. Broad-spectrum antibiotics, Meropenem  (1.0 g three times daily), was applied intravenously since PBD 3 as the empirical therapy for extensive burn patients and continued for ensured Pseudomonas aeruginosa-positive of the wound in this patient (Fig. 1). Calorie intake of Fresubin  1000 mL/day was commenced on PBD 5 via gastrointestinal (GI) tube as a supplemental nutrition other than oral intake of normal food, except on those days of surgical procedures. Not until PBD 13 did the patient show the signs of infection, such as chill, high fever, wounds infiltration, delirium, and neutrocytosis (Figs. 2 and 3), while his hemodynamic status remained stable, all coagulation criteria within normal range. Wound and blood culture were both reported Klebsiella pneumoniae-positive (multi-drug-resistant strain, tigecycline medium). Hence, treatment with tigecycline (0.5 g three times daily) was initiated intravenously on PBD 13, together with Meropenem , and worked well in controlling those infections till PBD 18. All lab findings coordinate with the severity of the patient during that period of time, including his coagulation status.
Nevertheless, concurrent with remission of signs of severe infection, there came the abnormal oozing of blood on the donor site during the third autografting and uncontrolled bleeding while removing the central venous line on PBD 23, which related to the prolonged activated partial thromboplastin time (APTT) 61.5 s, normal range 25.1-39.5 s, while prothrombin time (PT) 15.6 s, normal range 10.0-16.0 s, and the international normalized ratio (INR) 1.32 were normal. An intravenous bolus of 10 mg vitamin K1 was applied during the procedure and continued in the following 5 days. Further investigation of the patient's coagulation status was launched after the operation. There was no sign of DIC at this time, with normal value of platelets (227 x 1012/L), fibrin degradation products (FDP) 4.7 mg/L, normal range 0-5 mg/L, D-dimer 1.68 mg/L, normal range < 0.55 mg/L, and slightly reduced fibrinogen (Fg) 1.8 g/L, normal range 1.8-3.5 g/L. Complete screening of patient's coagulation factors was carried out on PBD 26 (Table 1). von Willebrand factor (vWF) level and activity were within the normal range, lupus anticoagulant (LAC) was negative, and coagulation factor VIII and V were normal, deficiency of multiple coagulation factors (Table 1: coagulation factor II, coagulation factor VII, coagulation factor IX, and coagulation factor X activities were 39%, 35%, 45.1%, and 28% respectively on PBD 26) that related to vitamin K deficiency (VKD) was indicated as the reason for coagulopathy in this patient. Unfortunately, specific detection of serum vitamin K concentration and protein induced in vitamin K deficiency (PIVKD) were not available in our hospital. However, what really mattered was to relief further risk of bleeding and coagulation crash as quickly as possible. Thereafter, supportive therapies, such as 200 ml fresh frozen plasma (FFP), was administered daily for consecutive days and 600 IU prothrombin complex was infused on PBD 26 when the patient was diagnosed of hypothrombinemia. Although the coagulation status remained abnormal on PBD 27, surgical debridement of the neck, trunk, and right lower extremity and grafting were performed. There was no abnormal bleeding either on the donor site or burn wounds, and wound healing of any sites was not interfered. At the same time, application of vitamin K1 intravenously increased to 20 mg daily for another 15 days, but showed mild effect to reverse the surging APTT level.
Nothing should be considered as the first priority, except finding out the exact reason for VKD. Concerning no short of vitamin K intake, no impairment of liver function, and vitamin K recycling occurred in this case, but scarcity of endogenous vitamin K generated by intestinal bacterial flora soon came to our view. Meropenem  application was discontinued on PDB 34. Interestingly, 2 days after, APTT improved to 47 s and came back to the normal range on PDB 39 along with normal value of coagulation factor II, VII, IX, and X (Figs. 1 and 4), even with combined usage of tigecycline (0.5 g three times daily) and fosfomycin sodium (4.0 g three times daily) intravenously, started on PBD 38, dealing with multi-resistant strain of Klebsiella pneumonia (tigecycline resistant). Another two operations were performed for grafting on PBD 40 and 52. Tigecycline and fosfomycin sodium were applied in the same dosage as previously used for multi-drug-resistant Klebsiella pneumonia still detected in wound culture. The patient was discharged on PBD 67 with all burn wounds recovered and no abnormality in coagulation status (Fig. 5).