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+A 73-year-old Hispanic male with a history of stage IV chronic kidney disease and three-vessel coronary artery disease was admitted for coronary artery bypass graft surgery and mitral valve repair.
+On post-operative day two, the patient developed cardiac tamponade and subsequently progressed to a cardiac arrest while temporary pacing wires were being removed.
+Advanced cardiovascular life support and emergent exploratory sternotomy were performed, and the patient was transferred to the intensive care unit (ICU) for further care.
+During the patient’s ICU admission, his renal failure progressed, requiring hemodialysis.
+A nasogastric tube was placed on post-operative day two for establishing early enteral nutrition.
+PEG tube insertion was suggested given his cognitive impairment and poor swallowing function on the Modified Barium Swallow test.
+His coagulation profile prior to the procedure revealed an international normalized ratio of 1.04 and partial thromboplastin time of 36 seconds.
+A complete blood count showed a hemoglobin of 11.6 grams per deciliter, a hematocrit of 34.9%, and 281×103 platelets per microliter.
+His blood urea nitrogen was 55 milligrams/deciliter, and his serum creatinine was 5.22 milligrams/deciliter.
+The patient was taking aspirin 81 mg per day due to recent cardiac surgery, but was not on any anticoagulant agents.
+He also did not have a history of coagulopathy.
+PEG tube insertion was performed on post-operative day eight under intravenous anesthesia.
+The esophagogastroduodenoscopy (EGD) was accomplished without difficulty, revealing diffuse moderately erythematous mucosa without bleeding in the gastric antrum.
+While attempting PEG tube placement, a rapidly expanding hematoma (Figure 1) developed at the needle insertion site.
+The procedure was stopped and the patient was sent back to the ICU with a nasogastric tube.
+A single dose of intravenous desmopressin (0.3 microgram/kilogram) was administered under the suspicion of uremic bleeding.
+No further gastrointestinal bleeding events were noted.
+To assess platelet function, a platelet function assay (PFA) was ordered after desmopressin injection.
+PFA collagen/epinephrine closure time was 195 seconds (normal <174 seconds), and collagen/ADP closure time was 76 seconds (normal <120 seconds), indicating platelet dysfunction due to either aspirin or uremia.
+Aspirin was discontinued, and he was monitored with a daily complete blood count and metabolic panel.
+Three days later the patient underwent a second attempt at PEG tube placement.
+PFA collagen/epinephrine closure time prior to this procedure had gone down to 141 seconds, possibly due to withholding aspirin and an improvement in renal function.
+EGD showed an area of flat, bluish gastric submucosal bruising at the site of the previous hematoma (Figure 2).
+The PEG tube was placed successfully at an adjacent site.
+Over the course of the following month, the patient continued to undergo feeding through the PEG tube with no adverse events.