To the Editor:

We would like to thank Ideno et al. [1] for their thoughtful comments regarding our case report.

The letter requests that we address two questions.

First, the authors ask what we think was the main cause of “increased hemorrhage” and then propose that our patient’s anemia may have been attributable to hemorrhage stemming from coagulopathy. While this is certainly a consideration given the significant acidosis and hemodilution, it was our impression that the anemia was primarily caused by hemodilution. The anemia was disproportionate to the amount of surgical blood loss and improved more significantly after diuresis than with transfusion of packed red blood cells.

The second question asks whether our patient suffered any coagulation disturbance during the perioperative course. There was a single set of coagulation studies drawn with initial labs in the post anesthesia care unit. These were significant for a fibrinogen level of 183 mg/dL and INR of 1.3, which are only slightly outside of the normal range at our institution (200–375 mg/dL and 0.8–1.2 respectively). These did not correspond with any clinical signs of postoperative hemorrhage (i.e. hemodynamic instability, hematuria, etc.) and therefore the anemia and mild coagulation disturbances were attributed to hemodilution.