warfarin and Hemothorax

Low-molecular-weight heparins (LMWH) are a class of medication used as an anticoagulant. They belong amongst the so called direct anticoagulants. The effect on the coagulation cascade is mediated through the inactivation of anti-factor Xa. They are used in prophylaxis of thrombosis because of their lack of fibrinolytic effect. If the dosage is adequate, the effect on the bleeding time is minimal and thus monitoring is not necessary unlike in case of direct anticoagulants. Nevertheless, the monitoring is advisable in patients with renal insufficiency in whom the renal elimination of LMWH and their metabolites is reduced, hence they can cumulate in the organism and increase the risk of various bleeding complications. We present a case study of an 83-year-old patient with a massive subcutaneous haematoma caused by the cumulation of LMWH and with the subsequent huge defect of the chest wall treated with negative wound pressure therapy (Vacuum Assisted Closure - V.A.C.).

Topics: Aged, 80 and over; Anticoagulants; Aortic Valve; Female; Hemothorax; Heparin, Low-Molecular-Weight; Humans; Negative-Pressure Wound Therapy; Warfarin

There are well defined indications in which chronic anticoagulant treatment has been widely applied. However, complications of this therapy are less discussed, although these complications may lead to serious or even fatal consequences.. The aim of the authors was to analyze data of patients admitted to their multidisciplinary intensive care unit for complications of chronic anticoagulant therapy between January 1, 2006 and December 31, 2011.. Data of 73 patients admitted for serious hemorrhagic complications of chronic anticoagulant therapy were retrospectively analysed.. Of the 73 patients, 63 patients had intracranial bleeding, most of them with traumatic origin. A few patients with other hemorrhagic complications such as spinal hematoma, gastrointestinal bleeding, hemorrhagic cystitis, hemothorax and intraabdominal bleeding were also noted. The INR values were out of therapeutic range in 43 patients. The mortality of patients was very high in spite of complex intensive care; 49 of the 73 patients (75.5%) died due to hemorrhagic complications.. Due to the high proportion of traumatic origin, the large number of out-of-range INR, and the high mortality, the authors strongly believe that regular patient follow-up, transmission of detailed information, and time-to-time reevaluation of the indications and contraindications of chronic anticoagulant therapy could help to decrease the number of serious and fatal complications of chronic anticoagulant therapy.. Bevezetés: A krónikus antikoaguláns kezelést jól körülhatárolt indikációs körrel, széles körben alkalmazzák. Kevesebb szó esik azonban az általa okozott vérzéses szövődményekről, amelyek súlyosak vagy akár halálos kimenetelűek is lehetnek. Célkitűzés: A Szent János Kórház és Észak-budai Egyesített Kórházak Központi Aneszteziológiai és Intenzív Terápiás Osztályán 2006. január 1. és 2011. december 31. között krónikus antikoaguláns kezelés kapcsán kialakult vérzéses szövődményes esetek elemzése. Módszer: A szerzők multidiszciplináris intenzív osztályán a vizsgált hat év alatt összesen 73 betegnél fordult elő intenzív ellátást igénylő vérzéses szövődmény krónikus antikoagulálás kapcsán. Eredmények: Hatvanhárom esetben intracranialis vérzést észleltek, ezen belül leggyakrabban traumás eredetűt. Kisebb számban előfordult még spinalis haematoma, gastrointestinalis vérzés, haemorrhagiás cystitis, haemothorax és hasüregi vérzés. A betegek felvételi INR-értéke 43 esetben a terápiás tartományon kívül esett. A betegek mortalitása igen magas volt, a komplex intenzív kezelés ellenére 49 beteg halt meg a vérzéssel összefüggésben (75,5%). Következtetések: A gyakori traumás eredetre, a terápiás tartományon kívül eső INR-értékek nagy számára és a magas mortalitásra tekintettel a szerzők véleménye szerint rendszeres betegkövetéssel, részletes felvilágosítással, a társbetegségek alakulásával párhuzamosan revideált indikáció/kontraindikáció alapján folytatott krónikus antikoaguláns kezeléssel a vérzéses szövődmények száma csökkenthető lenne. Orv. Hetil., 2013, 154(46), 1829–1835.

Topics: Acenocoumarol; Adult; Aged; Aged, 80 and over; Anticoagulants; Critical Care; Cystitis; Drug Administration Schedule; Female; Gastrointestinal Hemorrhage; Hemorrhage; Hemothorax; Humans; Hungary; Intensive Care Units; International Normalized Ratio; Intracranial Hemorrhages; Male; Middle Aged; Retrospective Studies; Warfarin

Although bleeding is the most serious complication of oral anticoagulant treatment, hemothorax is extremely rare. Herein, a case with localized pleural plaques and spontaneous hemothorax due to warfarin treatment which was improved with medical treatment is presented because of its rarity. The patients recieving oral anticoagulant treatment should be monitorized for effective anticoagulation and adverse effects, if pleural effusion occurs, hemothorax should be kept in mind in the differential diagnosis. Pleural pathologies such as pleural plaques or thickening may be risk factors for hemothorax.

Topics: Administration, Oral; Anticoagulants; Diagnosis, Differential; Hemothorax; Humans; Middle Aged; Risk Factors; Warfarin

The American Food and Drug Administration has suggested that proton pump inhibitors increase the international normalized ratio (INR) when used concomitantly with warfarin, by being metabolized by cytochrome P450 2C19. We therefore reviewed patients taking warfarin.. Two hundred and forty patients who took warfarin after surgery were divided into two groups: Group I (n = 114) had rabeprazole (10 mg/day) and Group II (n = 126) had lansoprazole (15 mg/day). The initial dose of warfarin was 3 mg and INR was initially assessed on postoperative day 4. Initial INR was significantly lower in Group I (1.66 +/- 0.87) than in Group II (2.06 +/- 1.03, P = 0.0011). Delayed cardiac tamponade and hemothorax occurred as complications in 6 and 1 patients, respectively, in Group II from 5 days to 3 months postoperatively. At the time of the occurrence of complications, the average INR increased to 3.95 (range from 3.11 to 5.86). There were no patients with delayed bleeding in Group I ( P = 0.015).. These results suggest that lansoprazole emphasizes the effects of warfarin. Rabeprazole could be safely used concomitantly with warfarin.

Topics: 2-Pyridinylmethylsulfinylbenzimidazoles; Aged; Anticoagulants; Cardiac Surgical Procedures; Cardiac Tamponade; Female; Hemothorax; Humans; International Normalized Ratio; Lansoprazole; Male; Middle Aged; Postoperative Hemorrhage; Proton Pump Inhibitors; Rabeprazole; Retrospective Studies; Risk Factors; Warfarin

We report the case of a 71-year-old man on warfarin for chronic atrial fibrillation presenting with a massive spontaneous soft tissue bleed. Despite reversing the effects of warfarin with large doses of intravenous vitamin K and fresh frozen plasma, bleeding continued, and his prothrombin time and activated partial thromboplastin time remained prolonged. The prothrombin time and activated partial thromboplastin time failed to correct with 50% normal plasma. Further investigations confirmed a lupus inhibitor with low levels of factors II, V, VII and XI. Factor II, V and XI levels normalized, however, when the patient's plasma was diluted 1:16 in buffer, suggesting the lupus inhibitor may have been interfering with these factor assays causing artefactual low results. Factor VII levels remained consistently low at all dilutions. The patient subsequently died following a massive left haemothorax despite surgical intervention and treatment with activated recombinant factor VII concentrate. We presumed the primary problem was bleeding from a local vascular lesion but the patient was never well enough to undergo confirmatory angiography. This case highlights the fact that patients with lupus inhibitors can develop severe haemorrhagic complications, and illustrates the complexities involved in both the investigation and treatment of abnormal bleeding in these patients.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Contusions; Factor VII Deficiency; Fatal Outcome; Hemorrhage; Hemothorax; Humans; Lupus Coagulation Inhibitor; Male; Partial Thromboplastin Time; Prothrombin Time; Warfarin

Some drugs are known to induce pleural effusion. Drug-induced pleural effusion is often associated with pleural fluid eosinophilia. Anticoagulant therapy may induce pleural effusion by at least two different mechanisms: bleeding complication (haemothorax) and allergic or toxic reaction. Authors describe 76-yr-old male with warfarin-induced pleural effusion. Since INR was 15.5, and the value of pleural effusion Hct exceeded significantly 50% of Hct value in blood, spontaneous haemothorax due to warfarin overdose was diagnosed. Pleural fluid analysis revealed relatively high percentage of eosinophils (13%), but it was probably secondary to the presence of numerous red blood cells in the effusion. The authors discuss different mechanisms of drug-induced pleural effusion, with special attention to eosinophilic pleural effusion and review the literature on the spontaneous haemothorax as a complication of anticoagulant therapy.

Topics: Aged; Anticoagulants; Drug Overdose; Hemothorax; Humans; Male; Pleural Effusion; Pulmonary Eosinophilia; Time Factors; Warfarin

If some medical problems are not noticed to in polytraumatized patients at the right time, they may be caused by serious complications. The haematological parameters, especially bleeding and coagulation factors, are very important for them. If they use warfarin, heparin or salicylates, they should be cared intensively. In this paper, a traffic accident case, a 48-year-old woman has been reported. She broke her iliac bone and made her hemothorax. In the first health centre the patient was admitted, Hemothorax was not recognized since chest graphics was not diagnosed at an earlier stage. When dyspnoea was began, pulmonary embolism diagnosis was made and warfarin was applied which caused retroperitoneal bleeding. In fact, it is not known whether hemothorax was caused by the first trauma or by the use of warfarin. In our hospital, with the teamwork of emergency room, thorax surgery, orthopaedics, internal medicine and chest department, correct diagnosis was made and correct treatment was applied, and the patient got out of the hospital in good health. In conclusion, patients with multiple traumas should be followed with a multidisciplinary approach. There are a lot of considerations in the follow-up and treatment of this class of patients. If the traumatized patients are used warfarin, they should be observed more carefully.

Topics: Accidents, Traffic; Anticoagulants; Diagnosis, Differential; Emergency Treatment; Female; Hemorrhage; Hemothorax; Humans; Ilium; Middle Aged; Multiple Trauma; Retroperitoneal Space; Trauma Severity Indices; Warfarin

Topics: Abdominal Muscles; Activated Protein C Resistance; Anticoagulants; Dyspnea; Ecchymosis; Factor V; Hemothorax; Humans; Male; Middle Aged; Point Mutation; Venous Thrombosis; Warfarin

Trauma patients are at significant risk for deep venous thrombosis (DVT) and pulmonary embolism (PE). Anticoagulation is standard therapy for DVT/PE, but may cause severe complications. We reviewed the course of 70 trauma ICU patients treated over a 28-month period. Thirty-six patients (51.4 percent) were treated by continuous IV heparin and/or oral warfarin. Of these, 13 patients (36 percent) developed complications requiring termination of anticoagulation. These included recurrent PE (four), subdural hematomas (three), hemothorax (two), heparin-induced thrombocytopenia (one), hemorrhagic pericardial effusion (one), retroperitoneal hematoma (one), and sudden unexplained drop in hemoglobin and shock (one). All patients with subdural hematomas had no prior evidence of head injury on brain computed tomography. All patients with recurrent PE received adequate anticoagulation therapy. Age > 55 was associated with increased risk of complications (8 of 13; p = .02:chi 2). Thirty-four other patients (48.6 percent) received inferior vena caval filters with no related complications or deaths. Anticoagulation for DVT/PE should be used selectively in trauma patients and avoided in elderly patients. Such patients should undergo early caval filter placement.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Hematoma; Hemothorax; Heparin; Humans; Middle Aged; Pulmonary Embolism; Recurrence; Retrospective Studies; Risk Factors; Thrombocytopenia; Thrombophlebitis; Warfarin; Wounds and Injuries

The cause of a fatal condition characterized by hemorrhagic cardiomyopathy, hemothorax, and coagulation defects in hysterectomy-derived male mice was investigated. Microscopic heart alterations included multifocal hemorrhage and necrosis with variable degrees of acute inflammation and fibroplasia that were most severe in the region of the atrioventricular junction. A spontaneous outbreak was arrested by increasing menadione Na-bisulfite (vitamin K) in the feed to 20 ppm. The complete syndrome including hemorrhagic cardiomyopathy was readily reproduced in germ-free male mice given a vitamin K-free diet, and in conventional male and female mice given Warfarin in the diet. We concluded that the cause of this condition was vitamin K deficiency.

Topics: Animals; Blood Coagulation Disorders; Cardiomyopathies; Female; Hemorrhagic Disorders; Hemothorax; Male; Mice; Mice, Inbred C3H; Mice, Inbred C57BL; Mice, Inbred CBA; Myocardium; Vitamin K; Vitamin K Deficiency; Warfarin

A 62-year-old patient on anticoagulant therapy presented with hemothorax, pulmonary hemorrhages and a high retroperitoneal hematoma with obstruction-infarction of the right kidney. Following plasma infusion and pleural drainage, the clinical condition stabilized and kidney function improved.

Topics: Hematoma; Hemothorax; Heparin; Humans; Infarction; Kidney; Lung Diseases; Male; Middle Aged; Retroperitoneal Space; Warfarin

An anterior mediastinal haematoma and left haemothorax developed in a hypertensive diabetic patient on oral anticoagulant therapy. This occurred in spite of well-controlled anticoagulation and the absence of other evidence of systemic bleeding. Angiography and daily chest X-ray follow-up were not only sufficient to confirm the diagnosis, but also avoided hazardous interventional procedures.

Topics: Female; Hematoma; Hemothorax; Humans; Mediastinal Diseases; Middle Aged; Warfarin

Topics: Adult; Female; Hemothorax; Humans; Mediastinal Diseases; Thrombophlebitis; Warfarin

Topics: Cardiac Catheterization; Factor VII; Heart Valve Prosthesis; Hemostasis; Hemothorax; Humans; Methods; Prothrombin Time; Thromboembolism; Vitamin K; Warfarin

Topics: Adult; Aged; Anticoagulants; Hemothorax; Heparin; Humans; Male; Middle Aged; Radiography; Warfarin

Topics: Animals; Dog Diseases; Dogs; Female; Hemothorax; Lung Diseases; Pleural Effusion; Warfarin