warfarin and Multiple-Organ-Failure

In November 2001, drotrecogin alfa (activated) was approved by the US Food and Drug Administration; in August 2002 it was approved by the European Medicines Agency. Since the approval of drotrecogin alfa (activated), however, critical care physicians have been faced with several challenges, namely its costs, selection of patients who are more likely to benefit from it, and the decision regarding when to start drotrecogin alfa (activated) treatment. There are also operational issues such as how to manage the infusion to deliver an effective treatment while minimizing the risk for bleeding, particularly in patients with deranged clotting, at around the time of surgery or during renal replacement therapy. While addressing these issues, this review remains practical but evidence based as much as possible.

Topics: Adult; Aged; Anti-Infective Agents; APACHE; Aspirin; Child; Clinical Trials as Topic; Cost-Benefit Analysis; Disseminated Intravascular Coagulation; Drug Administration Schedule; Drug Interactions; European Union; Heparin; Humans; IgA Vasculitis; Meningitis; Meningococcal Infections; Multiple Organ Failure; Pancreatitis; Practice Guidelines as Topic; Protein C; Recombinant Proteins; Renal Replacement Therapy; Risk Assessment; Sepsis; Survival Rate; Thrombocytopenia; United States; Warfarin

Two patients developed catastrophic multicentric skin necrosis while receiving warfarin to treat venous thromboembolism complicated by immune-mediated heparin-induced thrombocytopenia (HIT). Patient 1 developed skin necrosis involving the breasts, thighs, and face, as well as venous limb gangrene and bilateral hemorrhagic necrosis of the adrenal glands, resulting in death. The second patient developed bilateral mammary necrosis necessitating mastectomies, as well as skin necrosis involving the thigh. Neither patient had an identifiable hypercoagulable syndrome, other than HIT. HIT may represent a risk factor for the development of multicentric warfarin-induced skin necrosis (WISN).

Topics: Adrenal Gland Diseases; Aged; Amputation, Surgical; Anticoagulants; Antigens, Human Platelet; Autoantibodies; Autoimmune Diseases; Databases, Factual; Disseminated Intravascular Coagulation; Ecchymosis; Fatal Outcome; Female; Gangrene; Hemorrhage; Heparin; Humans; Mastectomy; Middle Aged; Multiple Organ Failure; Necrosis; Postoperative Complications; Pulmonary Embolism; Skin; Skin Diseases; Thigh; Thrombin; Thrombocytopenia; Thrombophilia; Thrombophlebitis; Vena Cava Filters; Warfarin

Thyroid storm is a rare disorder with a sudden onset, rapid progression and high mortality. We experienced a case of thyroid storm which had a devastating course, including multiple organ failure (MOF), severe hypoglycemia, disseminated intravascular coagulation (DIC), and stroke. It was difficult to make a diagnosis of thyroid storm in the present patient, because she did not have a history of thyroid disease and her serum FT3 level was normal. Clinicians should be aware that thyroid storm can occur even when there is an almost normal level of thyroid hormones, and that intensive anticoagulation is required for patients with atrial fibrillation to prevent stroke after thyroid storm.

Topics: Anti-Inflammatory Agents; Anticoagulants; Antithyroid Agents; Brain Edema; Decompression, Surgical; Disseminated Intravascular Coagulation; Female; Gabexate; Humans; Hydrocortisone; Methimazole; Middle Aged; Multiple Organ Failure; Stroke; Thyroid Crisis; Treatment Outcome; Triiodothyronine; Warfarin

We report a case of a 15-year-old boy who developed multiple organ failure secondary to a sport injury leading to infection with a Panton Valentine Leukocidin (PVL) secreting Community-Acquired Methicillin Sensitive Staphylococcus Aureus (CA MSSA). Aggressive antibiotic therapy eventually led to recovery.

Topics: Adolescent; Anti-Bacterial Agents; Antibiotics, Antitubercular; Anticoagulants; Athletic Injuries; Bacterial Toxins; Community-Acquired Infections; Exotoxins; Floxacillin; Humans; Leukocidins; Male; Martial Arts; Methicillin Resistance; Multiple Organ Failure; Rifampin; Staphylococcal Infections; Staphylococcus aureus; Warfarin

Topics: Anti-Bacterial Agents; Azithromycin; Blood Coagulation Disorders; Drug Synergism; Fatal Outcome; Humans; Male; Middle Aged; Multiple Organ Failure; Warfarin

Extracorporeal membrane oxygenation (ECMO) may serve as extracorporeal lung assist (ECLA) in patients with acute respiratory failure (ARF) or as extracorporeal heart assist (ECHA) in patients with low output syndrome (LOS) after open heart surgery. From 1988 to 1992 seven patients underwent ECMO in our hospital; four suffered from ARF and three from LOS. Various bypass techniques were employed. Two ARF patients, aged 58 and 18 years, had veno-venous bypass; in the latter, ECMO was reinstituted as a veno-arterial bypass one week after weaning. In a three-year-old boy, the ECMO outflow tubing was primarily connected to the pulmonary artery, and shortly afterwards relocated to the common carotid artery. In a 31-year-old man with ARF, and three LOS patients, a 56-year-old woman, and two men aged 68 and 70 years, ECMO was veno-arterial with direct access to the ascending aorta. A heparin-coated system was used, and all but one patient, who was treated with warfarin, received a daily low dose of heparin, which was withdrawn after from one to nine days. Six patients were weaned off ECMO after 4.5 to 21 days. Three ARF patients recovered completely; the child died. In one LOS patient, ECMO was withdrawn due to a poor general condition. Two others were weaned off ECMO and the intra-aortic balloon pump, and the inotropic support was significantly reduced, but both died of multiple system organ failure. Although no firm conclusions can be drawn from these few case reports, the heparin-coated system used as ECLA appears promising, whereas ECHA seems to imply a poor prognosis in patients who are not candidates for cardiac transplantation.

Topics: Acute Disease; Adolescent; Adult; Aged; Anticoagulants; Aorta; Cardiac Output, Low; Cardiac Surgical Procedures; Carotid Artery, Common; Child; Child, Preschool; Extracorporeal Membrane Oxygenation; Female; Heart; Heparin; Humans; Intra-Aortic Balloon Pumping; Lung; Male; Middle Aged; Multiple Organ Failure; Pulmonary Artery; Respiratory Insufficiency; Survival Rate; Syndrome; Warfarin