warfarin and Respiratory-Insufficiency

BACKGROUND Diffuse alveolar hemorrhage (DAH) caused by direct oral anticoagulants (DOACs) has increased in recent years with the increase in prescriptions of DOACs. Generally, DOACs are considered to have a lower bleeding risk than the traditional anticoagulant, warfarin. However, major bleeding, including DAH, due to DOACs can be seen in clinical practice, and there are few reports to elucidate when DOAC-associated alveolar hemorrhage occurs and whether DOAC-induced DAH has a trigger. CASE REPORT An 80-year-old man diagnosed and treated for atrial fibrillation with apixaban 2.5 mg twice daily for 1 year before admission, underwent 2 invasive medical procedures over a short period of time. Hemoptysis began after the procedures. He experienced shortness of breath and rapidly progressive hypoxic respiratory failure. His postsurgical oxygen saturation level dropped rapidly. Chest radiography and computed tomography images showed pulmonary infiltration and ground-glass opacity in both lungs. Apixaban treatment was discontinued, and mechanical ventilation was initiated. Bronchoalveolar lavage cytology revealed hemosiderin-laden macrophages. A diagnosis of diffuse alveolar hemorrhage (DAH) was made. In previous reports about DAH caused by DOACs, most patients had bleeding triggers; drug interactions in patients taking DOACs are one of such triggers. Although DOACs are relatively safe for elderly patients, DAH can occur in patients receiving either early-stage or long-term treatment. CONCLUSIONS The onset of DOAC-associated DAH is not limited to the early stages of medication initiation. Various triggers can induce DAH in patients receiving DOACs.

Topics: Administration, Oral; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Hemorrhage; Humans; Lung Diseases; Male; Pyridones; Respiratory Insufficiency; Stroke; Warfarin

Warfarin is one of the most frequently used anticoagulant agents in the clinic. The most important adverse effect of warfarin is hemorrhage of vital organs, such as lung and brain. Diffuse Alveolar Hemorrhage (DAH) is a rare clinical condition which occurs due to variety of medical disorders. Although it's rarely reported, DAH can be a result of coagulopathy prompted by warfarin therapy. In this study we present a case of DAH, caused by warfarin toxicity which referred to the hospital with non-specific respiratory symptoms.. A 41-year-old female patient referred to the hospital complaining of shortness of breath, cough and dizziness. She had been taking warfarin due to mitral valve replacement for the past 10 years. Her recent symptoms began shortly after taking amoxicillin, a few days before admission. Early clinical examination and paraclinical studies reveal DAH as the cause of respiratory symptoms. The patient was then intubated and received fresh frozen plasma, packed cells and oral vitamin K. Laboratory findings apart from increased INR, PT, ESR and CRP were all within normal range. After the initiation of treatment patient's INR decreased and her clinical condition improved. Follow-up CT-Scan and bronchoscopy also confirmed resolving DAH.. The usage of warfarin in anticoagulation should be closely monitored due to its narrow therapeutic window and other factors, including its interaction with other medications such as antibiotics. Warfarin toxicity can lead to DAH, a life-threatening condition which can be presented with non-specific symptoms and deteriorate patient's clinical condition in a short time. Therefore, it is of utmost importance to watch closely for primary symptoms of such rare incident in patients under warfarin therapy and initiate treatment as soon as possible, to prevent mortality.

Topics: Adult; Amoxicillin; Anti-Bacterial Agents; Anticoagulants; Bronchoscopy; Cough; Dizziness; Female; Hemorrhage; Humans; Lung Diseases; Pulmonary Alveoli; Respiratory Insufficiency; Tomography, Spiral Computed; Warfarin

Spontaneous spinal epidural hematoma (SSEH) manifests from blood accumulating in the epidural space, compressing the spinal cord, and leading to acute neurological deficits. The disease's cloudy etiology and rarity contribute to dangerously suboptimal therapeutic principles. These neural deficits can be permanent, even fatal, if the SSEH is not treated in a timely and appropriate manner. Standard therapy is decompressive laminectomy, though nonsurgical management is a viable course of action for patients who meet a criterion that is continuously being refined.. A 76-year-old woman on warfarin for a past pulmonary embolism presented to the emergency room with jaundice, myalgia, hematuria, neck pain, and an International Normalized Ratio (INR) of 14. Upon admission, she rapidly developed quadriplegia and respiratory distress that necessitated intubation.. T2-weighted magnetic resonance imaging (MRI) revealed an epidural space-occupying hyperintensity from C2 to S5 consistent with a spinal epidural hematoma. An incidental finding of dilated intrahepatic and common bile ducts prompted an endoscopic retrograde cholangiopancreatography, which demonstrated choledocholithiasis.. The patient's INR was normalized with Vitamin K and Beriplex. Upon transfer to the surgical spine team for assessment of a possible intervention, the patient began to demonstrate recovery of neural functions. The ensuing sustained motor improvement motivated the team's preference for close neurologic monitoring and continued medical therapy over surgery. Thirteen hours after the onset of her symptoms, the patient was extubated. A sphincterotomy was later performed, removing 81 common bile duct stones.. MRI demonstrated complete resorption of the SSEH and the patient maintained full neurological function at final follow-up.. Nonsurgical management of SSEH should be considered in the context of early and sustained recovery. Severe initial neural deficit does not necessitate surgical decompression. Choledocholithiasis and subsequent Vitamin K deficiency, particularly when coupled with anticoagulant use, can increase INR and is a novel proposed risk factor for SSEH. Furthermore, coagulopathies should be medically corrected before surgical intervention within a given timeframe, as spontaneous recovery may manifest. This should be favored over surgery in patients demonstrating early and sustained recovery, as nonsurgical management is 25% more effective in achieving full recovery.

Topics: Aged; Cholangiopancreatography, Endoscopic Retrograde; Choledocholithiasis; Conservative Treatment; Emergency Service, Hospital; Female; Follow-Up Studies; Hematoma, Epidural, Spinal; Humans; International Normalized Ratio; Intubation, Intratracheal; Pulmonary Embolism; Quadriplegia; Recovery of Function; Respiratory Insufficiency; Risk Assessment; Severity of Illness Index; Warfarin

Topics: Adult; Anticoagulants; Chronic Disease; Dyspnea; Edema; Endarterectomy; Female; Heparin; Humans; Hypertension, Pulmonary; Lower Extremity; Pulmonary Embolism; Recurrence; Respiratory Insufficiency; Thromboembolism; Warfarin

A case of warfarin-induced skin necrosis (WISN) treated with protein C concentrate (human) is reported.. A 46-year-old Caucasian woman was admitted to the hospital for a herpes viral infection complicated by neutropenic fevers of unknown origin. Broad-spectrum antibiotics were initiated, as well as enoxaparin for prophylaxis of deep venous thrombosis. By hospital day 7, the patient's platelets decreased by 50%; by hospital day 8, they decreased another 50%. A test for heparin antibody was positive, and enoxaparin was stopped. Two days later, the patient developed a clot in her peripherally inserted central catheter, and warfarin and argatroban were initiated. Within 24 hours of warfarin initiation, the patient developed swelling in her feet and new lesions on her inner thigh, buttock, face, feet, fingers, and arms. She was treated with phytonadi-one and fresh frozen plasma, but these treatments failed to slow the progression of her lesions, which had turned to necrotic tissue. WISN was suspected, and warfarin therapy was discontinued after three doses. After a consultation with a hematologist, treatment with protein C concentrate (human) was initiated. Within 24 hours of treatment with this product, progression of necrosis stopped, and the patient's respiratory failure resolved. The patient underwent multiple skin grafts, and the lesions healed without extensive scarring. She experienced no adverse effects with the administration of protein C concentrate (human).. A patient with WISN was treated with protein C concentrate (human) with overall good results and no adverse effects.

Topics: Anticoagulants; Female; Humans; Middle Aged; Necrosis; Protein C; Respiratory Insufficiency; Skin; Skin Diseases; Skin Transplantation; Warfarin

Topics: Aged, 80 and over; Anticoagulants; Drug Overdose; Erythrocyte Transfusion; Fatal Outcome; Female; Hemorrhage; Humans; Lung Diseases; Pulmonary Alveoli; Pulmonary Edema; Respiratory Distress Syndrome; Respiratory Insufficiency; 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

Topics: Adult; Aged; Anesthesia, Inhalation; Blood Pressure; Blood Transfusion; Female; Gastrointestinal Hemorrhage; Halothane; Heart Arrest; Hip; Humans; Hypotension, Controlled; Joint Prosthesis; Male; Methylmethacrylates; Middle Aged; Myocardial Infarction; Osteotomy; Pentolinium Tartrate; Postoperative Complications; Pulmonary Embolism; Respiratory Insufficiency; Sodium; Thromboembolism; Thrombophlebitis; Warfarin