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Abdominal Skin Necrosis after Enoxaparin Treatment  [PDF]
Haddad Maruan, Nierenberg Gabriel, Falah Mazen, Rosenberg Nahum
Open Journal of Clinical Diagnostics (OJCD) , 2014, DOI: 10.4236/ojcd.2014.41010
Abstract: Subcutaneous low molecular weight heparin (LMWH) injection is a prophylactic treatment for deep vein thrombosis after surgery in lower limb before the patient is fully ambulated. This treatment is usually safe. One of the major and rare complications of the LMWH injection is thrombocytopenia, which is usually self-limiting. We present a rare case of patient with thrombocytopenia, induced by subcutaneous injection of LMWH (enoxaparin) that was complicated with a large hematoma at the injection site with subsequential skin necrosis, sepsis with fatal outcome. We would like to emphasize this rare complication of the common prophylactic treatment by LMWH in order to pursue this diagnosis when similar cutaneous manifestation might appear in patients who receive prophylactic treatment with LMWH.
Surgeries for the Heart and Abdominal Aorta in a Patient with Heparin-Induced Thrombocytopenia: Manifestations Following Initial Heart Surgery  [PDF]
Shoh Tatebe, Makoto Taoka, Imun Tei, Shuko Nakamura, Ei-ichi Tei
Open Journal of Thoracic Surgery (OJTS) , 2012, DOI: 10.4236/ojts.2012.21003
Abstract: A 72-year-old man with abdominal aortic aneurysm and angina pectoris underwent coronary artery bypass grafting (CABG) prior to abdominal aortic surgery. Perioperatively, he developed thrombocytopenia ((29,000 mm3), which was suggested as heparin-induced thrombocytopenia. Cardiac status was also aggravated at the same time, suggestive of bypass graft thrombosis. The results of platelet factor 4 (pf4) antibody test were negative, but platelet aggregation test was positive for heparin. Heparin was immediately discontinued, and replaced by argatroban; the patient’s cardiac status improved. One month later, he underwent abdominal aortic surgery using argatroban without issues related to anticoagulation and hemostasis. Autologous donated fresh blood prepared by the “switch-back” method was also used in this case, and its value was confirmed.
Epidural Hematoma after the Use of Subcutaneous Unfractionated Heparin and History of Epidural Tumor  [PDF]
Basem A. Abdelfattah, Troy Buck, Scott Byram
Open Journal of Anesthesiology (OJAnes) , 2014, DOI: 10.4236/ojanes.2014.47023

The patient was a 66-year-old male with a history of renal cell carcinoma with metastasis to the L2, L3, and L4 vertebral bodies scheduled for a radical nephrectomy and adrenalectomy. Prior to surgery the patient had undergone 10 radiation treatments for the vertebral metastasis. Patient medications included colace, prednisone, ibuprofen (taken 4 days prior to procedure), sunitinib, hydrocodone, benazepril, nexium, rosuvastatin, allopurinol, and azor. Physical exam prior to surgery was normal with no focal findings. Laboratory values were within normal limits with a platelet count of 286. General anesthesia was planned with a pre-operative thoracic epidural for postoperative analgesia. The epidural was placed at the T9-T10 level without complication. Adequate pain control was present post operatively and the epidural was discontinued on post-operative day 3. At that time the patient was noted to have numbness over the bilateral lower extremities and decreased strength. Heparin 5000 units subcutaneous had been given 12 hours prior to discontinuation of the epidural. The patient was afebrile, hemoglobin was 7, white blood cell count was 9.7, and platelets were 166 at time of epidural removal. Subcutaneous heparin was restarted 6 hours after catheter removal. The anesthesia acute pain service was contacted by the primary service 25 hours after discontinuation of the epidural catheter regarding complaints of persistentbilateral lower extremity weakness and sensory loss. An magnetic resonance image (MRI) revealeda focus posterior to the spinal cord at the T10/T11 interspace likely representing a hematoma. A high intensity T2 signal within the central spinal cord at T10/T11 was also observed; likely a vascular infarct. The patient was immediately scheduled for a T9-T10 laminectomy and evacuation of the epidural hematoma. No significant abnormalities were noted in coagulation studies prior to surgery. The patient was discharged on post-operative day 20 with no neurologic deficits.An epidural hematoma is rare with an estimated occurrence of <1 in 150,000[1]. Issues related to anticoagulation therapy are involved in 25% - 30% of cases. The utilization of three times daily dosed (TID) heparin could have played a role in the development of this complication in the present case. Other contributing factors may have been chemotherapy and radiation therapy. These treatments are quite damaging to bone marrow and may cause severe marrow suppression thereby suppressing the function and number of

Heparin in psoriasis
Chacko Maria,Mathew Thomas,Sugathan P,Nair Laxmi
Indian Journal of Dermatology, Venereology and Leprology , 1998,
Abstract: Ten patients with chronic stable psoriasis of more than three years duration were treated with injection heparin 2500 IU subcutaneously twice a day for 7 days. Six patients showed aggravation. Three showed no response and one patient improved and went into remission after 6 months.
Another Example of Devastating Complication of Heparin-Induced Thrombocytopenia Post-Cardiac Surgery: Is Danaparoid the Culprit of Another Near Fatal Complication?  [PDF]
Fran?ois Bé?que, Donald Hickey, Karine Toledano, Jean-Francois Morin
International Journal of Clinical Medicine (IJCM) , 2010, DOI: 10.4236/ijcm.2010.12014
Abstract: We describe a patient who developed catastrophic consequences of heparin-induced thrombocytopenia (HIT) post car¬diac surgery, for which she required reoperation using CPB. We also illustrate the impact of intraoperative transe¬sophageal echocardiography (TEE) in the surgical management of this patient.
Liposomal Heparin-Spraygel in Comparison with Subcutaneous Low Molecular Weight Heparin in Patients with Superficial Venous Thrombosis. A Randomized, Controlled, Open Multicentre Study
Katzenschlager R,Hirschl M,Minar E,Ugurluoglu A
Journal für Kardiologie , 2003,
Abstract: Liposomales Heparin-Spraygel im Vergleich zu subkutanem niedermolekularem Heparin bei Patienten mit oberfl chlicher Venenthrombose. Eine randomisierte, kontrollierte, offene Multicenter-Studie. Ziel: Die oberfl chliche Venenthrombose (superficial vein thrombosis, SVT), die durch Kompressionsbehandlung sowie lokal angewandte oder systemische nichtsteroidale Antiphlogistika hinreichend behandelt werden kann, wird generell als relativ harmlos eingestuft. Allerdings kann eine SVT auch tiefer gehen, was eine aggressivere chirurgische und/oder systemische Behandlung n tig macht. In der vorliegenden randomisierten, kontrollierten, offenen, multizentrischen Vergleichsstudie wurden Wirkung und Toleranz des neuen galenischen liposomalen Heparin-Spraygels mit subkutan verabreichtem niedermolekularem Heparin verglichen. Methodik: 42 Patienten (31 Frauen, 11 M nner) mit diagnostizierter SVT, mittels Duplex-Sonographie best tigt, wurden eingeschlossen. Alle Patienten erhielten eine Kompressionstherapie, darüber hinaus war es ihnen erlaubt, Paracetamol (1000 mg/Tag) als Schmerzhemmer einzunehmen. Die Behandlungsergebnisse wurden nach 7 oder 14 Tagen überprüft. Die prim ren Endpunkte umfa ten Schmerzreduktion (VAS, VRS), Erythema (Planimetrie) und Schwellung (ordinale Skala). Bei jeder Visite wurde die L nge des Thrombus (mm) mittels Duplex-Sonographie gemessen. Ergebnisse: Keiner der 42 Patienten entwickelte eine tiefe Venenthrombose. Das Ergebnis der Schmerzevaluierung (VAS-Evaluation) zeigte eine vergleichbare Schmerzreduktion in beiden Gruppen. Der Medikamentenkonsum war ebenfalls vergleichbar. Erythema und Thrombengr e zeigten einen kontinuierlichen Anstieg in beiden Gruppen, ohne signifikante Unterschiede. Schlu folgerung: Die topische Anwendung von liposomalem Heparin-Spraygel mit Kompressionstherapie zeigte in der Behandlung oberfl chlicher Venenthrombosen eine vergleichbare Wirkung zum subkutan verabreichten niedermolekularen Heparin.
Heparin and other anticoagulants in amniotic fluid embolism (AFE): Literature review and concept of the therapy  [PDF]
Mieczys?aw Uszyński, Waldemar Uszyński
Open Journal of Obstetrics and Gynecology (OJOG) , 2013, DOI: 10.4236/ojog.2013.37106

Aim: The objective of this study is to review all the reported outcomes of heparin application in amniotic fluid embolism (AFE) so far and to find out why, when and how heparin or other anticoagulants should be used in AFE. Material and methods: We searched Medline (from 1969 to 2011), using two key words: 1) amniotic fluid embolism; 2) amniotic fluid embolism and heparin. The search for the former produced 1127 replies, of which 208 were case reports of AFE. In response to the other key word, there were 94 articles. We looked through all the articles, selecting those relevant for our study. Results: In the years 1969-2011, 208 AFE cases were reported. Heparin (unfractionated heparin) or low molecular weight heparin (LMWH) was applied in 20 cases (9.6%), being the main drug in 11 cases (5.3%) and in 6 cases as a component of spectacular treatment of AFE (surgical treatment and extracorporal membrane oxygenation). In one of these cases anithrombin (AT) with LMWH was used. In one patient heparin therapy was considered to be unsuccessful and hence recombinant plasminogen activator (rt-PA) was instituted. All the patients survived. Conclusions: 1) The attempts to use heparin in AFE could be defined as promising, although the number of treated patients is too small for conclusion; 2) The postulate to use heparin at the very onset of AFE (a bolus of 10,000 U followed by monitored intravenous infusion) has serious justification: one of the pathways of AFE is the target for heparin (coagulation pathway).

Heparin-induced thrombocytopenia: an update
Massimo Franchini
Thrombosis Journal , 2005, DOI: 10.1186/1477-9560-3-14
Abstract: Heparin is a drug widely used for thromboprophylaxis or treatment in many clinical situations, including cardiovascular surgery and invasive procedures, acute coronary syndromes, venous thromboembolism, atrial fibrillation, peripheral occlusive disease, dialysis and during extracorporeal circulation [1,2]. However, it can cause serious adverse effects, including heparin-induced thrombocytopenia (HIT) which is a common, serious and potentially life-threatening condition [3-6]. Unfortunately, because thrombocytopenia is common in hospitalized patients and can be caused by a variety of factors [7], HIT often remains unrecognized.Heparin-induced thrombocytopenia is defined as a decrease in platelet count during or shortly following exposure to heparin [8]. Two different types of HIT are recognized. The first, HIT type I (also called heparin-associated thrombocytopenia in the past), is a benign form not associated with an increased risk of thrombosis. The mechanism of HIT type I is still unknown but it is likely to be non-immune, probably related to its platelet pro-aggregating effect. This form of HIT affects up to 10% of patients under treatment with heparin and is characterized by a mild and transient asymptomatic thrombocytopenia (rarely less than 100,000 platelets/μL) that develops early (usually within the first two days of starting heparin) and disappears equally quickly once the heparin is withdrawn. The second form of HIT, HIT type II, is immune-mediated and associated with a risk of thrombosis. It has recently been proposed that the term "HIT type I" be changed to "non-immune heparin associated thrombocytopenia" and that the term "HIT type II" be changed to "HIT" to avoid confusion between the two syndromes [9].In this review we briefly analyze the main characteristics of the clinically relevant, immune-mediated, second type of HIT, focusing particularly on the epidemiology, pathophysiology, clinical manifestations and treatment of this syndrome. For simplicity
Trombocitopenia induzida por heparina e necrose cutanea por varfarina: relato de caso
Kaiber, Flávia Larissa;Malucelli, Tiago Osternack;Baroni, Eloína do Rocio Valenga;Schafranski, Marcelo Derbly;Akamatsu, Hélcio Takeshi;Schmidt, Carolina Cecília Finkler;
Anais Brasileiros de Dermatologia , 2010, DOI: 10.1590/S0365-05962010000600024
Abstract: this paper describes a case of heparin-induced thrombocytopenia complicated by warfarin-induced skin necrosis in a 74-year old female patient hospitalized with diagnoses of a hip fracture, deep vein thrombosis and pulmonary thromboembolism. warfarin-induced skin necrosis is a rare complication of anticoagulant therapy, with high morbidity and mortality that may be associated with heparin-induced thrombocytopenia.
Estudo clínico de 35 pacientes com diagnóstico de erisipela internados no Hospital Central da Irmandade da Santa Casa de Misericórdia de S?o Paulo
Okajima, Renata Mie Oyama;Freitas, Thaís Helena Proen?a de;Zaitz, Clarisse;
Anais Brasileiros de Dermatologia , 2004, DOI: 10.1590/S0365-05962004000300005
Abstract: background: erysipelas and cellulitis are common skin infections. objectives: the aim of this paper is to investigate the frequency, risk factors, clinical features, complications, principal drugs used for treatment and the disease course. methods: the authors studied 35 ward patients who had been diagnosed with erysipelas, and were admitted to the central hospital of irmandade da santa casa de misericórdia de s?o paulo between april and august 2002. results: among the patients in the ward during the study 0.87% had been diagnosed with erysipelas. the most common local risk factor was lymphedema, followed by previous episodes of erysipelas. among the general risk factors, diabetes mellitus, alcohol abuse and cancer were most frequently observed. local inflammatory signs were found in 97.8% of the patients. four cases were observed to have complications, which were: necrosis, abscess, deep thrombophlebitis and septicemia. the course was satisfactory in more than 97% of patients. conclusions: therapy with penicillin was associated with a decrease of complications (p<0.05) and at a lower cost compared to other antibiotic therapies (p<0.05). when anticoagulants were combined to the therapy, there was a lower incidence of complications (p<0.05).
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