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Acquired Bleeding Disorders Associated with Disease and Medications
Published in Harold R. Schumacher, William A. Rock, Sanford A. Stass, Handbook of Hematologic Pathology, 2019
William A. Rock, Sue D. Walker
Enoxaparin sodium and Dalteparin sodium are low-molecular-weight (LMW) heparins with antithrombotic properties characterized by a higher ratio of anti-FXa to anti-FIIa activity than unfractionated heparin. These LMW heparins effectively catalyze the inactivation of activated factor X by AT-III, but do not prolong the aPTT or the thrombin time as standard heparin does. This may lead to a more favorable ratio of antithrombotic activity to hemorrhagic risk compared to standard heparin. Enoxaparin prevents postoperative DVT following hip replacement surgery, and Dalteparin is indicated for prophylaxis against DVT in patients undergoing abdominal surgery who are at risk for thromboembolic complications. Like other anticoagulants, these should be used with care in patients with increased risk of hemorrhage, or in patients receiving platelet inhibitors because of the increased risk of bleeding. The incidence of hemorrhagic complications during treatment with heparin has generally been low, however. The most common complication is hematoma at the subcutaneous injection site. In the normal clinical prophylactic use of LMWH, monitoring is not necessary. Hemorrhagic complications associated with heparin therapy may be largely neutralized by the slow i.v. injection of protamine sulfate.
Case preparation
Published in Peter A. Schneider, Endovascular Skills: Guidewire and Catheter Skills for Endovascular Surgery, 2019
Informed consent is best obtained in the office when the patient is afforded time to consider issues and to consult with family. Patients on warfarin or other anticoagulants should be considered on a case-by-case basis. It is usually safe to perform either arteriography or endovascular intervention in patients on antiplatelet therapy as long as there are no other factors that are likely to promote hemorrhage, such as dialysis dependency. It is usually not necessary to stop antiplatelet agents prior to endovascular intervention. If for some reason the antiplatelet agent must be stopped, it should be 10 days prior to the procedure. If endovascular intervention is required, warfarin should be stopped approximately 5 days prior to the procedure. Patients who require anticoagulation to be continued, except for a “window” when it is stopped, may often be treated with outpatient enoxaparin sodium to shorten the hospital stay. At the operator’s discretion is whether a prothrombin time should be obtained on the day of the procedure. Patients with renal insufficiency are managed with preoperative hydration with a bicarbonate infusion and mucomyst. Methods of preprocedural evaluation are available that help to limit the contrast required for the study. These are discussed in Chapter 11. A contrast agent that is less toxic to the kidneys (e.g., CO2) should also be considered. Patients with a history of contrast allergy should be treated before the procedure with prednisone and diphenhydramine. This protocol is detailed in Chapter 13.
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Published in Caroline Ashley, Aileen Dunleavy, John Cunningham, The Renal Drug Handbook, 2018
Caroline Ashley, Aileen Dunleavy, John Cunningham
A linear relationship between anti-Xa plasma clearance and creatinine clearance at steady-state has been observed, which indicates decreased clearance of enoxaparin sodium in patients with reduced renal function. In patients with severe renal impairment (CRCL<30 mL/min), the AUC at steady state is significantly increased by an average of 65% after repeated, once daily subcutaneous doses of 40 mg.
Bilateral Cystoid Macular Edema after COVID-19: 1 Year Follow Up
Published in Ocular Immunology and Inflammation, 2023
Oğuzhan Kılıçarslan, Aslıhan Yılmaz Çebi, Didar Uçar, Fevzi Şentürk, Cengiz Aras
A 66-year-old male patient was referred to us with bilateral decreased vision. The patient had complained of blurry vision for a week. He had cough and fever prior to this presentation, and the SARS-COV-2 polymerase chain reaction (PCR) test had resulted positive with nasal swab. The patient had been hospitalized and treated for COVID-19 pneumonia for 8 days. At the first day of hospitalization, the ferritin value was 959 nanograms, CRP was 32.9 mg/L, and D-dimer was 214 ng/mL. During follow-up, all these parameters had returned to normal levels. The patient had received oseltamivir 75 mg twice a day for eight days, hydroxychloroquine 200 mg twice a day for seven days, and azithromycin 500 mg twice a day for eight days. 0.6 ml enoxaparin sodium had been given via the subcutaneous route once a day for eight days. After 1 week of his discharge (15th day of COVID-19 diagnosis), he complained of blurred vision in both eyes.
An unexpected event after deep vein thrombosis in spinal cord injury: Ruptured Baker’s cyst
Published in The Journal of Spinal Cord Medicine, 2022
A 61-year-old female patient was referred to our clinic for rehabilitation. Her clinical history included operation for lumbar spinal stenosis 3 weeks prior, where weakness of both legs persisted after the operation. Neurological examination of the patient was performed according to the Neurological Classification of SCI developed by the American Spinal Injury Association (ASIA), and her ASIA Impairment Scale (AIS) grade was T12 AIS C. The patient, who received 40 mg subcutaneous enoxaparin sodium once daily between the operation and discharge, was not undergoing antiaggregant treatment when she presented to our outpatient clinic. According to the Modified Ashworth Scale, grade 1 spasticity was present in the bilateral ankle plantar flexors. Laboratory results were unremarkable. Three weeks after hospitalization for rehabilitation, the patient developed pain and swelling in her left lower extremity and Doppler ultrasound revealed acute DVT. The vascular consultant initiated 60 mg subcutaneous enoxaparin sodium twice a day.
Spontaneous bleeding in a patient on enoxaparin with poor renal function
Published in Baylor University Medical Center Proceedings, 2019
Jenny A. Shih, Richard E. Alexander, David Nagle, Andrew Z. Fenves
In our patient case, the conventional creatinine-based formulas overestimated her kidney function. Creatinine-based equations placed her renal function within the range of stage 2 chronic kidney disease (GFR 60–89 mL/min/1.73 m2) or stage 3A chronic kidney disease (GFR 45–59 mL/min/1.73 m2), and the cystatin C equation revealed a more impaired function within the range of stage 3B chronic kidney disease (30–44 mL/min/1.73 m2) (Table 1). We believe that her GFR was low at 31 to 35 mL/min/1.73 m2 as estimated by the cystatin C equation given her creatinine variability due to her older age, female gender, and decreased muscle mass from poor functional status on home oxygen. Moreover, the dosing of enoxaparin sodium was likely too high for her renal function, placing her at increased risk of spontaneous bleeding. In patients with mild to moderate renal impairment, enoxaparin clearance can be reduced by as much as 44%.7 The use of cystatin C alone or in combination with creatinine can predict lower risks of death and end-stage renal disease.8