Heparin
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Heparin Acute blood loss anaemia, haematuria, epistaxis and oropharyngeal bleeding: case report
A 32-year-old man developed acute blood loss anaemia, haematuria, epistaxis and oropharyngeal bleeding during anticoagulant treatment with heparin. The man, who had a history of diabetes mellitus, presented to the emergency department with progressive shortness of breath since few days. Four days prior to presentation, he was diagnosed with COVID-19 infection. On admission, he was tachycardic, diaphoretic, tachypneic, anxious and had lung sounds indicative of crackles. He had severe hypoxaemia and was placed on a nonrebreather mask. Further examination revealed mild diffuse bilateral pulmonary consolidations. Therefore, he was intubated due to severe acute respiratory distress syndrome (ARDS) and transferred to the COVID-19 ICU. He was started on standard ARDS treatment with lung-protective ventilation, pronation, neuromuscular blockade with rocuronium bromide [rocuronium] for ventilator asynchrony and epoprostenol. On further examination, he was diagnosed with pneumomediastinum with subcutaneous emphysema and Staphylococcus aureus infection. On days 5–6 of hospitalisation, his oxygenation worsened and he developed hypercarbia. Based on further evaluation, he was started on veno-venous extracorporeal membrane oxygenation (VV-ECMO), and an improvement in his oxygenation and hypercarbia was noted. He was receiving continuous heparin infusion [dosage not stated] as an anticoagulation for the ECMO circuit. Thereafter, he developed acute blood loss anaemia, haematuria, epistaxis and oropharyngeal bleeding secondary to heparin [duration of treatment to reactions onset not stated]. The man was treated with frequent blood transfusions. Despite the possibility of development of a hypercoagulable state, the heparin infusion was reduced to lower the partial thromboplastin time up to 45–60 seconds. Eventually, his treatment with heparin was discontinued for 5 days [outcomes not stated]. On day 27, a venous duplex was negative for acute or chronic venous thrombus in all the extremities. On day 19, an improvement in his lung function and lung compliance was noted. On day 20, he underwent tracheostomy and on day 23, a successful decannulation was performed and VV-ECMO was removed. His hospital course included a total of 35 days of mechanical ventilation. However, mechanical ventilation removal was delayed due to ventilator-associated pneumonia secondary to Staphylococcus aureus and Klebsiella pneumoniae. On day 39, his COVID-19 test was negative, and he underwent aggressive rehabilitation with physical therapy and occupational therapy. On day 47, he was discharged without requirement of supplemental oxygen or support devices and was decannulated from the tracheostomy. Rajdev K, et al. A Case of Extracorporeal Membrane Oxygenation as a Salvage Therapy for COVID-19-Associated Severe Acute Respiratory Distress Syndrome: Mounting 803507064 Evidence. Journal of Investigative Medicine High Impact Case Reports 8: 10 Sep 2020. Available
