retroperitoneal bleed

[rn4cicu]

I have been taking care of a pt that had a retroperitoneal bleed secondary to Lovenox injection. This is the first time I have heard of this and was wondering how frequently you see this in your practice???

[dianah, ASN]

Might be worth it to call the vendor rep. of the various closure devices your facility uses, to give an inservice to the nurses who care for pts post-device placement. Then you and others can ask questions directly.

[lalaxton]

i have seen several RP bleeds in patients on Lovenox alone, not post angio. If you read the product monograph it is listed as an adverse effect. I always watch patients carefully for complaints of leg or abd pain. One doc I work with lost his grandmother to a RP bleed on Lovenox that was diagnosed too late!

[RNCENCCRNNREMTP]

I found this info after a quick medline search:

Title

Enoxaparin-induced retroperitoneal hematoma.

Source

Annals of Pharmacotherapy. 37(6):822-4, 2003 Jun.

Abstract

OBJECTIVE: To report 2 cases of retroperitoneal hematoma in elderly patients receiving enoxaparin. CASE SUMMARIES: Two white men, aged 70 and 71 years, received enoxaparin 80 mg subcutaneously twice a day for 8 and 4 days, respectively. Baseline hemoglobin and hematocrit values were 9.5 g/dL and 28.9% and 11.2 g/dL and 32.8%, respectively. In both cases, after the hemoglobin and hematocrit values decreased to 6.6 g/dL and 20.4% and 5.1 g/dL and 15.2%, respectively, a computed tomography scan revealed a retroperitoneal hematoma. DISCUSSION: Enoxaparin is a frequently used anticoagulant. Major bleeding episodes are reported to occur at a rate of up to 5.2%. Factors that increase the risk of bleeding in patients receiving enoxaparin are the use of high doses of enoxaparin, advanced age, renal impairment, and the concomitant use of drugs affecting hemostasis. Both of these patients received relatively high doses of 0.80 and 0.94 mg/kg subcutaneously twice a day, were elderly, and had mild renal impairment; 1 received aspirin concomitantly, while the other received aspirin 4 days prior and warfarin 1 day prior to bleeding. CONCLUSIONS: There are very few published reports implicating enoxaparin as a factor in retroperitoneal hematoma. It is hoped that the addition of these 2 cases to the medical literature creates more awareness that retroperitoneal hematoma should be considered in the differential diagnosis in patients receiving enoxaparin and experiencing unexplained decreases in hemoglobin and hematocrit.

Title

Fatal spontaneous retroperitoneal hematoma secondary to enoxaparin.

Source

Southern Medical Journal. 96(1):58-60, 2003 Jan.

Abstract

An 83-year-old woman was transferred to our cardiac intensive care unit with an acute non-Q-wave myocardial infarction and pulmonary edema. Enoxaparin was one component of the treatment regimen used. Her hospital course was complicated by episodes of hypotension, as well as by recurrent left hip and left thigh pain. The defining event occurred when the patient became acutely hypotensive and developed abdominal distention, peritoneal signs, intense left flank pain, and a 3.3 g/dl hemoglobin decrease. Abdominal computed tomography showed a 9 x 6 x 20 cm left retroperitoneal hematoma. The hematoma was spontaneous, secondary to enoxaparin use. The patient died despite vigorous supportive care. Enoxaparin is being increasingly used in patients with acute coronary syndromes. Review of the medical literature revealed that this is the first reported case of a patient with an acute coronary syndrome who died as a result of an enoxaparin-induced, spontaneous retroperitoneal hematoma. This article reviews important clinical signs and symptoms, identifies high-risk patient populations, and discusses management strategies.

Title

Hemothorax and retroperitoneal hematoma after anticoagulation with enoxaparin.

Source

Southern Medical Journal. 95(8):936-8, 2002 Aug.

Abstract

A 58-year-old woman with chronic obstructive pulmonary disease had spontaneous bilateral hemothorax and a retroperitoneal hematoma after 4 days of anticoagulation therapy with enoxaparin (1 mg/kg subcutaneously every 12 hours) for suspected pulmonary thromboembolism. The patient was successfully managed with red blood cell and plasma transfusions, multiple thoracenteses for evacuation of blood from the pleural space, short-term mechanical ventilation, and administration of bronchodilators, corticosteroids, and antibiotics. This is the first report of spontaneous hemothorax and the third report of spontaneous retroperitoneal hematoma associated with enoxaparin therapy.

[dianah, ASN]

I repeat, scary! Be always watching . . .

[MICUReg.Nut.]

This article discusses the fatal complication of rp bleed associated with enoxaparin (lovenox) injections subq and asociated rapid decompensation and treatment/management modalities. It's very good.

Also of note for all you clinicians working with pt's that undergo any femoral artery cannulation procedure: pay attention to the level of the stick your pt had.....the higher the stick the higher the likelihood of serious bleeding post procedure as the natural anatomy assists in arterial occlusion post procedure if the stick is low.....thus the entry wound is generally located near the top of the thigh as opposed to above the groin crease.

A Retroperitoneal Bleed Induced By Enoxaparin Therapy

Retroperitoneal bleeding is one of the most serious, potentially lethal complications of anticoagulation therapy. Although well documented in fully heparinized and coumadinized patients, there are only few reports of life-threatening hemorrhages in low-molecular- weight heparin (LMWH)-treated patients. We present a case of almost fatal spontaneous retroperitoneal bleeding in a 71-year-old woman with pneumonia and acute coronary syndrome. . . .

LOW-MOLECULAR-WEIGHT HEPARINS (LMWHS) have proven to be as safe and effective as unfractionated heparin for the prophylaxis and treatment of acute coronary syndrome (ACS), non-Q-wave myocardial infarction (NQWMI), venous thrombosis, and pulmonary thromboembolism. As a result of their safety and efficacy, along with the advantages of decreased laboratory monitoring and outpatient administration, the prescription of LMWH has altered clinical practice in the United States.1 However, a high incidence of local bleeding complications has been reported with enoxaparin (Lovenox), mostly at the injection or instrumentation sites. . . .

In high-risk patients, enoxaparin activity (anti-factor Xa) should be carefully monitored.

Story from REDORBIT NEWS:

A Retroperitoneal Bleed Induced By Enoxaparin Therapy - Health News - redOrbit

Published: 2005/06/09 06:00:18 CDT

© RedOrbit 2005

[yincaixin]

I have met a baby before heart surgery nurses draw blood from femoral vein, after the cpb,the baby has retroperitoneal bleed.fortunely we found it in time .

[Bossy Boss]

A patient could bleed post heart cath 3 days afterwards (RB-or pseudo hemotoma bleed) . Which makes it crazy.We have a post heart cath do's and don'ts sheet we send them home with a copy, we have them sign. We don't give lovenox till 6hrs after sheath pull. We don't use angio seal to often. So I love when they use the wrist.

[Golfenaround]

I had a pt. who was a cardiac pt. and she was a rather larger woman. Came on to the unit, while doing my morning assessment she complained of ® flank pain. Her abd. was getting larger, 30 mark drop in hemoglobin from a.m. labs, went to CT, diagnosed. She was elderly as well. The internal medicine (locum) who was working with us for the week told me that it isn't uncommon and hers was related to enoxaparin. First time I had a pt. with this at all and I have been nursing since 1993. (18 yrs). I would of suspected post op, trauma pt. but not this. I can't remember her dose of lovenox. Very interesting though.

There wasn't anything to do surgically and thankfully she was a DNR so family was called in and we kept her comfortable.

[MemorialCCRN-CSC]

Post interventional Retroperitneal bleeds do unfortunately occur and can be exacerbated by the use of low molecular heparins and anti-platlet agents. And with the increasingly over-weight population it can become a more difficult complication to prevent. In patients with unusually high femoral artery access sites it can be very tricky to acheive adequate homostatis regardless of methods used. Classic signs to look for are the flank pain and also the sudden urge to pass gas and have a bowel movement. Most retroperitneal hematomas don't require surgical intervention and will be treated with blood products till space is filled and bleed tampenodes off. Psuedoanurysms on the other hand to tend to be more aggressively treated with thrombin injection or surgical intervention. As far as issues related to just the use of lovenox and not associated with cardiac interventions, I have only come across one case of a spontaneous rectus sheath hematoma that was self limiting but did require the transfusion of some blood products to maintain adequate circulating volume.

[tahoe77]

I'm betting this retro-bleed would've happened regardless of what type of anticoagulation he/she was being given. The Lovenox surely made it worse, but it's not some side-effect unique to the drug.

(hey KC, that 1mg/kg bid is a big dose for prophylaxis. We usually give 40mg sq qd for prevention(maybe more if patient weighs alot). The 1mg/kg/bid is more for chest pain/dvt)

I'm in agreement. The retro bleed probably would have already happened. Did the pt have a vascular intervention

or groin incision? I have seen high doses of lovenox but its for treatment of thrombus from mi.

Something else is going on with your guy and it sounds like maybe the lovenox sent the pt over

the edge.