Advertisement

Protamine sulfate for the reversal of enoxaparin associated hemorrhage beyond 12 h

Published:September 28, 2018DOI:https://doi.org/10.1016/j.ajem.2018.09.043

      Abstract

      Clinical practice guidelines recommend protamine sulfate for reversal of enoxaparin associated bleeds dependent on the time from last administration and dose of enoxaparin. We present a case of a hemodynamically unstable patient with an enoxaparin induced abdominal wall hematoma/hemorrhage and the previous enoxaparin administration 21.5 h prior to presentation with a therapeutic anti-Xa assay (0.8 IU/mL) upon assessment in the emergency department. Along with resuscitative efforts, an interdisciplinary team collaborated to administer protamine sulfate 50 mg intravenous once (0.5 mg per 1 mg of enoxaparin) to reverse the therapeutic anticoagulation. Our case demonstrates the importance of monitoring renal function and the potential for accumulation of enoxaparin in patients with renal dysfunction leading to prolonged therapeutic anti-Xa assays. With the availability of anti-Xa assays, future reversal recommendations of enoxaparin associated bleeds using protamine sulfate should include the initial anti-Xa assay as a guide for the dosing regimen.

      Keywords

      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Dhakal P.
        • Rayamaijhi S.
        • Verma V.
        • et al.
        Reversal of anticoagulation and management of bleeding in patients on anticoagulants.
        Clin Appl Thromb Hemost. 2017; 23: 410-415
        • Garcia D.
        • Baglin T.
        • Weitz J.
        • et al.
        Parenteral anticoagulants: antithrombotic therapy and prevention of thrombosis 9th ed: American College of Chest Physicians Evidence-based clinical practice guidelines.
        Chest. 2012; 141: e24S-43S
        • Frontera J.
        • Lewin J.
        • Rabinstein A.
        • et al.
        Guideline for reversal of antithrombotics in intracranial hemorrhage.
        Neurocrit Care. 2016; 24: 6-46
        • Naranjo C.A.
        • Busto U.
        • Sellers E.M.
        • et al.
        A method for estimating the probability of adverse drug reactions.
        Clin Pharmacol Ther. 1981; 30: 239-245
        • Chow S.
        • Zammit K.
        • West K.
        • et al.
        Correlation of antifactor Xa concentrations with renal function in patients on enoxaparin.
        J Clin Pharmacol. 2003; 43: 586-590
        • Chawla L.
        • Moore G.
        • Seneff M.
        Incomplete reversal of enoxaparin toxicity by protamine: implications of renal insufficiency, obesity, and low molecular weight heparin sulfate content.
        Obes Surg. 2004; 14: 695-698
        • Van Veen J.
        • Maclean R.
        • Hampton K.
        • et al.
        Protamine reversal of low molecular weight heparin: clinically effective?.
        Blood Coagul Fibrinolysis. 2011; 22: 565-570