Abstract: . . .  thrombin inhibitor, and lepirudin (Refludan), a recombinant form of the direct thrombin inhibitor hirudin. If necessary, an inferior vena cava filtration device such as the Greenfield filter can be implanted. These devices prevent pulmonary em- bolization by trapping embolic material originating from ar- eas of the vasculature distal to their placement point. 25 11. On day 3 of heparin therapy, L.N.s Hct has dropped from a baseline of 36.5% to 29%, and blood is noted in his urine. De- scribe an approach to evaluate and interpret this event. Hemorrhage. Bleeding is the most common adverse effect associated with heparin. A summary of eight inception cohort  . . .
. . .  synthe- sis. Hypoaldosteronism leading to hyperkalemia has been de- scribed with both high-dose and low-dose heparin therapy, may occur as quickly as within 7 days after initiation of hep- arin therapy, and appears to be reversible after discontinuation of heparin. 5 Patients with diabetes or renal failure may be at greatest risk. Hypersensitivity Reactions. Other rarely occurring adverse ef- fects associated with heparin include generalized hypersensi- tivity reactions, such as urticaria, rash, rhinitis, conjunctivitis, asthma, and angioedema, as well as a reversible temporal alopecia. 5 ADJUSTED-DOSE SUBCUTANEOUS ADMINISTRATION 13. By day . . .
. . .  hem- orrhagic effects. 27 In addition, bleeding episodes can occur when coagulation test results are within the therapeutic range. These conflicting results may be explained in part by the in- fluence of additional risk factors for bleeding and by the ef- fect of heparin on platelet function and vascular permeability. These two factors, in addition to heparins anticoagulant ef- fect, influence hemorrhagic complications. L.N. has developed hematuria despite an acceptable inten- sity of anticoagulation. He should be questioned and exam- ined for the presence of nose bleeding (epistaxis), increased tendency to bruise (ecchymosis), bright red blood in the stool (hematochezia), . . .
. . .  administra- tion volume, the dose should be simplified to 20,000 U SC every 12 hours. L.N.s aPTT should be checked 6 hours after the first dose, with adjustment of dosing as necessary. Because of the reduced bioavailability of SC heparin in comparison with IV administration, increased dosing may be required. A weight-based dosing nomogram, specific for a reagent with a THROMBOSIS 16- 11 Koda-Kimble_Ch16_001-034 4/6/04 8:42 AM Page 11 Page 12 therapeutic aPTT range of 60 to 100 seconds, is described in Table 16-7. REVERSAL OF EFFECT 14. P.B. is a 64-year-old woman with DVT. On day 4 of hep- arin therapy, she . . .
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