Internal Medicine

P1: RLJ/OZN P2: KUF

0521779407-D-01 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:41

466 Deep Venous Thrombosis

■Side Effects

➣Warfarin-induced skin necrosis

➣Due to depletion of Protein C

➣More common in pts with Protein C or S deficiency

➣Caused by initial large coumadin loading dose

➣Avoid large loading dose

■Bleeding

➣Proportional to degree of anticoagulation

➣Treat with: blood replacement if needed and reversal of

coumadin (fresh frozen plasma and/or vitamin K)

■Thrombolytic therapy

➣No decrease in post-thrombotic syndrome, pulmonary em-

bolism compared to heparin therapy

➣Increased risk of bleeding (puncture site and intracranial)

■Surgical Thrombectomy

➣Reserved for ileofemoral DVT with impending venous gangrene

➣High incidence of rethrombosis and venous complications

follow-up

During Treatment

■Check coagulation studies as needed for heparin (not for LMW) and

coumadin

■Counsel patients regarding other meds that alter coumadin activity

Routine

■Check for later development of post-thrombotic syndrome

■Lifelong anticoagulation for patients with documented hyperco-

aguable syndrome

complications and prognosis

Complications

■Pulmonary Embolism (PE)

➣Most common cause of preventable in-hospital death

➣200,000 death/year in US

➣Most pts die within 2 hours of PE

➣Treat with heparin (LMW or unfractionated)

➣Consider placement of IVC filter if PE occurs on adequate anti-

coagulation

■Post-thrombotic syndrome (Chronic venous insufficiency)

➣Occurs in 25% of patients with DVT despite current therapy

Major cause of disability in young patients