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