Introduction Hemorrhagic complications due to Warfarin use are frequently seen. Hemothorax is a rare complication, and trauma is a major risk factor. Massive non-traumatic hemothorax is an extremely rare condition.
Tube thoracostomy drainage is the primary mode of treatment. In cases of retained hemothorax, surgical procedures are recommended. Treatment options are limited for patients who are not surgical candidates.
First described in 1981, intrapleural administration of fibrinolytics seems to be a safe procedure for treatment of retained traumatic hemothorax. Intrapleural administration of t-PA & DNase has also been successfully used for infected pleural fluid & is associated with reduced hospital stay & need for surgery.
Our report focuses on successful treatment of Coumadin induced non-traumatic hemothorax with these agents.
Case Report A 72 yo male on Coumadin for Afib, was brought to the hospital because of SOB, confusion & hypoxemia in the 70's. CXR revealed new large left sided pleural effusion. Relevant labs included Hgb of 6.7 g/dl (4 gram below baseline), INR 7.1 & platelet count 323. Sampling of the pleural fluid showed Hgb of 7.2 & hemotocrit 21.6. Coagulopathy was corrected and decision was made to proceed with tube thoracostomy.
Patient drained almost a liter of old blood in the subsequent 24 hrs. It stopped afterwards. CXR revealed improved but persistent opacity. His health precluded surgery as an option. After long discussion with the patient, t-PA 10 mg & DNase 5 mg Once Daily was started. Pt. received a total of 3 doses with significant improvement in symptomatology and imaging. He drained almost 7 liters of old blood and was able to come off of supplemental oxygen. Hgb stayed stable after initial resuscitation.
Discussion For treatment of retained hemothorax secondary to trauma, administration of fibrinolytics has been validated in several studies. Response measured by radiologic/clinical improvement as well as PFTs is impressive. Bleeding risk is low & pleuritic pain is the most common reported adverse effect.
We propose that t-PA & DNase at the dose of 10 mg & 5 mg Daily respectively, is a safe treatment for selected patients with spontaneous non-traumatic hemothorax secondary to Coumadin use.
More data is needed in medical ICU patients before this regimen can be generalized⇓.
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