Case report - Gluteal hematoma in two spinal cord patients on enoxaparin for venous thromboembolism prophylaxis: evidence needed for a wiser choice.

Introduction: Acute spinal cord injury is associated with an increased risk of thromboembolic events. Low-molecular-weight heparins are first-line medications for both the treatment and prevention of venous thromboembolism. Pharmacological prophylaxis may be indicated for high-risk patients and low-risk patients may be managed with non-pharmacological measures. Case presentation: We report two cases of gluteal hematomas that occurred in patients with chronic spinal cord injury who were under prophylactic doses of enoxaparin at a tertiary rehabilitation hospital. There was no local trauma. The patients needed multiple surgical interventions and rehabilitation treatment was delayed. Discussion: There is a lack of evidence to correctly estimate the thromboembolic risk in chronic spinal cord injury and the duration of prophylaxis. Over-prescription of pharmacological prophylaxis may expose patients to unnecessary risks. These patients frequently present with polypharmacy and reducing the amount of prescribed medication may begin with reducing prophylactic treatments for venous thromboembolism, which may be an overtreatment based on risk overestimation.

Spontaneous mesenteric hematoma associated to warfarin with surgical resolution. / [Hematoma mesentérico espontáneo asociado a warfarina con resolución quirúrgica.]

Spontaneous mesenteric hematoma isinfrequent. It has been related to prolonged anticoagulation, mainly with warfarin. No definitive treatment has been established; A treatment is suggested in hemodynamically stable patients, while in patients in shock, the surgical treatment is suggested. Our goal is topresent the case of a mesenteric hematoma associated with prolonged conservative anticoagulation with surgical resolution. Female patient with 67 years old, consulted for 24 hours of evolution abdominal pain and signs of peritonism; Computed tomography was performed with a diagnosis of spontaneous mesenteric hematoma. In the context of a clinically stable patient anticoagulated with warfarin, emergency laparotomy with intestinal resection of the segment affected by the hematoma was decided. Pathological anatomy reports massive submucosal hemorrhage. Conclusion: Surgical behavior in patients with hemodynamically stable peritonism can be safe and effective

El hematoma mesentérico espontáneo es una entidad infrecuente. Se lo ha relacionado con anticoagulación prolongada, principalmente con el uso de warfarina. No se ha establecido un tratamiento estándar hasta la fecha; sugiriéndose en pacientes hemodinámicamente estables un tratamiento conservador, mientras que en pacientes inestables el tratamiento quirúrgico. Nuestro objetivo es presentar el caso de un hematoma mesentérico asociado a anticoagulación prolongada con resolución quirúrgica. Paciente de sexo femenino de 67 años de edad, consultó por dolor abdominal de 24 horas de evolución y signos de peritonismo; se realizó tomografía computada con diagnóstico de hematoma mesentérico espontáneo. En el contexto de una paciente clínicamente estable anticoagulada con warfarina, se decidió laparotomía de urgencia con resección intestinal del segmento afectado por el hematoma. El informe de anatomía patológica revela hemorragia masiva submucosa. Conclusión: La conducta quirúrgica en pacientes con peritonismo, estables hemodinámicamente, puede considerarse seguro y efectivo.

First report of hepatic hematoma after presumed Bothrops envenomation.

In Latin America, Bothrops envenomation is responsible for the majority of accidents caused by venomous snakes. Patients usually present local edema, bleeding and coagulopathy. Visceral hemorrhage is extremely rare and considered a challenge for diagnosis and management. We report the first case of hepatic hematoma owing to the bothropic envenomation in a 66-year-old man who was bitten in the left leg. He presented local edema, coagulopathy, and acute kidney injury. Radiological findings suggested hepatic hematoma, with a volume of almost 3 liters. The hepatic hematoma was gradually absorbed without the need for surgical intervention with complete resolution in 8 months.

First report of hepatic hematoma after presumed Bothrops envenomation

ABSTRACTIn Latin America, Bothrops envenomation is responsible for the majority of accidents caused by venomous snakes. Patients usually present local edema, bleeding and coagulopathy. Visceral hemorrhage is extremely rare and considered a challenge for diagnosis and management. We report the first case of hepatic hematoma owing to the bothropic envenomation in a 66-year-old man who was bitten in the left leg. He presented local edema, coagulopathy, and acute kidney injury. Radiological findings suggested hepatic hematoma, with a volume of almost 3 liters. The hepatic hematoma was gradually absorbed without the need for surgical intervention with complete resolution in 8 months.

Venous thromboembolism prophylaxis in the massive weight loss patient: relative risk of bleeding.

BACKGROUND: Measures that can reduce the incidence of venous thromboembolism (VTE) are of great clinical importance. In addition to the use of sequential compression devices (SCDs), chemoprophylaxis with low-molecular-weight heparin (LMWH) has been recommended by the American College of Chest Physicians for major general surgery procedures. There remains inconclusive evidence to support guidelines for the plastic surgery population, and some surgeons hesitate to use anticoagulation due to concerns about bleeding in broad planes of dissection. The purpose of this study was to evaluate the risk of postoperative complications secondary to chemical thromboprophylaxis in massive weight loss patients. METHODS: Five hundred forty-six surgical cases were enrolled in an institutional review board-approved prospective clinical database in the 2 years before and after routine LMWH use was initiated. Inclusion required weight loss of greater than 50 lb. Group 1 had SCDs only (n = 334), whereas group 2 had SCDs and LMWH 6 hours postoperatively (n = 212). Risk of VTE was calculated and complications of LMWH administration were analyzed. RESULTS: The overall risk of deep venous thrombosis and pulmonary embolism was 0.18%. There was no statistical difference between the groups (P > 0.05). Overall risk of hematoma was 5.4%, in concordance with the literature. There was no difference in hematoma risk between the groups (4.6% before and 6.6% after LMWH; P = 0.3). The transfusion rate was 8.5% before use of LMWH (group 1) and 7.6% after (group 2; P = 0.7). CONCLUSIONS: Strategies to reduce VTE rates remain important in all areas of plastic surgery. We have demonstrated no increased risk of transfusion or hematoma and a low overall incidence of VTE after implementing a chemoprophylaxis regimen. Postoperative LMWH can provide an excellent balance between VTE prophylaxis and the risk of bleeding complications.

Assessment of the outcomes associated with periprocedural anticoagulation management in children with acute lymphoblastic leukemia.

OBJECTIVE: To report the outcomes of an institutional protocol for periprocedural anticoagulant (AC) management in children with acute lymphoblastic leukemia (ALL). STUDY DESIGN: Children being treated for ALL who received full-dose (therapeutic) anticoagulation before undergoing at least 1 lumbar puncture (LP) were included in this retrospective cohort study. The main outcome was the risk of traumatic LP; exploratory analysis included the risks of symptomatic spinal hematoma and progression/recurrence of the thrombotic event. Analyses were conducted using logistic regression analysis with a generalized estimating equation approach. RESULTS: Twenty-two children with ALL receiving an AC underwent a total of 396 LPs. Although traumatic LP was associated with full-dose AC therapy in univariable analysis, a multiple logistic regression model controlling for other risk factors for traumatic LP showed that AC therapy was not significantly associated with the risk of traumatic LP when the ACs were held as per the institutional protocol. No patient developed symptomatic spinal hematoma. Exploratory analysis revealed that AC dose, a likely marker of thrombus burden, was significantly associated with progression/recurrence of the thrombotic event in univariable analysis. CONCLUSION: In our cohort, recent AC therapy was not statistically associated with an increased risk of bleeding after LP when following a specific protocol for periprocedural AC management. The risk associated with the progression/recurrence of thromboembolic events requires further evaluation.

Neuropatía femoral y hematoma bilateral de músculos psoas-iliaco asociados a tratamiento con warfarina / Femoral neuropathy and bilateral hematoma: psoas-iliac muscles associated with a warfarin treatment

Se presentó un hombre de 70 años que sufrió un hematoma bilateral de los músculos psoas-iliacos como consecuencia del tratamiento con warfarina. Después de 6 d de tratamiento analgésico, valores de índice internacional normalizado inferiores a 1,5 y control del sangrado, se indicó la warfarina para continuar la profilaxis por la prótesis valvular mecánica. Fue egresado con secuelas motoras por la neuropatía femoral y se ha mantenido con tratamiento fisioterapéutico. Se diagnosticó neuropatía por compresión del nervio femoral, por hematoma de los músculos psoas-ilíacos. Los casos de hematomas retroperitoneales son escasos en la literatura médica, en Cuba no encontramos casos publicados...

This is the case of a man suffered of a bilateral hematoma of psoas-iliac muscles as a consequence of warfarin treatment. After 6 days od analgesic treatment, values of INR lower than 1,5 and bleeding control warfarin was prescribed to continue the prophylaxis by mechanical valvular prosthesis. He was discharged with motor sequelae due to femoral neuropathy maintained with a physiotherapy treatment. A neuropathy by compression of femoral nerve due to hematoma of psoas-iliac muscles was diagnosed. The cases of retroperitoneal hematomas are scarce in medical literature and in Cuba there were not published cases...

[Spontaneous intramural hematoma of the small bowel due to use of oral anticoagulants: case report and review of the literature]. / Hematoma intramural espontáneo de intestino delgado debido al uso de anticoagulantes orales: reporte de caso y revisión de la literatura.

We describe a case of 78 year-old woman under anticoagulant therapy who presented abdominal pain, nausea, vomiting and an elevated prothrombin time levels (INR = 9.03). The ultrasound and abdominal CT showed a thickened small bowel wall mainly involving duodenum and jejunum. The endoscopy showed an ecchymotic aspect of duodenum and jejunum. The patient received conservative medical treatment and her symptoms spontaneously subsided.

[Iliopsoas muscle hematoma during treatment with warfarin]. / Hematoma de músculo iliopsoas na vigência de tratamento com varfarina.

Warfarin is a widely used drug for the prevention of thromboembolic events. Knowledge of its adverse effects is necessary for patient follow-up. Although the development of blood dyscrasias is a potential complication in these patients, retroperitoneal bleeding is rare. This article reports the case of a patient who developed iliopsoas muscle hematoma during treatment with warfarin after implantation of a metallic prosthetic aortic valve. The clinical manifestations involved important differential diagnoses.

Síndrome dolorosa miofascial do músculo psoas: complicação do tratamento intervencionista: relato de caso / Psoas muscle miofascial painful syndrome: complication of the interventional treatment: case report

JUSTIFICATIVA E OBJETIVOS: A infiltração anestésica do músculo psoas para tratamento da síndrome dolorosa miofascial apresenta reconhecida eficácia, tendo como complicações estabelecidas a infecção local e o hematoma. O objetivo do presente estudo foi relatar um caso de síndrome dolorosa miofascial do músculo psoas com complicação decorrente do tratamento intervencionista.RELATO DO CASO: Paciente do sexo feminino, 49 anos, com queixa de dor lombar e abdominal há cinco anos, com piora há dois anos. Na consulta relatou dor lombar, com irradiação para a região inguinal esquerda, contínua, com intensidade 8 pela escala analógica visual (EAV), apesar do uso de fórmula contendo fluoxetina, meloxicam e amitriptilina. A hipótese diagnóstica foi de síndrome dolorosa miofascial do psoas, sendo realizada infiltração anestésica do músculo, com alívio imediato e completo da dor. Dezoito dias após o procedimento a paciente apresentou dor de intensidade 6 e com história clínica compatível com hematoma subagudo. Trinta e cinco dias após o primeiro exame, a ressonância nuclear magnética (RNM) mostrou regressão total da coleção intramuscular, com persistência apenas de tênue área de edema e realce mio-fibrilar. Realizou-se infiltração muscular com toxina botulínica medicamentosa com duloxetina (60 mg/dia), sendo obtida a remissão total do quadro doloroso. CONCLUSÃO: O caso mostrou a eficácia da infiltração do músculo psoas com anestésico local e corticoide como medida terapêutica indicada para relaxamento muscular imediato, com desativação dos pontos-gatilho e consequente alívio da dor, acelerando assim o processo de recuperação e mostrou que o hematoma é uma complicação que pode ser resolvida com tratamento clínico.

BACKGROUND AND OBJECTIVES: Anesthetic infiltration of the psoas muscle to treat painful myofascial syndrome is recognized as effective and has as established complications local infection and hematoma. This study aimed at reporting a case of psoas muscle painful myofascial syndrome with a complication caused by the interventional treatment.CASE REPORT: Female patient, 49 years old, with lumbar and abdominal pain complaint for five years which has worsened in the last two years. Patient reported lumbar pain, with irradiation to the left inguinal region, continuous, with intensity 8 according to visual analog scale (VAS), in spite of using a formula with fluoxetine, meloxicam and amitriptyline. Diagnostic hypothesis was painful psoas myofascial syndrome. The muscle was infiltrated with anesthetics with immediate and complete pain relief. Eighteen days after the procedure, patient presented pain of intensity 6 and with clinical history compatible with sub-acute hematoma. Thirty-five days after the first exam, MRI has shown total regression of the intramuscular collection with persistence of just a subtle area of edema and myo-fibrillary enhancement. Muscle was infiltrated with botulinic toxin drug with duloxetine (60 mg/day), with total remission of pain. CONCLUSION: This case has shown the efficacy of infiltrating the psoas muscle with local anesthetics and steroid as therapeutic measure indicated for immediate muscle relaxation, with deactivation of trigger-points and consequent pain relief, thus accelerating the recovery process, and has shown that hematoma is a complication which may be solved with clinical treatment

Hematoma de músculo iliopsoas na vigência de tratamento com varfarina / Iliopsoas muscle hematoma during treatment with warfarin / Hematoma de músculo iliopsoas en la vigencia de tratamiento con warfarina

A varfarina é droga amplamente utilizada na prevenção de fenômenos tromboembólicos e o conhecimento de seus efeitos adversos faz-se necessário para o acompanhamento dos pacientes. Embora o desenvolvimento de discrasias sanguíneas seja complicação potencial nesses pacientes, a ocorrência de sangramento retroperitoneal é rara. Este artigo discute o caso de um paciente que evoluiu com hematoma do músculo iliopsoas durante tratamento com a referida droga, pós-implante de prótese aórtica metálica, com quadro clínico envolvendo importantes diagnósticos diferenciais.

Warfarin is a widely used drug for the prevention of thromboembolic events. Knowledge of its adverse effects is necessary for patient follow-up. Although the development of blood dyscrasias is a potential complication in these patients, retroperitoneal bleeding is rare. This article reports the case of a patient who developed iliopsoas muscle hematoma during treatment with warfarin after implantation of a metallic prosthetic aortic valve. The clinical manifestations involved important differential diagnoses.

La warfarina es un fármaco ampliamente utilizado en la prevención de fenómenos tromboembólicos, y el conocimiento de sus efectos adversos se hace necesario para el seguimiento de los pacientes. Aunque el desarrollo de discrasias sanguíneas es la complicación potencial en estos pacientes, la ocurrencia de sangrado retroperitoneal es rara. Este artículo discute el caso de un paciente que evolucionó con hematoma del músculo ileopsoas durante tratamiento con el referido fármaco en el postimplante de prótesis mitral metálica, con cuadro clínico implicando importantes diagnósticos diferenciales.