Hemorrhagic complications associated with dabigatran use.

OBJECTIVE: Dabigatran is a direct thrombin inhibitor approved for anticoagulation in non-valvular atrial fibrillation and, in some countries, for thromboembolism prophylaxis following select orthopedic surgeries. Despite decreased rates of thromboembolism, bleeding remains a risk due to the inability to conveniently monitor anticoagulant effect and the lack of a reversal agent. CASE SERIES: We present four cases of dabigatran-related bleeding. A 79-year-old man on aspirin, clopidogrel, and dabigatran presented with rectal bleeding and epistaxis. He died despite transfusion and administration of prothrombin complex concentrate. A 73-year-old woman on dabigatran and aspirin survived after transfusion and an emergent sternotomy for cardiac tamponade. An 86 year-old man with kidney disease and thrombocytopenia received packed red blood cells, platelets, and fresh frozen plasma for rectal bleeding while on dabigatran. An 80 year-old man on dabigatran had a subdural hematoma after falling and hitting his head. Serial imaging showed no progression. CONCLUSION: The absence of a reversal agent for dabigatran raises concern for uncontrollable bleeding and death. Dabigatran's listed contraindications include active bleeding and a history of dabigatran hypersensitivity reaction. Wider use may result in bleeding rates higher than anticipated from clinical trials. Risks factors that may have contributed to bleeding in these patients include concomitant bleeding diathesis, antiplatelet agent use, renal insufficiency, advanced age, and fall risks.

Poisoning and suicide by cyanide jewelry cleaner in the US Hmong community: a case series.

Over 200 000 persons of Hmong ethnicity live in the United States. The majority of this Southeast Asian ethnic group live in California, Minnesota and Wisconsin. Tradition plays a strong role in the Hmong population, and difficulty in assimilation into "Western ways" has been reported to result in depression and suicide attempts. Some products sold at Southeast Asian ethnic markets are well-known within the Hmong community to be lethal but are essentially unknown to the outside community. We describe eight cases in which cyanide-containing products were ingested by Hmong patients. Seven cases were suicide attempts involving the ingestion of a locally-purchased substance intended for cleaning metal, coins, or jewelry. One case involved the fatal ingestion of a cyanide-containing "herbal" cure. In the majority of the cases, cyanide was not initially suspected, and treatment was delayed due to lack of information regarding the product ingested. In the two patients who survived, the cyanide antidote kit (sodium nitrite, amyl nitrite, and sodium thiosulfate) was administered early. Clinicians should be aware that unusual and potentially lethal products are easily available at ethnic markets. Cyanide toxicity should be suspected, and empiric antidote therapy initiated early, in patients of Hmong or Southeast Asian descent who present with sudden and unexplained cardiovascular collapse and metabolic acidosis, especially in the setting of a suspected suicidal ingestion.

Have advances in extracorporeal removal techniques changed the indications for their use in poisonings?

During the past 25 years, numerous changes have taken place in the use of hemodialysis as a therapeutic modality. Advances in technologies and a progression in our collective understanding of the pharmacokinetics of certain xenobiotics have resulted in alterations in the indications, effectiveness, and safety of hemodialysis. However, these changes have not necessarily been reflected in the current published data regarding treatment of intoxications. Reported clearance rates often reflect what was achievable in the 1970s and 1980s, and more recent reports are frequently lacking. Our goal in this review is to summarize the changes in hemodialysis and in other extracorporeal removal technologies and highlight the effects of these changes on the current indications for hemodialysis of the poisoned patient. Changes in dialysis performance that are reviewed in this article include the use of high-efficiency and high-flux dialysis membranes, improved hemodynamic stability because of ultrafiltration control, and the use of bicarbonate as a source of base. We review the indications for hemodialysis for removal of specific toxins, including vancomycin, methotrexate, carbamazepine, and valproic acid.