Post-op care

Question 1

In which of the following patients is heparin contraindicated?

Hemodynamically stable 80yo M with documented PE
20yo M with closed head injury 6d ago
23yo F in 3rd trimester pregnancy
44yo F with heparin-induced thrombocytopenia
23yo M with liver injury from gunshot wound 5d ago, now with femoral DVT

Answer 1

Heparin-induced thrombocytopenia.

Heparin does not cross placenta and not contraindicated in pregnancy. Can give patients LMW heparin 48hr after head injury, or 24hr after intra-abdominal injury.

Question 2

36yo M s/p ex lap with distal pancreatectomy, splenectomy for GSW to abdomen. Blood loss of 3L prior to surgery. Post-op, stable in ICU with hematocrit 28% and INR 1.7. What’s the most appropriate DVT prophylaxis?

Pneumatic compression device
LMW heparin
5000U fractionated heparin TID
5000U fractionated heparin BID
withhold prophylaxis until INR normalized

Answer 2

LMW heparin. More effective than fractionated heparin in DVT prophylaxis in high-risk pts (trauma pts with high blood loss). Can be initiated within 36hr of injury.