A 60-year-old man with a history of Type 2 DM, HD and CKD Stage 3 is admitted to the medical ICU secondary to septic shock. He remains hypotensive with SBP below 90 despite IV fluid resuscitation. He is then started on norepinephrine (Levophed) via a central line placement in the left internal jugular vein (LIJ). Soon after the placement of the central line, the patient’s left upper extremity is swollen and tender with 2+ pitting edema. An ultrasound of the left upper extremity shows that patient has a deep vein thrombosis (DVT). He has no history of previous DVT’s.
What is the next best step in the management of this patient?
- A) Start the patient on low molecular weight heparin (Lovenox) for 3 months
- B) Start the patient on low molecular weight heparin (Lovenox) indefinitely
- C) Start the patient on low molecular weight indefinitely and switch to rivaroxaban (Xarelto)
- D) Start unfractionated heparin and bridge to warfarin for a total of 3 months
- E) Start unfractionated heparin and bridge to warfarin indefinitely
D) Start unfractionated heparin and bridge to warfarin for a total of 3 months
Patient has a provoked DVT due to central line placement in LIJ. Patient also has no history of previous DVT’s. Hence this is his first episode. Therefore, this patient needs to be on anticoagulation for 3 months. However, the patient has CKD stage 3, hence low molecular weight heparin medications such as Lovenox is contraindicated. Therefore, the best choice for the above questions is unfractionated heparin bridged to warfarin for 3 months.
Dr. Raj Dasgupta