Ms. D was a 79-year-old, morbidly obese (323 lb, 5 feet, 1 inch tall) Caucasian woman with an extensive medical and surgical history that included bilateral knee replacement several years previously. She developed large blisters (bullous skin reaction) that contained sero-sanguineous fluid. The blisters were disseminated over her body but were most prevalent on the arms, anterior upper chest (predominantly above the breasts), and anterior upper and lower legs. A wound ostomy continence (WOC) nurse specialist was consulted to evaluate and offer recommendations for treatment.
History. Ms. D was admitted to a subacute care facility’s critical care unit in the summer of 2003. She was transferred from the acute care setting following a month-long tertiary care hospitalization. Originally, Ms. D was admitted to the tertiary care facility primarily for congestive heart failure that did not respond to medical therapy. Cardiac catheterization revealed severe aortic valve stenosis and cardiomegaly. The patient was referred to cardiac surgery and had an aortic valve replacement (AVR) with a St. Jude mechanical valve. The surgeon had wanted to use a bioprosthetic valve but Ms. D’s body structure required use of a mechanical valve and subsequent requisite lifelong anticoagulation.
Ms. D’s postoperative course was complicated by a prolonged ICU stay for ongoing low cardiac output syndrome. She also developed respiratory failure and required a tracheotomy with mechanical ventilation. She had a Groshong catheter placed for IV therapy. In addition, she developed tachycardia-bradycardia syndrome and required a pacemaker. Subsequently, she developed atrial fibrillation despite cardioversion attempts and pacing efforts.
Because of the mechanical heart valve and the atrial fibrillation, Ms. D was started on intravenous heparin. Within a week, she developed severe thrombocytopenia; heparin-induced thrombocytopenia (HIT) syndrome was suspected. A HIT assay was positive for heparin-induced platelet antibodies. The heparin was discontinued. Unfortunately, gastrointestinal bleeding also complicated Ms. D’s postoperative course. She was started on argatroban to treat the HIT syndrome and required multiple transfusions. Per chart history, Ms. D’s subsequent anticoagulant therapy included enoxaparin sodium (Lovenox, Rhone-Poulenc Rorer Pharmaceuticals, Inc., Collegeville, Pa.) until a final progression to longer-term oral anticoagulation (warfarin). The exact temporal relationship of argatroban, enoxaparin sodium, and warfarin usage was not specified in the chart history (See Discussion).
On transfer to the subacute care facility, Ms. D’s diagnoses were listed as status post aortic valve replacement, sick sinus syndrome, cardiomegaly, status post pacemaker, atrial fibrillation, hypothyroidism, hypertension, hypercholesterolemia, and ventilator-dependent respiratory failure (VDRF). Her allergies were listed as heparin and heparin products.
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