Heparin

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An event is serious (based on the ICH definition) when the patient outcome is:

• * death

• * life-threatening

• * hospitalisation

• * disability

• * congenital anomaly

• * other medically important event

A 66-year-old woman developed nasal haemorrhage and haemoglobinuria during anticoagulant therapy with heparin [routes, dosages and time to reaction onset not stated].

The woman presented in February 2020 with the primary complaints of fever, cough, headache and dyspnoea for a duration of one day. Her medical history was significant for hypertension for 8 years, for which she had been receiving treatment with candesartan cilexetil [candesartan]. Based on the clinical presentation and laboratory findings, she was confirmed to have severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. After the first 3 days of hospitalisation, she received an off-label treatment with umifenovir [Arbidol] in the isolation ward and underwent non-invasive and invasive ventilation subsequently. However, her condition worsened rapidly as she presented with severe bradycardia, decreased blood oxygen saturation and became haemodynamic instability. She was intubated after transfer to the ICU due to respiratory failure and heart failure. However, her condition continued to deteriorate rapidly. Subsequently, she was cannulated for veno-venous extracorporeal membrane oxygenation (VV-ECMO) support. During ECMO cannulation, she started receiving treatment with heparin, which was pumped continuously for anticoagulation. During hospitalisation, she also received hormonal therapy along with an off-label treatment with chloroquine diphosphate [chloroquine phosphate], ribavirin, aciclovir and convalescent-anti-SARS-CoV-2-plasma [convalescent plasma]. Additionally, she was found to have systemic inflammatory response syndrome, and she received various concomitant medications including antibacterials and antifungal prophylaxis along with continuous renal replacement therapy. She also underwent tracheostomy. On admission day 19, she developed pneumothorax, which disappeared after carrying out 14-day closed thoracic drainage. During ongoing anticoagulation therapy with heparin, she successively developed nasal haemorrhage and haemoglobinuria, indicating haemolysis.

Therefore, the woman's dose of heparin was reduced. As a result, her symptoms (nasal haemorrhage and haemoglobinuria) improved by day 40. She was weaned off from ECMO on day 53. On follow-up (3 months after ECMO decannulation), she received respiratory and cardiac rehabilitation without experiencing any discomfort.