title: Clinical challenges in a patient with dabigatran-induced fatal hemorrhage.
abstract: OBJECTIVE
  To report clinical challenges in managing dabigatran-induced bleeding.
  
  
  METHODS
  A 78-year-old woman came to the hospital with severe coagulopathy, respiratory failure, hypotension, and bleeding secondary to dabigatran therapy. At admission, creatinine clearance was 15 mL/min; prothrombin time, 147.5 seconds; activated partial thromboplastin time, >200 seconds; and international normalized ratio, 12.42. Medications taken at home included dabigatran, 150 mg BID. During the hospitalization, multiple blood product transfusions were given, vitamin K and prothrombin complex concentrate were administered, and dialysis was initiated in an attempt to achieve hemostasis. Despite multiple interventions, coagulopathy persisted (prothrombin time, 70.8 seconds; activated partial thromboplastin time, >200 seconds; and international normalized ratio, 6.05), with continued bleeding. On hospital day 5, the patient died.
  
  
  CONCLUSIONS
  According to the Naranjo probability scale, bleeding associated with dabigatran revealed a probable relationship. This fatal case illustrates our concern about the usefulness of currently recommended anticoagulation laboratory tests and of the efficacy of blood transfusion, dialysis, and prothrombin complex concentrate in managing life-threatening bleeding secondary to dabigatran. In addition, clinicians should be cognizant of the renal recommendations for the newer oral anticoagulant agents to prevent potentially catastrophic results.
authors.affiliation: Jackson Memorial Hospital, Miami, Florida, USA.
authors.forename: Ennie L
authors.initials: EL
authors.lastname: Cano
authors.forename: Marta A
authors.initials: MA
authors.lastname: Miyares
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects*; D001562:Benzimidazoles / Q000009:adverse effects*; D000069604:Dabigatran; D017809:Fatal Outcome; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced*; D006801:Humans; D007022:Hypotension / Q000139:chemically induced; D012131:Respiratory Insufficiency / Q000139:chemically induced; D012720:Severity of Illness Index; D015091:beta-Alanine / Q000009:adverse effects / Q000031:analogs & derivatives*
chemical_list: D000925:Anticoagulants; D001562:Benzimidazoles; D015091:beta-Alanine; D000069604:Dabigatran