Fatal dabigatran toxicity secondary to acute renal failure

We describe the case of a 74-year-old man taking dabigatran 150 mg twice daily for atrial fibrillation who presented to the emergency department after 20 mL of hematemesis at home. Laboratory evaluation revealed a partial thromboplastin time of 99 seconds, international normalized ratio of 11.7, and creatine of 3.1 mg/dL (baseline creatine, 0.9 mg/dL). Upper endoscopy revealed diffuse gastritis and bleeding. Despite treatment with packed red blood cells and fresh frozen plasma, the patient's hematemesis persisted resulting in significant aspiration requiring endotracheal intubation. Per poison control center recommendations, the patient's presumed dabigatran toxicity was treated with fresh frozen plasma, prothrombin complex concentrate, recombinant factor VIIa, and dialysis. Although the patient's international normalized ratio and partial thromboplastin time improved to 2.0 and 46 seconds, respectively, the patient developed aspiration pneumonia resulting in sepsis, multiorgan dysfunction, disseminated intravascular coagulation, and death on hospital day 6. Further laboratory evaluation revealed an initial dabigatran level of 370 ng/mL and a postdialysis level of 170 ng/mL (mean peak therapeutic concentration, 130 ng/mL). This case demonstrates the potential for emergent gastrointestinal bleeding from dabigatran toxicity secondary to renal failure as well as the limited therapeutic options available in the treatment of dabigatran associated bleeding.
Source: The American Journal of Emergency Medicine - Category: Emergency Medicine Authors: Tags: Case Reports Source Type: research