Clinical experiences of a surgeon in the use of heparin

Abstract Intermittent intravenous injections of heparin for the treatment of acute deep venous thrombosis were used for the first time at the Department of Surgery, General Hospital, Mariestad, Sweden. This form of therapy, combined with free movements of the affected limb and early ambulation, was started in October 1940 and has been used continuously since. In a period of 18 years, 1940 to 1958, 937 cases were treated. A dose of 150 mg. (15,000 units) was injected intravenously as soon as thrombosis had been diagnosed. Additional similar doses were given at four-hour intervals, except that no injections were given during the night. On the subsequent days, three or four doses of the same size were given. After three to four days the temperature generally had returned to normal and edema and tenderness had disappeared. Injections of heparin were then decreased to two, and the patient was allowed out of bed. Treatment was discontinued on the next day, and on the following day the patient could usually be discharged from the hospital. In specified cases a slightly modified procedure was employed. When massive pulmonary embolism was the predominant feature, a more concentrated heparinization was made during the first 24 hours. No determinations of the coagulation time were made in the course of routine treatment. They were regarded as superfluous, and their omission did not result in any overdosage of heparin. In 95 per cent of the cases the course of recovery was entirely normal. Edema and tenderness subsided in a few days, and the temperature and pulse returned to normal after a further day or two. The mean duration of recumbency was 4.4 days. Prior to any form of treatment, symptoms of pulmonary embolism were present in 59 of the 937 cases. Many of these patients were in poor condition, and 10 had had repeated attacks. With the exception of two, who died from a complicating bronchopneumonia, all patients recovered after heparin therapy. The normal course of recovery was interrupted in one way or the other in 47 (5%) of the 937 cases. Seven deaths occurred, including those mentioned above. Recurrence of the thrombotic process, making further heparinization necessary, was observed in 24 Instances (2.6%). A slight hemorrhagic tendency was recorded 14 times (1.5%). The complication was harmless. In none of the cases was it found necessary to administer antidotes. The conclusion is drawn that hemorrhage is an uncommon complication, occurring only once or twice in a hundred patients, of a mild nature. If heparin therapy is to be successful, two points are Considered to be of the utmost importance. One is the necessity of establishing a very early diagnosis of the condition, if possible, at a time when the process is still confined to the lower part of the leg. Suitable measures to obtain this end are discussed in detail. The other point is the necessity to make the patient ambulant before heparinization is discontinued. Many failures with heparin treatment can be ascribed to neglect of this procedure.