Can administering dalteparin (low molecular weight heparin) to a patient with an active bowel perforation be considered negligence, regardless of prognosis?

Administering Dalteparin to a Patient with Active Bowel Perforation is Medical Negligence

Administering dalteparin to a patient with an active bowel perforation constitutes medical negligence, regardless of the patient's prognosis, as it directly violates established contraindications and would accelerate mortality.

Contraindications to Anticoagulation

Active bowel perforation is an absolute contraindication to anticoagulation therapy for several critical reasons:

• The ESMO Clinical Practice Guidelines explicitly list "active, uncontrollable bleeding" and "active peptic or other gastrointestinal ulceration" as contraindications to anticoagulation 1.

• The American Society of Clinical Oncology guidelines similarly identify "active, uncontrollable bleeding" and "active peptic or other GI ulceration" as relative contraindications to anticoagulation 1.

• Bowel perforation represents a surgical emergency with high mortality risk (approximately 19.6%) even without the additional complication of anticoagulation 2.

Clinical Reasoning

Why this constitutes negligence:

1. Direct violation of standard of care:

   • Administering an anticoagulant like dalteparin in the setting of active bowel perforation directly contradicts established medical guidelines.
   • This violation would be apparent to any reasonably competent physician.

2. Predictable harm acceleration:

   • Dalteparin would significantly increase bleeding from the perforation site, accelerating blood loss and hastening death.
   • The WSES guidelines for perforated peptic ulcers emphasize that mortality increases with every hour of delay to surgery 1.

3. Alternative management exists:

   • The standard of care for bowel perforation is immediate surgical intervention 1.
   • If the patient was deemed too unstable for surgery, non-operative management without anticoagulation would be the appropriate alternative.

Poor prognosis is not a defense:

The fact that a patient "was going to die anyway" does not justify administering a medication that is clearly contraindicated and would hasten death. This violates the fundamental medical principle of "first, do no harm."

Legal Considerations

From a medicolegal perspective, administering dalteparin in this scenario would likely constitute:

1. Breach of duty: By violating clear contraindications in established guidelines.
2. Causation: The anticoagulant would directly contribute to increased bleeding.
3. Damages: Accelerated mortality and increased suffering.

Proper Management Algorithm

For a patient with active bowel perforation:

1. Immediate surgical consultation for definitive management
2. Hold all anticoagulants including dalteparin
3. Resuscitation with IV fluids and blood products as needed
4. Broad-spectrum antibiotics for peritonitis
5. If surgery is contraindicated due to extreme instability:
   • Consider non-operative management with nil by mouth, IV hydration, nasogastric decompression, and antibiotics 1
   • Still withhold anticoagulation

Only after surgical repair and confirmation of hemostasis should VTE prophylaxis be reconsidered, and even then with caution.