Can Fragmin (Dalteparin) Be Used in a Patient with Active Bleeding?
No, Fragmin (dalteparin) should not be used in patients with active bleeding, as this represents an absolute contraindication to all low molecular weight heparins including dalteparin. 1
Absolute Contraindications to Dalteparin
The presence of active bleeding at any site, tissue, or organ is a clear contraindication to dalteparin use according to established guidelines 1. Specifically:
- Active major bleeding is listed as a condition where dalteparin "should not be used" 1
- Uncontrollable active bleeding state (except when due to disseminated intravascular coagulation) is an absolute contraindication 1
Clinical Decision Algorithm
When evaluating a patient for dalteparin therapy, you must first assess for active bleeding:
- If active bleeding is present: Do not initiate dalteparin regardless of thrombotic risk 1
- If bleeding has resolved: Reassess the bleeding risk versus thrombotic risk before considering anticoagulation 1
- If patient requires thromboprophylaxis urgently: Consider mechanical prophylaxis (intermittent pneumatic compression devices or graduated compression stockings) until bleeding resolves 1
Additional High-Risk Scenarios Requiring Extreme Caution
Even after bleeding resolves, dalteparin should be used with extreme caution in patients with conditions associated with increased hemorrhage risk 1:
- Bacterial endocarditis (relevant to your patient with presumed infection) 1
- Severe thrombocytopenia 1
- Liver failure with elevated INR >1.5 1
- Uncontrolled arterial hypertension (systolic >200, diastolic >110) 1
The Infection/ETT Context
The presence of an endotracheal tube and culture-positive infection does not independently contraindicate dalteparin 2. However, these factors may increase bleeding risk through:
- Potential for airway bleeding or trauma from the ETT 1
- Coagulopathy associated with severe infection or sepsis 1
- Need for invasive procedures that could precipitate bleeding 1
The active bleeding itself—not the infection or ETT—is the determining contraindication. 1
When Anticoagulation Becomes Appropriate
Once bleeding has completely resolved and the source is controlled, you can reassess for thromboprophylaxis 1. At that point:
- Dalteparin 5000 IU subcutaneously once daily is the standard prophylactic dose for hospitalized medical patients 3
- Major bleeding risk with prophylactic dalteparin is low (0.49%) in acutely ill medical patients 3
- Monitor platelet count in any patient receiving dalteparin, particularly with concurrent infection 1
Critical Pitfall to Avoid
Do not attempt to "balance" active bleeding against thrombotic risk by using lower doses of dalteparin—active bleeding is an absolute contraindication regardless of VTE risk 1. The only exception mentioned in guidelines is uncontrollable bleeding due to disseminated intravascular coagulation, where the underlying coagulopathy itself requires treatment 1.