A massive overdose of 6,600mg enoxaparin and its treatment with protamine

Abstract We report a case of an intentional massive overdose of 6,600mg (660,000 IU) enoxaparin, which is the highest enoxaparin administration recorded in literature. At admission, the patient's activated partial thromboplastin time (aPTT) was >180 seconds and anti-Factor Xa level was >2 IU/mL. She was treated with two doses of protamine sulfate 50mg with subsequent normalization of aPTT and anti-Xa level over 48 hours, the time evolution of which we present here. The only major complication sustained by the patient was a knee hemarthrosis which was managed conservatively. There was no significant decrease in hemaglobin nor was blood product transfusion required. This case demonstrates the use of protamine sulfate amidst a paucity of guidelines for its use in massive enoxaparin overdosing cases, for which we propose the conservative use of protamine guided by aPTT as a possible managementregime.