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Anticoagulant Acute Injectable Flashcards

1
Q

What is the virchow’s triad

A

Vascular wall injury

Venous stasis

Hypercoaguability

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2
Q

What can cause vascular wall injury

A

Surgery

Trauma

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3
Q

What compromises of venous stasis

A

Vericose veins

Immobility

Travel (Serena williams)

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4
Q

What can cause hypercoaguability

A

Thrombophilia

Pregnancy

Cancer

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5
Q

What complications can arise from DVT

A

Pulmonary embolism

Postphlebitic syndrome

Loss of limb

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6
Q

DVT that occurs above the knee is called

A

Proximal

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7
Q

DVT that occurs below the knee is called

A

Distal

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8
Q

What are the complications of pulmonary embolism

A

Hypertension

Death

Shock

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9
Q

Which form of pulmonary embolism is serious

A

Saddle embolism

Lobar embolism

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10
Q

What veins are VTE most likely to occur

A

illiac

Popliteal

Subclavian

Superior and inferior vena cava

Femoral

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11
Q

What are the risk factors for VTE

A

Age

History of VTE (strongest risk factor)

Venous stasis

Vascular wall injury

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12
Q

Some patient are prone to clotting (thrombophilia) what is the hereditary basis for this pathology

A

Protein C deficiency

Protein S deficiency

Antithrombin III deficiency

Factor V Leiden: protein C resistance

Prothrombin gene mutation

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13
Q

Some patient are prone to clotting (thrombophilia) what is the acquired basis for this pathology

A

Antiphospholipid antibody syndrome

                    - Lupus anticoagulant
                     - Beta 2 glycolprotein antibodies
                      - Anticardiolipin antibody
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14
Q

What are the clinical signs of DVT

A

Unilateral pain and tenderness

Palpable cord ( thrombus )

Unilateral swelling and discoloration

Positive homan’s sign

Often silent

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15
Q

What is a positive homan’s sign

A

Pain upon dorsiflexion of the foot

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16
Q

What two imaging tool allow for DVI diagnosis

A

Venography (gold standard)

Ultrasonography (good sensitivity and specificity for proximal DVT)

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17
Q

Why is the D-dimer lab test done for DVT

A

To exclude diagnosis of DVT or PE

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18
Q

What are the clinical signs and symptoms PE

A

Nonspecific

Sudden onset:
Cough

Tachycardia

Dyspnea

Pleuritic chest pain

Tachypnea

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19
Q

What are the more serious signs of PE

A

Hemoptysis

Cardiovascular collapse

Acute right heart failure

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20
Q

What imaging tool are used for PE diagnosis

A

Pulmonary angiography (gold standard)

CT pulmonary angiography (high sensitivity and specificity)

V/Q scan (radioactive albumin)

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21
Q

What are the goals of VTE

A
  • reduce recurrence
  • prevent post thrombotic syndrome
  • reduce thrombus extension
  • prevent PE development
  • decrease mortality
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22
Q

Which patient population are at risk of developing VTE

A

Hospitalized

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23
Q

What are the non-pharmacologic intervention

A

Early ambulation

Graded compression socks

Intermittent pneumatic compression

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24
Q

What are the pharmacology interventions for VTE

A

Heparin

LMWH

Factor Xa inhibitors

Oral DTI

Warfarin

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25
Q

What are the two LMWH used in prophylaxis of VTE

A

Enoxaparin

Daltepairin

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26
Q

How is enoxaparin dosed prophylaxis

A

30 mg SC every 12 hours initiated 12 hours - 24 hours after surgery

          -Hip and knee replacement

40 mg SC every 24 hours:

          - Acute medical illness
          - Initiated 12 hours before hip replacement surgery

Or

            -Initiated 2 hours before abdominal surgery
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27
Q

What is the post operative dose of dalteparin giving prophiylatically before hip replacement surgery

A

2500 units SC 4-8 hours after surgery followed by 5000 units SC every 24 hours

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28
Q

How is dalteparin dose prophylactically the evening before a hip replacement surgery

A

5000 units SC 10-14 hours before

2500 units 4-8hours after followed by 5000 units every 24 hours

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29
Q

How is dalteparin dose prophylactically the day of a hip replacement surgery

A

2500 units SC 2 hours prior to surgery

2500 units 4-8 hours after surgery followed by 5000 units every 24 hours

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30
Q

How is fondaparinux dosed prophylatically for total hip and knee replacement and hip fracture surgery

A

2.5mg SQ every 24 hours

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31
Q

How is Apixaban dosed prophylatically for total hip and knee replacement

A

2.5 mg twice daily

32
Q

How is dabigatran dosed prophylatically for total hip and knee replacement

A

110-220mg initially followed by 220mg daily

33
Q

How is rivaroxaban dosed prophylatically for total hip and knee replacement

A

10mg daily

34
Q

How is unfractionated heparin dosed prophylatically for total hip and knee replacement and hip fracture surgery

A

5000 units SQ every 8 - 12 hours

35
Q

How is warfarin dosed prophylatically for total hip and knee replacement and hip fracture surgery

A

Dose adjusted

36
Q

How is aspirin dosed prophylatically for total hip and knee replacement and hip fracture surgery

37
Q

True or false: anticoagulant therapy is used both inpatient and outpatient

38
Q

When is anticoagulant therapy considered safe for outpatient treatment

A
  • patient is hemodynamically stable
  • no comorbidity that would cause hospitalization
  • no recent trauma or surgery
  • no current hemodialysis or active bleeding
39
Q

When is heparin alternatives to VTE treatment considered

A

Allergy or HIT

40
Q

Patient with high mortality risk are not first treated with anticoagulant, when is a patient considered high mortality risk

A

Hemodynamics instability ( SBP < 90 mmHg or vasopressor use)

sPESI ≥1:

    80 yrs, cancer, chronic pulmonary disease, pulse ≥ 110, 
    SBP < 100, oxygen < 90%

Right ventricular dysfunction

Elevated cardiac troponins

41
Q

What therapy is used in high mortality risk patient or rescue for hemodynamic deterioration despite anticoagulants

A

Thrombolytic agents:

Alteplase or streptokinase

Or

Thrombectomy(Surgery) (Surgery)

42
Q

What medications falls under the antithrombotic class indirect thrombin inhibitor

A

Unfractionated Heparin or LMWH

43
Q

What medication make up LMWH

A

Enoxaparin

Dalteparin

Tinzaparin

44
Q

What medications of antithrombotic agent falls under the class Factor Xa Inhibitor

A

Fondaparinux

Apixaban

Endoxaban

Rivaroxaban

Betrixaban

45
Q

What medications of antithrombotic agent falls under the class direct thrombin inhibitor

A

Argatroban

Bivalirudin

Desirudin

Dabigatran

46
Q

What medications of antithrombotic agent falls under the class vitamin K antagonist

47
Q

Which antithrombotic are considered DOACs

A

Betrixaban

Edoxaban

Apixaban

Rivaroxaban

Dabigatran

48
Q

In the treatment of VTE with heparin,fondaparinux or LMWH when should a switch be done to dabigatran or Edoxaban

A

After the first 5 days switch to:

Dabigatran 150 mg PO twice daily through maintenance and prevention

Or

Edoxaban 60 mg PO daily through maintenance and prevention

49
Q

In the treatment of VTE with heparin,fondaparinux or LMWH when should an overlap with warfarin be done

A

After 5 days and INR > 2.0 and dose adjust to INR target of 2.5 through maintenance and prevention

50
Q

In VTE treatment how is Apixaban dosed

A

First 7 days: 10 mg twice daily

Day8-prevention: 5 mg twice daily

After the first 6 months: 2.5 mg twice daily

51
Q

In VTE treatment how is rivaroxaban dosed

A

First 21 days: 15 mg twice daily

Day 22 till prevention: 20 mg daily

After the first 6 months; 10 mg daily

52
Q

What is the target INR for warfare dosing

53
Q

When patient has transient risk factor (stasis): immobility, surgery or estrogen use, how long should duration of therapy be

54
Q

When patient has unprovoked DVT or PE (i.e no underlying cause) how long should duration of therapy be

A

3 months to long term

55
Q

For patients with DVT or PE and cancer after the first 3-6 months initial treatment, how long should treatment be extended

A

Indefinitely or after cancer resolves

56
Q

For patients with recurrent VTE or continuous risk factor such as thrombophilias, how long should therapy last

57
Q

What therapy is preferred when term is considered

58
Q

What is the basis for heparin dosing during the acute phase treatment

59
Q

What is heparin loading dose during acute phase treatment

A

70-100 units/kg

60
Q

What is heparin maintenance infusion rate during acute phase treatment

A

15-25 units/kg/hr

61
Q

How’s heparin dose adjusted

A

Based on aPTT

62
Q

How is infusion rate adjusted for heparin

A

Use Nomogram

63
Q

For acute phase treatment how is enoxaparin dosed

A

1 mg /kg SQ every 12 hrs

or

1.5 mg/kg SQ every 24 hrs

64
Q

For acute phase treatment how is dalteparin dosed

A

200 IU/kg SQ every 24 hours

65
Q

What is the basis for LMWH dosing and what if patient is obese

A

A) weight

B) use actual body weight

66
Q

When patient has renal insufficiency (CrCl <30 ml/min) what is the preferred treatment

A

Heparin over LMWH

67
Q

How is unfractionated heparin and LMWH dosed prophylaxis

A

UH: lower doses SQ BID or TID

LMWH: lower doses SQ daily or BID

68
Q

How is heparin monitored

A

Measure aPTT 6 hours after initiation and after any dose adjustment

69
Q

How is LMWH monitored

A

Not routinely done

70
Q

For pregnant patient what therapy is preferred

A

LMWH over heparin

71
Q

How is hemorrhage managed for patient on heparin or LMWH

A

Use protamine to reverse hemorrhage

72
Q

How’s protamine dosed

A

1 mg for every 100 units of heparin

1 mg for 60% LMWH

73
Q

When is a patient on heparin experiencing HIT

A

Platelet <100,000 or drop by >30 -50%

If its 5-10 days of heparin therapy

Thrombosis is present

No other explanation for low platelet

74
Q

How is HIT managed

A

Discontinue Heparin

Consider switching to DTIs, fondaparinux or DOACs

75
Q

For direct thrombin inhibitors, which should PTT be monitored

A

Argatroban

76
Q

Which have long half life

A

Factor Xa inhibitors

Pharmacotherapy (12 decks)

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