Anticoagulation

Question 1

What anticoagulant is used for neonatal and pediatric patients?

Answer 1

Heparin (Loading dose for neonatal pt= 100 units/kg

Question 2

What anticoagulant is a direct thrombin inhibitor?

Answer 2

Bivalridin or Argatroban (not common)

Question 3

What is the desired range for ACTs? What factors affect how this range is determined?

Answer 3

-Bolus dose of heparin in the NICU> 300s
- Maintenance dose 180-220s
-If the patient is bleeding, ACT 160-180s (for slight bleeding)
- AntiXa for normals is 0.3-0.7 (patient this is bleeding dropped to 0.2-0.25

Question 4

What elements are required for heparin to work?

Answer 4

ATIII

Question 5

What test measures the effectiveness of Bivalrudin?

Answer 5

PTT, ACT & TEG

Question 6

What does PTT measure? What is a normal PTT? What range of PTT values is used for patients on ECMO?

Answer 6

PTT measures how long it takes to form a clot
25-35 is the normal range
ECMO patient range is 60-80 (if stranding/clots seen will increase range)

Question 7

What are the two pathways in the coagulation cascade? How is each pathway activated?

Answer 7

Extrinsic and Intrinsic
Extrinsic is activated by tissue injury (Factor 3 to Factor 7)
Intrinsic is activated by foreign body and inflammation activation (TF 12)
They both lead to the common pathway at Factor 10

Question 8

What are the tests used to evaluate anticoagulation in the neonate?

Answer 8

ACT and TEG initially, then AntiXa and PTT

Question 9

What is the bolus dose of heparin given to a large pediatric or adult patient

Answer 9

10,000 IU

Question 10

What is the bolus dose of heparin given to an infant or small child?

Answer 10

100 IU/kg

Question 11

Which drug will CRRT affect? Why?

Answer 11

Heparin
It will pull it across the membrane and clear it out

Question 12

What is the reversal agent of heparin? Bivalrudin?

Answer 12

Heparin- protamine
Bivalrudin- none

Question 13

Calculate the bolus dose of heparin for a 4kg patient. (The concentration of heparin is 1000 units/ 1ml)

Answer 13

4kg x 100 IU/kg = 400 IU

1000 IU/ 1ml x 1/400 IU = .4 ml

Question 14

Calculate the infusion rate of heparin with the following information:
A) concentration of heparin 100 units/ml
B) dose 30 units/kg/hr (infusion)
C) patient weight 4 kg
D) what would you do if the next ACT came back with a level of 240 seconds

Answer 14

Decrease dose per protocol, could do nothing and wean per AntiXa

Question 15

What is the ACT? What does it measure? What are the units of the ACT?

Answer 15

Activated clotting time
Measures the entire time it takes for a clot to form from whole blood
Seconds

Question 16

What bedside device(s) are used to run this test?

Answer 16

POC Hemochron Elite

Question 17

Why is the ACT elevated in the prime?

Answer 17

Only PRBCs are used in the prime then there are no clotting factors

Question 18

What anticoagulant does the ACT measure best?

Answer 18

Heparin
(A Kaolin activated ACT will give a falsely high measurement for Bivalrudin)

Question 19

Is the ACT an exact measurement?

Answer 19

No, it has +/- 20% error

Question 20

What are factors that affect anticoagulation?

Answer 20

Platlet function, temperature, ATIII deficiency, Hypotension, Sepsis, Liver dysfunction, DIC, Body inhabitus

Question 21

What is the dose of heparin to place in the adult circuit?

Answer 21

No heparin goes into the adult circuit, bolus dose given to patient

Question 22

What is the dose of heparin for the neonatal circuit?

Answer 22

0.2 mls (20 units)