Anticoagulation

Question 1

What anticoagulant is used for the neonatal and pediatric patients?

Answer 1

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

Question 2

What anticoagulant is a direct thrombin inhibitor?

Answer 2

Bivalrudin or Argatroban (not common)

Question 3

What is the desired range for ACT? 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 160s-180s (for slight bleeding) or ACT
-Anti Xa for normals is 0.3-0.7 (for a patient that is bleeding dropped to 0.2-0.25

Question 4

What elements are required for heparin to work?

Answer 4

ATII

Question 5

What test measures the effectiveness of bivalirudin?

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 (Tissue Factor 3 to Factor 7)
Intrinsic is activated by foreign body & inflammation activation (TF 12)
They both lead into the common pathway at Factor 10.

Question 8

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

Answer 8

ACT & TEG Initially, then AntiXa & 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

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

Answer 12

4kg x 100 IU/kg = 400 IU
1000 IU/1mL x 1/400 IU = .4 mL

Question 13

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 13

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

Question 14

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

Answer 14

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

Question 15

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

Answer 15

POC Hemochron (Signature Elite)

Question 16

Why is the ACT elevated in the prime?

Answer 16

Only pRBCs are used in the prime then there are no clotting factors.

Question 17

What anticoagulant does the ACT measure best?

Answer 17

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

Question 18

Is the ACT an exact measurement?

Answer 18

No, has a +/- 20% error

Question 19

What are factors that affect anticoagulation?

Answer 19

Platelet function, temperature, ATIII deficiency, Hypotension, Sepsis, Liver
Dysfunction, DIC, Body Inhabitus

Question 20

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

Answer 20

No heparin goes into the circuit - bolus dose is given to the patient

Question 21

What is the dose of Heparin for the neonatal circuit?

Answer 21

0.2 mls (20 units)