Anticoagulation & Blood D/O Part 2 Flashcards by Silver Gold

Enoxaparin Boxed Warning

Don’t use with Nauraxial Anesthesia

Lumbar epidural puncture

Can cause hematoma → paralysis

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Enoxaparin

Contraindications

Uncontrolled active bleed

History of heparin-induced thrombocytopenia

Hypersensitivity to pork products

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Enoxaparin

Side Effects

Bleeding, anemia, injection site reactions (e.g., pain, bruising, hematomas), thrombocytopenia

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Enoxaparin

Monitoring

↑ Anti-Xa activty ↑ anticoagulation:
Low body wt
Reduced kidney function

↓ Anti-Xa activty ↓ anticoagulation
High body wt
Pregnancy

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Antidotes for Reversal

Heparins

Protamine

Injection

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Protamine

Boxed Warning

Hypersensitivity

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Protamine

Side Effects

Hypotension, bradycardia, flushing, anaphylaxis

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Protamine

Monitoring

aPTT, anti-Xa levels, cardiac monitoring (ECG, BP, HR)

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Protamine

Rapid IV infusion causes?

Hypotension

Administer as a slow IV push or infusion (max 50 mg over 10 minutes)

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Protamine

UFH Reversal Dosing

Reverses the UFH given in the last 2-2.5 hours

1 mg protamine reverses ~100 units heparin; max 50 mg

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Protamine

LMWH Reversal Dosing

Less effective at reversal of LMWH

Reverses the enoxaparin given in the last 8 hours

1 mg protamine is given per 1 mg of enoxaparin

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Idarucizumab (Praxbind) & Andexanet alfa (Andexxa) safety

Thromboembolic risk

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Sickle Cell Disease: Infection risk

Functions of a healthy spleen

Removes old and damaged RBCs

Stores WBCs and helps immune function

Clears bacteria from the body

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Sickle Cell Disease: Infection risk

Which bacteria do you have to worry about?

Streptococcus pneumoniae

Haemophilus influenzae

Neisseria meningitidis

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Sickle Cell Disease: Infection risk

Functional asplenia

RBC sickling causes infarctions (ischemic attacks) of the spleen

The spleen shrinks and becomes fibrotic (no longer functions)

Patients are at increased risk for infections

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Vitamin B12 deficiency

Pernicious anemia (antibodies to intrinsic factor)
Drug-induced (eg, long-term metformin or PPI use)
Low intake or ↓ absorption (eg, gastric bypass, Crohn’s disease)
Alcohol use disorder

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Vitamin B12 deficiency

Signs & symptoms

Fatigue, weakness, shortness of breath, pallor, glossitis
Neurologic dysfunction
* Peripheral neuropathy
* Cognitive impairment
* Psychiatric symptoms

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Vitamin B12 deficiency

Laboratory findings

↓ Hgb, RBCs, reticulocyte count
↑ MCV (> 100 fL), methylmalonic acid, homocysteine
↓ Serum vitamin B12

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Vitamin B12 deficiency

Treatment

Cyanocobalamin (vitamin B12)
* Parenteral (SC or IM injection)
* Nasal spray (Nascobal)
* Tablets

Parenteral preferred for pernicious anemia, sever deficiency or neurologic symptoms

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Vit B12 & B9 (Folate)

Causes

Vegetarian or vegan diet

Alcohol use disorder

Gastrointestinal disease or surgery

Drug-induced (eg, metformin, PPI)

Pernicious anemia (B12 only)

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Vitamin B12 deficiency

Symptoms

Peripheral neuropathy, visual disturbances, psychiatric symptoms

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Folate deficiency

Symptoms

Tongue and oral mucosa ulceration

Skin, hair, and nail pigmentation changes

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Which of the following are signs/symptoms that could indicate a patient is bleeding? (Select ALL that apply.)

A. Xerostomia

B. Red or black stools

C. Epistaxis

D. Metallic taste in mouth when she brushes her teeth

E. Ecchymosis

Red or black stools

Epistaxis

Metallic taste in mouth when she brushes her teeth

Ecchymosis

Epistaxis - Nosebleed
Ecchymosis - bruising
Xerostomia - dry mouth

Dabigatran Pellets

Indication

For 3 months to 12 y/o

Tx of VTE or PPx of recurrence

Must receive parenteral anticoagulation for at least 5 days prior to initiation

# Dabigatran Pellets Dosage adjustments

Avoid if eGFR < 50 mL/min/1.73m2

# Dabigatran Pellets Administration

Mix with soft foods or apple juice; use within 30 minutes Avoid with milk products Do not administer via feeding tubes

# Dabigatran Pellets Storage

Store unopened packets in aluminum bag Use within 6 months of opening

# Deabigatran Capsules Indications

8 years to < 18 years: treatment1 of VTE & prophylaxis of recurrence Adult patients * Reduce risk of stroke & embolism in NVAF * Treatment1 of VTE & prophylaxis of recurrence * Prophylaxis of VTE after hip replacement surgery ## Footnote Child: Must receive parenteral anticoagulation for at least 5 days prior to initiation

# Deabigatran Capsules Dosage adjustments

NVAF: avoid if CrCl < 15 mL/min VTE: avoid if CrCl < 30 mL/min

# Deabigatran Capsules Administration

Capsule must be swallowed whole with full glass of water Take with food if GI distress occurs

# Deabigatran Capsules Storage

Bottle: use within 4 months of opening Blister pack: use by expiration date

# Sickle Cell Disease Non-drug Tx

Blood transfusions * Supply HgbA * Maintain serum Hgb ≤ 10 g/dL * Risk: iron overload (→ hemosiderosis) Bone marrow transplantation

AF ≤ 48 hrs

Initiate AC & Cardiovert Immediately Continue AC for 4 wks

AF ≥ 48 hrs

Initiate AC for 3 wks Then Cardiovert Continue AC for 4 wks

Risk of Bleeding Mnemonic

HAS-BLED H - Hypertension (SBP > 160 mmHg) - 1 A - Abnormal liver or kidney function - 1-2 S - Stroke - 1 B - Bleeding tendency or predisposition - 1 L - Labile INR (if on warfarin) - 1 E - Elderly (age > 65 years) - 1 D - Drugs (aspirin, NSAIDs) or excessive alcohol use - 1-2

# Venous Thromboembolsim (VTE) Deep Vein Thrombosis (DVT) | Symptom

Unilateral extremity swelling

# Venous Thromboembolsim (VTE) Pulmonary Embolism (PE) | Symptom

Shortness of breath | Can also cause symptoms similar to DVT

# Venous Thromboembolsim (VTE) Diagnosis

Laboratory test: D-dimer Imaging: * Ultrasound * MRI venography * Pulmonary CT angiogram

# Venous Thromboembolsim (VTE) Non-pharmacologic PPx

Intermittent pneumatic compression (IPC) devices Graduated compression stockings Long-distance travelers * Frequent ambulation * Calf muscle exercises * Do NOT use aspirin or anticoagulants, unless otherwise indicated

# Venous Thromboembolsim (VTE) Provoked vs Unprovoked

Provoked: Know the cause of (eg, surgery or reversible risk factor) Tx for 3 months Unprovoked: Don't know the cause Tx > 3 months

# Venous Thromboembolsim (VTE) Clot confirmed then

D/C estrongen-containg meds & SERMs

# Venous Thromboembolsim (VTE) What to give to pts w/out cancer?

For the 1st 3 months: Oral factor Xa inhibitors (rivaroxaban, apixaban, edoxaban) Dabigatran

# Venous Thromboembolsim (VTE) What to give to pts w/ cancer?

Oral factor Xa inhibitors (preferred) Other oral anticoagulants & LMWHs

# Venous Thromboembolsim (VTE) Warfarin Bridging

Initial Tx period: * Warfarin + * LMWH or UFH for 5d Maintenance period: Dose adjuse warfarin to goal INR ## Footnote Continue PN anticoagulation for min 5d & until the INR is therapeutic for min 24 hrs

# Venous Thromboembolsim (VTE) Pregnancy PPx

Pharmacologic: LMWH preferred Non-Pharmacologic: Intermittent pneumatic compression devices

# Venous Thromboembolsim (VTE) Pregnancy Tx | Present Blood Clot

LMWH preferred Monitor w/ anti-Xa levels ## Footnote DOACs not recommended

# Venous Thromboembolsim (VTE) Pregnancy w/ Warfarin

Positive pregnancy test: stop warfarin start LMWH After 13 weeks: optional to resume Close to delivery: Switch to LMWH

# Management of supratherapeutic INR < 4.5 w/ none or minimal Bleeding

Hold or decrease warfarin dose

# Management of supratherapeutic INR 4.5–10 w/ none or minimal Bleeding

Hold 1–2 doses of warfarin Resume warfarin when INR is therapeutic

# Management of supratherapeutic INR > 10 w/ none or minimal Bleeding

Hold warfarin Administer 2.5–5 mg **oral** vitamin K Resume warfarin at a lower dose when INR is therapeutic

# Management of supratherapeutic INR Any Serious or life threatening bleeding

Hold warfarin Administer **IV** vitamin K (phytonadione) 5–10 mg & four-factor prothrombin complex concentrate (4-PCC, Kcentra) ## Footnote Fresh frozen plasma can be used if 4-PCC is unavailable

# Vitamin K or phytonadione (Mephyton) Boxed Warnings

Severe reactions resembling hypersensitivity reactions after IV administration

# Vitamin K or phytonadione (Mephyton) Side Effects

Anaphylaxis, flushing, dizziness, rash

# Vitamin K or phytonadione (Mephyton) Notes

SC route not recommended due to variable absorption Do not use IM administration due to risk of hematoma Protect from light during administration

Perioperative Management of Warfarin

Stop warfarin 5 days before surgery High risk for thromboembolism: bridge with LMWH or UFH * Discontinue LMWH 24 hours before surgery * Discontinue UFH 4-6 hours before surgery Resume warfarin after hemostasis