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Medically Complex Patient > Bleeding Disorders and Anti-Coagulation > Flashcards

Bleeding Disorders and Anti-Coagulation Flashcards

1
Q

What are intentional bleeding disorders?

A

result of tx or prevention of a disease, ie just had a stroke, preventing another

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2
Q

How are bleeding disorders acquired?

A

result of disease, side-effect of tx

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3
Q

3 categories of why ppl bleed:

A

inherited, acquired, intentional disorders

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4
Q

Phases of clotting;

A

vascular, platelet, coagulation (fibrinolytic)

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5
Q

Phases of clotting we are concerned w:

A

platelet, coagulation,

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6
Q

Bleeding can be instantaneous in these phases;

A

vascular and platelet phases

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7
Q

When does bleeding occur int he coagulation phase?

A

min to hrs later

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8
Q

coagulation phase is aka:

A

fibrinolytic phase

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9
Q

Pts can have issues in this phase of clotting after they leave the office:

A

coagulation phase (fibrinolytic)

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10
Q

When does the vascular phase begin?

A

immediately after injury

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11
Q

What happens during vascular phase?

A

vessels constrict and retract, fluid pressure from blood collapses adjacent vessels

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12
Q

What meds can affect the vascular phase?

A

none

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13
Q

When does the platelet phase begin?

A

secs after injury

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14
Q

What makes platelets sticky?

A

exposure of endothelial tissues, platelet plug seals site

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15
Q

How long does the coagulation phase take?

A

10-20m

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16
Q

Via which pwy(s) does blood in surrounding tissue coagulate?

A

both extrinsic and common pwys

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17
Q

Via which pwy(s) does blood in vessels coagulate?

A

both intrinsic and common

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18
Q

Intrinsic pwy:

A

(APPT) kininogen/ kallikrein, FXIIa, FXIa, FVIII (?), FXa, Thrombin, Fibrin

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19
Q

Extrinsic Pwy:

A

(PT) FVIIa, FX, FXa, Thrombin, Fibrin

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20
Q

Common Pwy:

A

X, Prothrombin, thrombin, fibrinogen, Fibrin

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21
Q

Partial Thromboplastin Time measures which pwy>?

A

Intrinsic

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22
Q

Prothrombin Time measures which pwy?

A

extrinsic pwy

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23
Q

How to measure from fibrinogen to fibrin?

A

thrombin time

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24
Q

All pwys end w formation of:

A

fibrin

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25
Q

Factors assoc w common pwy:

A

X, V, II, Fibrinogen, Fibrin

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26
Q

What activates the intrinsic pwy?

A

surface activation

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27
Q

What activates the extrinsic pwy?

A

tissue thromboplastin

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28
Q

Problems w vascular phase;

A

usually non-specific, confined to skin, mucosa and gingiva, petechiae, ecchymosis, purpura, aging, Cushing’;s syndrome, collagen disorders, Vit C deficiency

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29
Q

How can Cushing’s syndrome lead to non-specific minor bleeding problems?

A

high dose exogenous steroids

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30
Q

Collagen disorder related to CV defects and excessive growth:

A

Marfan

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31
Q

Lits 2 collagen disorders:

A

Marfan, Ehler-Danlos

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32
Q

Congenital platelet disorders, rare or common?

A

rare

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33
Q

Types of acquired thrombocytopenia:

A

Idiopathic, Immune

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34
Q

Types of immune thrombocytopenia:

A

lupus, HIV

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35
Q

What is thrombocytopenia?

A

low platelet count

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36
Q

ITP sf:

A

Idiopathic thrombocytopenia

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37
Q

Type of thrombocytopenia that can be cyclic:

A

idiopathic

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38
Q

Normal platelet count:

A

150,000-400,000/microL

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39
Q

Platelet count necessary for major surgery:

A

80,000

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40
Q

Platelet count necessary for minor surgery:

A

50,000+

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41
Q

At risk for spontaneous bleeding if platelet count is below:

A

20,000

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42
Q

TF? A pt will most likely not clot if their platelet count is ½ of low/normal.

A

F. probably will

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43
Q

How can a surgical proc be performed on a pt w low platelet count?

A

Call hematologist, use exogenous blood products

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44
Q

Thrombocytopenia can result from;

A

aplastic anemia, leukemia, bone marrow suppression (chemo), kidney disease

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45
Q

Is a platelet count needed for a pt who had chemo mos ago?

A

yes

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46
Q

TF? With platelet dysfunctino, the platelet count is normal.

A

T

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47
Q

Causes of platelet dysfunctino:

A

dialysis, meds

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48
Q

meds that can cause platelet dysfunction:

A

ASA, NSAIDS, platelet aggregate inhibitors

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49
Q

Why can dialysis lead to platelet dysfunction?

A

it damages platelets

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50
Q

Drugs that effect platelet aggregation:

A

aspirin, non-steroidals, plavix

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51
Q

How to test for platelets?

A

platelet count, platelet function tests

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52
Q

4 Platelet function tests:

A

closure time assay, viscoelastometry, Platelet aggregometry, flow cytometry (bleeding time)

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53
Q

Superficial wound healing is mainly about:

A

platelets

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54
Q

Platelet function test that is no longer done:

A

bleeding time

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55
Q

Coagulation phase disorders:

A

hemophilia A and B

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56
Q

Hemophilia A:

A

Factor VIII deficiency (intrinsic pwy)

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57
Q

hemophilia B:

A

Factor IX deficiency (intrinsic pwy)

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58
Q

hemophilia B is aka:

A

Christmas disease

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59
Q

Other factor deficiencies;

A

IX, X, XI, XII

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60
Q

TF? There are no factor deficiencies affecting the extrinsic pwy.

A

T. check (only 8-12)

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61
Q

Meds are most likely to effect which phase of clotting?

A

coagulation phase

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62
Q

hereditary disorder that effect platelet adhesion and FVIII:

A

Von Willebrand’s, hereditary blood clotting disorder

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63
Q

How many types of Von Willebrand’s are there?

A

4

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64
Q

Is Von Willebrand’s usually serious?

A

no

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65
Q

Tx for Von Willebrand’s;

A

nasal meds

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66
Q

Most severe type of Von Willebrand’s:

A

Type 3, low FVIII

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67
Q

Acquired coagulation phase bleeding disorders:

A

Liver disease, meds, DIC

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68
Q

Factors involved w Vit K dependent, acquired bleeding disorder;

A

II, VII, IX, X

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69
Q

Where are Vit K dependant factors produced?

A

liver

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70
Q

Prevalence of alcoholism:

A

5%

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71
Q

Medical/ intentional anticoagulation:

A

recent MI, CVA (stroke), Thromophlebitis, Atrial fibrillation, pulmonary emboli, Deep vein thrombosis, Thrombogenic implanted devices

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72
Q

Drugs used to thin blood:

A

platelet aggregate inhibitors, Heparin, Low molecular weight heparins, Coumadin, New Xa inhibitors

73
Q

Ex of platelet aggregate inhibitors:

A

ASA, Plavix, Persantine, Aggrenox, NSAIDs

74
Q

Ex of Low molecular weight heparins:

A

Lovenox, Normiflo, Sandoparin

75
Q

What does Plavix do?

A

inhibits ADP-induced platelet aggregation

76
Q

Plavix is used to treat;

A

recent MI, stroke, established peripheral artery disease

77
Q

Plavix is aka;

A

clopidorgel bisulfate

78
Q

How many mg is a baby aspirin:

A

81mg

79
Q

All pts taking Plavix are also taking:

A

Aspirin

80
Q

When are platelet aggregate inhibitors used?

A

if pt can’t tolerate ASA or in conjunction w ASA

81
Q

ASA sf:

A

acetylsalicylic acid

82
Q

NSAIDs may increase:

A

GI Bleeding

83
Q

When to discontinue the use of platelet aggregate inhibitors:

A

only for major surgery

84
Q

How long to discontinue the use of platelet aggregate inhibitors for major surgery:

A

7-10d prior to surgery

85
Q

Why must platelet aggregate inhibitors be discontinued 7-10d prior to major surgery?

A

life span of the palatelet

86
Q

What to ask pt on platelet aggregate inhibitors:

A

nosebleeds? Hard time stopping bleeding if you get minor cuts? spontaneous gingival bleeding?

87
Q

Is Heparin available in oral form?

A

no, IV, subcutaneous injection

88
Q

1/2 life of Heparin:

A

2-4h (short)

89
Q

When is Heparin used?

A

inpatient basis, dialysis

90
Q

How are the intrinsic and common pwys measured?

A

Partial Thromboplastin Time (PTT)

91
Q

Drug of choice to anticoagulate briefly:

A

Heparin

92
Q

Pts we can not see:

A

just had dialysis, drunk, 180 S BP, Dr lowered their Coumadin yesterday bc their INR was 6, ADA says INR above 4 provided local hemostatic measures are used, everyone else says INR under 3 is safe, Pt taking different doses of Coumadin throughout week bc they can’t stabilize pt, pt has blood coumadin levels checked weekly

93
Q

Heparin is connected to this pwy and this test:

A

intrinsic and common pwy, PTT

94
Q

How are Low molecular weight heparins delivered?

A

injection, themselves or PCP

95
Q

What type of dug is Lovenox?

A

Low molecular weight heparin

96
Q

When are Low molecular weight heparins most commonly used:

A

temporarily or bridging bw different meds, ie Weaning off coumadin for surgery but want to protect pt in the meantime, at risk or 4h vs. 4d

97
Q

This is a structural analog of Vit K:

A

Coumadin (Warfarin)

98
Q

TF? Coumadin is available in injectable form.

A

F

99
Q

What does coumadin inhibit?

A

Vit K dependent synthesis of factors II, VII, IX, X in the liver (extrinsic, INR)

100
Q

Which pwy and test is coumadin assoc w?

A

extrinsic, INR

101
Q

Issue w Coumadin:

A

hard to titrate, rebound effects, hypercoagulable, hard to regulate

102
Q

1/2 life of Coumadin:

A

active 2-3d after dose

103
Q

When to discontinue Coumadin:

A

ONLY Inpatient, should never need to do, discontinue for 3d, treat on 4th

104
Q

INR sf:

A

international Normalized Ratio

105
Q

INR standardized:

A

PT values across labs (extrinsic pwy)

106
Q

What does INR measure:

A

extrinsic and common pwy

107
Q

elevated INR cold indicate:

A

severe liver disease w related bleeding

108
Q

Normal INR value, healthy person not on meds

A

1

109
Q

Therapeutic range for most condiitons EXCEPT valve replacement:

A

2-3

110
Q

Threapeutic range for pts w valve replacements

A

2.5-3.5

111
Q

Don’t work on a pt if their INR value is:

A

4.5+

112
Q

Most condition that ppl are on coumadin for want INR values of:

A

2.0-3.0 (therapeutic range)

113
Q

INR value of 1.8, more or less likely to bleed?

A

less

114
Q

Should coumadin levels be inc or dec of the pts INR value is 1.8?

A

inc

115
Q

What does it mean if a drug has interactions w Aspirin?

A

it is very likely to have many other interactions

116
Q

Interaction between two or more drugs or agents resulting in a pharmacologic response greater than the sum of individual responses to each drug or agent:

A

potentiation

117
Q

Coumadin can interact via potentiation w these drugs:

A

ASA, acetaminophen, COX-2 inhibitors (osteoarthritis), penicillin, erythromycin, Tetracycline, cephalosporins, Fluconazole, Vitorin, Lexapro, Paxil, Zoloft, Effexor, Nexium, Prevacid, Protonix, Ultram

118
Q

COX-2 inhibitors are sed to treat:

A

osteoarthritis

119
Q

Coumadin can interact via antagonization w these drugs:

A

Barbiturates, steroids, ascorbic acid, dicloxicillin

120
Q

Most important factor effecting anticoagulation and effects of Coumadin.

A

Diet, Vit K, esp leafy green veggies

121
Q

Ask pts taking Coumadin this:

A

any changes in diet lately

122
Q

When to stop Coumadin before dental proc:

A

never

123
Q

Before doing dental proc we should:

A

verify INR is in therapeutic range

124
Q

TF? Coumadin is volatile in terms of effects,

A

T

125
Q

Which is more dangerous to do in terms of bleeding SRP or simple single tooth extraction?

A

SRP (perio procedure)

126
Q

How recently should the last INR have been taken?

A

depends, # of proc sites, soft or bony tissue, stability of pt, freq of blood draws, dosage change, complications

127
Q

INR has been the same level for years and been on the same dosage for years, accept INR value from

A

3mo ago (pushing it)

128
Q

Level of pt stability if they have Coumadin levels checked every 4wk:

A

moderately stable

129
Q

Level of pt stability if they have Coumadin levels checked every 12wk:

A

stable

130
Q

If doctor recently changed Coumadin levels, you need an INR value within:

A

the last day

131
Q

If a pt is changing Coumadin levels but needs an extraction, when should you schedule the extraction?

A

Day after next INR test

132
Q

TF? Coumadin should be discontinued 7-10d prior to dental treatment

A

F. don’t discontinue

133
Q

INR 4 indicates:

A

overmedicated

134
Q

Why don’t we stop Coumadin:

A

excessive bleeding in mouth is detectable and stoppable, risk of bleeding to death is much lower than risk of throwing a clot and having a serious medical condition (stroke, death), initial start of Coumadin makes pt hypercoagulable in short term, very difficult to re-establish stable levels for some

135
Q

Chance of bleeding to death in western society:

A

very low

136
Q

What leads to the hypercoagulable state w initial restart fo Coumadin?

A

affects protein C and protein S, both natural anticoagulants

137
Q

Eliquis, Xarelto xaban moa:

A

Factor 10a inhibitors (prothrombin to thrombin)

138
Q

These are both natural coagulants:

A

Protein S, Protein C

139
Q

MOA of Pradaxa:

A

acts a little further down cascade than Factor Xa, direct Thrombin inhibitor (IIa)

140
Q

New Anticoagulants:

A

Eliquis, Xareltoo, Pradaxa

141
Q

FII:

A

Prothrombin

142
Q

FIIa:

A

Thrombin

143
Q

FVIIIa is used to:

A

convert soluble fibrin monomers to insoluble fibrin polymers

144
Q

Extrinsic and INtrinsic pwys meet at this point of the cascade:

A

FXA

145
Q

Problem w Xa inhibitors:

A

don’t know current numbers or how likley they are to bleed, no blood test

146
Q

Higher bioavailability, Coumadin or Xa inhibitors.

A

Xa inhibitors

147
Q

% of Xa that will be active in a persons body at any age:

A

90%

148
Q

1/2 life of Xa ihibitors:

A

5-19h, good fo daily dosing

149
Q

When to schedule pt taking Xa inhibitors if they take meds at night:

A

late afternoon, as little in their system as possible

150
Q

Benefits of Xa inhibitors:

A

predictable pharmokinetics, no routine monitoring, high bioavailability, 1/2 life that works well w daily dosing

151
Q

Bioavailability of Coumadin:

A

25-75% (varies w age, ethnicity, health status group)

152
Q

What is the reversal agent for Xa inhibitors.

A

NONE

153
Q

TF? Eliquis has a reversal agent.

A

F. in the works

154
Q

TF? Xarelta has a reversal agent.

A

F. in the works

155
Q

TF? Pradaxa has a reversal agent.

A

T. idarucizumab

156
Q

Eliquis should be discontinued at least ___ prior to elective surgery or invasive proc w LOW risk of bleeding or where bleeding would be non-critical in location and easily controlled. (All dental proc)

A

24h

157
Q

How long to discontinue Eliquis prior to elective surgery or invasive procedures with a MODERATE OR HIGH risk of unacceptable or clinically significant bleeding.”

A

at least 48hr

158
Q

If anticoagulation must be discontinued to reduce risk of bleeding with surgical or other procedures, Xarelto should be stopped at least ___ before the procedure…

A

24hr

159
Q

If possible, discontinue PRADAXA ___ (CrCL>150ml/min) or ____ (CrCl < 50 ml/min) before invasive or surgical procedures because of the increased risk of bleeding…

A

1-2 days, 3 to 5 days

160
Q

What does, how long before surgery discontinuation of Pradaxa should begin?

A

creatinine clearance (kidney function

161
Q

What does whether or not to discontinue anticoagulants for simple surgical proc depend upon?

A

If pt is at high or low risk for thromboembolism (time daily dose after proc or skip 1d)

162
Q

Factors that inc risk of thromboembolism:

A

Recent deep vein thrombosis, or pulmonary embolism (w/in 3mo), High-risk prothrombotic condition (protein C or s deficiency), high risk prosthetic valve (caged-ball or tilting disk), high risk atrial fibrillation (CHADS score 5-6), atrial fibrillation w rheumatic heart disease, recent stroke from atrial fibrillation or heart valve (w/in 6mo)

163
Q

What to ask PCP is pt is taking Eliquis:

A

My pt is on Eliquis, we want to extract 2 teeth, what do you recommend?

164
Q

TF? If on XA inhibitor we must contact physician if doing invasive procedure.

A

T

165
Q

For the new anticoagulants (Pradaxa, Eliquis, Xaralto) should we consult the PCP?

A

yes

166
Q

Should we contact the PCP for pts w Hemophelia/ Von Willebranads disease?

A

contact hematologist, might need factor augmentation, DDAVP, local measures

167
Q

What does DDAVP do?

A

slows amount of urine kidneys make, vasopressin replacement

168
Q

Steps to take for pt w liver disease:

A

Contact PCP and ask for INR, Platelet count, local measures?

169
Q

Steps to take for pt taking Coumadin:

A

INR? (how recent?), local measures

170
Q

Local hemostatic measures:

A

Atraumatic surgical technique, sutures, direct pressure
Gelatin sponges “Gelfoam” placed in socket, cellulose polymer- “Surgicel” placed in socket, vasoconstrictors in LA, tranexamic acid (read about, but he’s never used, mouthrinse hemostatic props), topical thrombin (placed directly on wound, available in clinic)

171
Q

Local hemostatic measure we have in clinic:

A

topical thrombin

172
Q

Only coagulant meds that you might discontinue:

A

Xeralto, Eliquis

173
Q

Pwy that Heparin and Lovenox both work on and test:

A

intrinsic, PTT

174
Q

Pwy Coumadin works on and test:

A

extrinsic (INR)

175
Q

Test for Xeralto and Eliquis:

A

non (Xa inhibitors)

176
Q

Test for ASA, Plavix:

A

Platelet function test (rarely done)

177
Q

Injectable only anticoagulants:

A

Heparin, Lovenox

178
Q

What to do if platelet fxn test is too low for ASA and Plavix pts:

A

defer or transfuse

Medically Complex Patient (4 decks)

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