Ch. 7 Bleeding, Coagulopathies & Anticoagulation Flashcards
If a patient gets several units of blood d/t bleeding, which electrolyte would you anticipate replacing along with the blood and why?
Calcium, because citrate in binds to the calcium in blood products
Post-operative Bleeding
* Causes
* Pop at risk for bleeding
- Use of heparin with bypass circuit
- Incomplete hemostasis after surgery
- Decreased clotting factors d/t exposure to circuit
- hypothermia during CPB
- Coagulopathy
- Platelet dysfunction/thrombocytopenia
- Older, female, any redo surgery, emergent or high risk surgery
Reversal agents
1. Heparin
2. Coumadin
3. Bleeding with low fibrinogen
- Protamine sulfate
- Vitamin K, FFP, PCC (K-centra / factor IX)
- Cryoprecipitate
Protamine administration
* What is protamine made from?
* Never give more than
* Dose ratio
* Side effects
- fish sperm (caution: fish allergy)
- Never give more than 50 mg over 10-20 mins -> Hypotension d/t histamine reaction
- 1mg for every 100 units of haparin (1:100)
- Heparin rebound: the idea that heparin returns to circulation after being neutralized with protamine during surgery, which can lead to increased bleeding temporarily, Treated with protamine infuision
Warfarin reversal
* Medication and dose
* Administer no faster than
- Vitamin K (phytonadione) 1-2.5 mg IV
- administered no faster than 1mg/min,
Life threatening bleeding
* Treatment (4)
- Vitamin K 10 mg IV slowly
- FFP
- prothrombin complex concentrate (PCC KCENTRA)
- NovoSeven - recombinant factor seven
Cryoprecipitate
* Indication
* Goal
* Each bag will increase fibrinogen by
- Low fibrinogen
- Goal >100 mg/dL
- Each bag will increase fibrinogen by 6-8 mg/dL
How to determine bleed souce?
- Coags - CBC/TEG
Prothrombin Complex Concentrate (PCC)
* Action
* Contraindicated in what 2 states
* Indication
- Reverses the effects of warfarin and other vitamin K antagonists
- Contraindicated in HIT and DIC because it contains heparin
- Used for significant bleeding when INR>8
Tranexamic Acid (TXA)
* Class
* Action
* Dose
- AKA Lysteda, Cyklokaprin this is an Anti-fibrinolytic
- Promotes clotting by slowing down the breakdown of blood clots
- 10 - 15 mg/kg IV over 20 min, then 1 mg/kg/hr for 6-10 hrs
von Willebrand Disease
* Definition
* symptoms
* treatment
* dose
* watch out for
- Genetic clotting disorder defined by deficiency in von willebrand factor which is needed for platelet adhesion
- Platelet count <150K, decreased production with increased sequestration and plt destruction
- Bleeding treatment: Desmopressin (DDAVP), stimulated release of vWF
- Dose: 0.3 mcg/kg IV over 20-30 min,
- monitor for water retention and dilutional hyponatremia because this is a synthetic analog of antidiuretic hormone
Amicar (aminocaproic acid)
* intended use
* class
- Used to control bleeding
- Anti-fibrinolytic
NovoSeven
* Definition
* Indication
* Dose
* Risks
- Recomdinant factor VIIa. Stimulates the generation of thrombin, expedites platelet activatiion and fibrin clot formation
- Used in intractable bleeding and uncontrolled coagulopathies for rapid correction of PT
- 50 mcg/kg slowly over 2-5 mins
- Risk of thrombosis, stroke, MI, PE
Warfarin
* Action
* Lab to monitor
* Goal (2)
* Reversal
- Acts on common coagulation pathways
- Monitor PT/INR
- Goal INR 2-3 therapeutic for DVT prophylaxis, PE prophylaxis, A fib
- Goal 2.5-3.5 Mechanical prosthetic valves
- Reversal Vitamin K or FFP, K centra (PCC)
Heparin
* Action
* Lab to monitor
* Goal ACT, when to take out the sheath
* Reversal
- Acts on common coagulation pathways
- Monitor aPTT, anti-Xa, ACT
- Therapeutic ACT 300-350, D/c femoral sheath when ACT <150 sec
- Reversal Protamine
