Class 8 Deck 2 Flashcards
During bridging therapy, there is an increased risk of what when Novel anticoags are abruptly stopped?
-Stroke
Hemodialysis can remove what Novel anticoag?
-dabigatran / pradaxa
What drug can reverse rivaroxaban and apixaban?
-4 factor prothrombin complex concentrate (Kcentra®)
4 factor prothrombin complex concentrate (Kcentra®) contains what 5 things?
- Factors II, VII, IX, X (inactivated)
- Heparin
Activated 4 factor Prothrombin Complex Concentrate
(FEIBA) contains what? and what does it reverse?
- Factors II, IX, X, activated VII
- Dabigatran
What is the potential problem of Activated 4 factor Prothrombin Complex Concentrate (FEIBA)?
-Thrombotic effects of activated factor VII
What does Factor IX Complex (Profilnine SD) do? and what does it contain?
- Reversal for rivaroxaban or apixaban when combined w/ rFactor VIIa
- Contains II, IX, X (no heparin)
What drug reverse all Novel anticoags?
-Recombinant Factor VIIa (NovoSeven®)
What kind of drug is used to keep clots from breaking down?
-Hemostatics like Amicar / Tranexamic acid / DDAVP
How does Epsilon Aminocaproic Acid (Amicar®): work?
- Inhibits plasminogen which inhibits fibrinolysis
- Indirect inhibitor of plasmin’s anti platelet effect
When is Epsilon Aminocaproic Acid (Amicar®): used?
- Treatment of excessive bleeding
- reduces bleeding after CPB
- Stops oozing in patient w/ cirrhosis
Why should rapid infusion of Epsilon Aminocaproic Acid (Amicar®) be avoided?
- Hypotension
- Brady
- Arrhythmias
Tranexamic Acid inhibits what?
plasminogen binding sites
when is Tranexamic Acid used?
- Bleeding prophylaxis in Post Bypass, Trauma, Joint replacment
- Massive transfusion protocol
What is desmopressin (DDAVP) and how does it effect hemostasis?
- Synthetic ADH
- Causes endothelial cells to release: VIII (VWB), plasminogen activator and prostaglandins
- Increase platelet adhesions
When is DDAVP used as a hemostatic?
- Uremia
- Liver disease
- Hemophilia A
- Minimize blood loss during cardiac/spine surgery
What are the side effects of DDAVP?
- Hypo/Hypertension
- Hyponatremia
- Nausea
Name the 5 thrombolytic agents?
- Altepase
- Reteplase
- Tenecteplase
- Streptokinase
- Urokinase
How do the t-PA agents work?
Converts plasminogen to plasmin
How is streptokinase different from the other thrombolytic agents?
- No intrinsic enzymatic activity
- Forms a 1:1 complex with plasminogen and cleaves free plasminogen to plasmin
- Requires loading dose
How is urokinase different from the other thrombolytic agents?
- 2 chain serine protease from human kidneys
- Converts plasminogen to plasmin
- Very expensive
When are thrombolytic agents used?
- Lysing thrombi during MI
- Treat PE
- Venous thrombi
- to open occluded catheters
What are the advantages of uro/streptokinase?
- Lack fibrin specificity
- Induce systemic lysis state
What are the toxicity concerns for thrombolytic agents?
- Hemorrhage (lysis of fibrin)
- Intracranial hemorrhage
- fibrinolytic activity can last 7-24hrs after last dose
How does aspirin inhibit platelet aggregration?
Cyclo-oxygenases inhibitor, which decreases Thromboxane -A2
-Last the life of the platelet
How do NSAIDs inhibit platelet aggregration?
-Temporary depression of thrombaxane-A2
Name the platelet aggregation inhibitors that are Thienopyridine P2Y12 receptor agonists.
- Clopidogrel (Plavix®) p.o.
- Ticlopidyne (Ticlid®) p.o.
- Prasugrel (Effient®) p.o.
- Ticagrelor (Brilinta®) p.o.
How is Ticagrelor (Brilinta®) different from the other Thienopyridine P2Y12 receptor agonists.
- It is reversible
- Stop 5 days prior to surgery
Name the platelet aggregation inhibitors that are Platelet Glycoprotein (GP IIb/IIIa) Receptor Inhibitors
Abciximab (ReoPro®) I.V.
Eptifibatide (Integrilin ®) I.V.
Tirofiban (Aggrastat ®) I.V.
When are Thienopyridine P2Y12 receptor agonists used?
- Prevention of thrombosis in cerebral, vascular and coronary disease.
- For patients who cannot tolerate aspirin
Much like aspirin, platelets exposed to P2Y12 Receptor Antagonists (except ticagrelor) remain affected for how long?
-Lifespan of the platelet
Clopidogrel (Plavix) should be stopped how long prior to surgery?
5 days
Ticlid should be stopped how long prior to surgery? and what is the reversal?
- 10-14 days
- Methylprednisolone and platelet transfusions
Which P2Y12 Receptor Antagonists are pro-drugs?
-Plavix and effient
Thienopyridine P2Y12 receptor Antagonists adverse effects?
- Bleeding
- Diarrhea and Rash
- TTP
- Neutropenia
How do Platelet Glycoprotein (GP IIb/IIIa) Receptor Inhibitors work?
-Inhibit fibrinogen binding to platelets (Inhibit platelet aggregation)
When are Platelet Glycoprotein (GP IIb/IIIa) Receptor Inhibitors used?
- Ischemic complications of PCI
- Unstable angina and MI
Adverse effects of Platelet Glycoprotein (GP IIb/IIIa) Receptor Inhibitors.
- Bleeding
- Thrombocytopenia
- N/V
- Hypotension
- Anaphlyxis
What should be monitored when on low dose coumadin, and when can a catheter be removed?
- PT/INR
- INR<1.5
Use of what drugs represents a significant risk for hematoma during neuraxial block?
- Factor Xa inhibitors
- LMWH and Fondaparinux
What is Dextran 40? and When is it used?
- Low molecular weight dextran
- Expanding intravascular volume
- Decreases blood viscosity
What are the side-effects Dextran 40?
- Allergic reactions
- Increased bleeding time
- Rouleaux formation
