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Heme/Onc > Coagulation disorders > Flashcards

Coagulation disorders Flashcards

1
Q

What are the RFs for VTE?

A 
Age
H/o VTE
Venous stasis
Venous injury
Hypercoaguable disorders
Drug therapy
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2
Q

What are the pieces of Virchow’s triad?

A

Venous stasis
Vascular injury
Hypercoagulability

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3
Q

What are the types of venous stasis?

A

Immobility
Paralysis
A fib
LV dysfunction

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4
Q

What are the types of vascular injury?

A

Indwelling catheter
Trauma
Surgery

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5
Q

What are the types of hypercoagulability?

A

Protein C and S deficiencies
Antithrombin deficiency
Malignancy

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6
Q

What are the types of hypercoagulable hereditary disorders?

A 
Activated protein C resistance/Favtor V Leiden mutation
Prothrombin gene mutation
Protein C deficiency
Protein S deficiency
Antithrombin deficiency
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7
Q

In patients with Factor V Leiden mutation, what happens to clot formation?

A

Continues unchecked

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8
Q

What is protein C?

A

Endogenous anticoagulant responsible for degrading factor V and preventing further activation of the coagulation cascade

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9
Q

What does the prothrombin gene mutation cause?

A

Increased levels of prothrombin (needed in clot formation)

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10
Q

What is protein S?

A

One of the cofactors responsible for activation of protein C

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11
Q

What is antithrombin responsible for?

A

Inactivation of factors X and II

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12
Q

What are acquired hypercoagulable disorders?

A

Pregnancy
Antiphospholipid antibodies
Drug therapy
Malignancy

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13
Q

How does pregnancy cause hypercoagulable disorders?

A

D/t increased levels of estrogen during pregnancy and the immediate postpartum period

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14
Q

Where are antiphospholipid antibodies commonly found?

A

Patients with autoimmune disorders such as lupus or inflammatory bowel disease

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15
Q

What do antibodies do in the coagulation cascade?

A

Activate the coagulation cascade and platelets while inhibiting the activity or proteins C and S

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16
Q

What are s/sx of SVT?

A 
Unilateral calf, leg or thigh swelling
Leg pain/calf tenderness
Increased leg warmth
Edema
Erythema
Palpable thrombosed vein
Homan's sign
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17
Q

What are the s/sx of PE?

A 
Dyspnea
Tachypnea
Tachycardia
Hemoptysis
Chest pain and/or tightness
Cough
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18
Q

What is the diagnosis of DVT/PE?

A

D-dimer

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19
Q

What is the D-dimer normal range?

A

0-250

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20
Q

Does the D-dimer have a low or high positive predictive value and specificity?

A

Low

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21
Q

What are non-invasive DVT-specific diagnostic testing?

A

Duplex ultrasonography

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22
Q

What is duplex ultrasonography?

A

Can measure the rate and direction of blood flow and visualize clot formation in proximal veins of the legs

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23
Q

What is preferred to venography?

A

Duplex ultrasonography

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24
Q

What are he invasive diagnostic tests for DVT?

A

Contrast venography

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25
Q

What are the contraindications for Contrast venography?

A

Nephrotoxicity
Dye allergy
Metformin use (must d/c during therapy)

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26
Q

What is the gold standard for DVT diagnosis?

A

Contrast venography

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27
Q

What drug must be d/c before using contrast venography?

A

Metformin

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28
Q

What are the contraindications for contrast venography?

A

Nephrotoxicity

Dye allergy

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29
Q

What does contrast venography used to visualize?

A

Entire venous system in lower extremity and abdomen

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30
Q

What are PE specific non invasive diagnostic tests?

A

Ventilation-perfusion (V/Q) scanning

Contrast-enhance spiral chest CT

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31
Q

What are the PE specific invasive diagnostic tests?

A

Pulmonary angiography?

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32
Q

What is the gold standard for PE diagnosis?

A

Pulmonary angiography

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33
Q

What are the contraindications to pulmonary angiography?

A

Renal dysfunction

Dye allergy

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34
Q

What are the indications UFH?

A

Acute DVT +/- PE

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35
Q

What are the doses for UFH treatment?

A

80 U/kg IV bolus + 18 U/kg/hr IV

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36
Q

What are the indications for enoxaparin?

A

Acute DVT w/ or without PE

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37
Q

What is the treatment fosing for enoxaparin with a CrCl < 30?

A

1 mg/kg SC once daily

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38
Q

What is the outpatient enoxaparin treatment dosing for enoxaparin w/o a PE?

A

1 mg/kg SC q12h

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39
Q

What are the inpatient treatment options for enoxaparin?

A

1 mg/kg SC q12h
OR
1.5 mg/kg SC once daily

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40
Q

What is dalteparin indicated for?

A

VTE in cancer

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41
Q

What is the dosing schedule for dalteparin?

A

200 IU/kg SC once daily for 1 month
Then
150 IU/kg SC once daily for 5 months

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42
Q

What is the dalteparin dosing in CrCl < 30?

A

Anti-Xa level target 0.5-1.5 IU/ml

43
Q

What is the indication for tinzaparin?

A

Acute DVT +/- PE

44
Q

What is the dosing for tinzaparin?

A

175 IU/kg SC daily

45
Q

What are the indications for fondaparinux?

A

Acute DVT or PE

46
Q

What are the doses for fondaparinux?

A

<50 kg: 5mg SC daily
50-100 kg: 7.5mg SC daily
> 100 kg: 10mg SC daily

47
Q

When is fondaprinux contraindicated?

A

CrCl <30 ml/min

48
Q

What labs are we monitoring for UFH?

A

aPTT or anti-Xa

Range 0.3-0.7

49
Q

What are the labs we are monitoring for LMWH?

A

Anti-Xa levels

Range 0.5-1.0

50
Q

What labs do we monitor for fondaparinux?

A

none

51
Q

What labs do we monitor for Warfarin?

A

INR

52
Q

What labs do we monitor with DOACs?

A

None

53
Q

If a patient has cancer and their first episode with DVT?

A

For at least 6 months

54
Q

When is indefinite therapy with LMWH an option?

A

Second episode or recurrent VTE

55
Q

What are the disadvantages of warfarin in cancer?

A

NTI
Frequent monitoring
Potential interactions with a range of other drugs and foods
Frequent interruptions may be necessary d/t invasive procuders
Warfarin resistance

56
Q

What are the advantages of LMWH over warfarin in cancer?

A

Body weight adjusted dose
No lab monitoring
Predictable anticoagulant response
Rapid onset of action

57
Q

What did the CLOT study compare?

A

LMWH vs Oral anticoagulants

58
Q

What did CLOT prove?

A

Less recurrence of VTE with LMWH

Less bleeding with LMWH

59
Q

What are the oral anti-Xa inhibitors?

A

Rivaroxiban
Apixiban
Edoxaban

60
Q

What are the direct thrombin inhibitors?

A

Dabigatran

61
Q

According to the NCCN, DOACs can be used for acute management when?

A

Patients who refuse or have compelling reasons to avoid LMWH

62
Q

Which DOACs can be used for acute management of VTE?

A

Apixaban

Rivaroxaban

63
Q

According to the NCCN, DOACs can be used for chronic management when?

A

For patients who refuse or have compelling reasons to avoid LMWH

64
Q

Which DOACs are acceptable alternatives as second line agents for chronic management of VTE?

A

Apixaban
Dabigatran
Edoxaban
Rivaroxaban

65
Q

What is the UFH regimens for prophylaxis?

A

5,000 units SC every 8 hours

66
Q

What is the obesity dosing for UFH prophylaxis?

A

7,500 units SC every 8 hours

67
Q

What is the enoxaparin prophylactic dose?

A

40 mg SC once daily

68
Q

What is the enoxaparin obesity prophylactic dose?

A

40mg SC every 12 hours

69
Q

What is the dalteparin prophylactic dose?

A

5,000 units SC once daily

70
Q

What is the dalteparin prophylactic obesity dose?

A

Consider 7,500 units SC daily

71
Q

What is the tinzaparin prophylactic dose?

A

75IU/kg SC once daily

72
Q

What is the tinzaparin prophylactic obesity dose?

A

Limited data

73
Q

What is the fondaparinux prophylactic dose?

A

2.5 mg SC daily

74
Q

What is the fondaparinux obesity prophylactic dose?

A

5mg SC daily

75
Q

What are the prophylactic recommendations for hospitalized patients?

A

UFH
LMWH
fondaparinux

76
Q

What are prophylaxis recommendations for post surgery?

A

UFH
LMWH
fondaparinux
Mechanical compression devices combination in high risk patients

77
Q

What are prophylaxis recommendations for extended post-surgical prophylaxis?

A

Up to 4 weeks post surgery in high risk patients

78
Q

What are prophylaxis recommendations for ambulatory patients with cancer?

A

No prophylaxis recommended

79
Q

What are prophylaxis recommendations for patients with central venous catheters?

A

No prophylaxis recommendations

80
Q

What prophylaxis regimens are recommended in renal insufficiency?

A

UFH recommended
Caution with LMWH
Fondaparinux CI

81
Q

What prophylaxis regimens are recommended in obesity or weight less than 50 kg?

A

UFH recommended

Caution with LMWH and fondaparinux

82
Q

What prophylaxis regimens are recommended in active chemotherapy?

A

Recommended in myeloma patients receiving thalidomide or lenalidomide plus chemotherapy or dexamethasone

83
Q

What special populations are contraindicated for anticoagulants?

A

Mechanical compression devices

84
Q

If an ambulatory patient is recieving thalidomide or lenalidomide with chemotherapy or dexamethasone, what anticoagulant should be used?

A

LMWH

Adjusted dose warfarin (INR ~ 1.5)

85
Q

If a patient is undergoing surgery, what kind of therapy should be used?

A

Start prophylaxis preoperatively or early postoperatively

86
Q

For an average risk patient undergoing surgery, how long should we use prophylaxis treatment?

A

Continue for 7-10 days

High-risk: continue for 4 weeks

87
Q

What are mechnical compression devices?

A

Intermittent pneumatic calf compression devices (IPC’s)

Graduated compression stockings (GCS’s)

88
Q

What are the underlying complications of DIC?

A

Severe sepsis
Solid tumors
Severe trauma
Obstetrical complications

89
Q

What does DIC stand for?

A

Disseminated Intravascular coagulation

90
Q

What is the pathophysiology of bleed?

A
  1. Systemic activation of coagulation
  2. Intravascular deposition of fibrin (thrombosis of small and midsize vessels and organ failure)
  3. Depletion of platelets and coagulation factors (bleeding)
91
Q

What are the diagnostic tests for DIC?

A 
Elevated D dimer
Decreased antithrombin
Decreased fibrinogen
Thrombocytopenia
Decreased Protein C and S
Increased fibrinopeptides A and B
Elevated prothrombin fragments 1 and 2
Evidence of end-organ failure
92
Q

What are the s/sx of DIC?

A

Bleeding and/or thrombosis
Petechiae
Cyanosis
Hemorrhagic bullae

93
Q

What is the treatment of DIC?

A 
Treat underlying disorder
FFP
Cryoprecipitate
Anticoagulation
Vit K
94
Q

What are packed RBCs (PRBCs) used for?

A

To restore oxygen-carrying capacity to the blood

95
Q

How long do PRBCs last?

A

Up to 42 hours after donation

96
Q

1 unit of PRBCs should raise hgb by how much to have an appropriate response?

A

1

97
Q

How can PRBCs be modified?

A

Leukoreduction
Irradiated
Washed RBS to remove plasma

98
Q

When are PRBCs used?

A 
Hgb < 7
Active bleeding
Oncologic patients
-undergoing myelosuppressive therapy
-palliative care
99
Q

How do we premedicate for PRBCs?

A

APAP

Antihistamine

100
Q

When is FFP used?

A 
Bleeding d/t excessive warfarin
Vit K deficiency
DIC
Deficiency of multiple coagulation factors
Part of massive transfusion protocols
Plasma exchange
101
Q

What is cryoprecipitate?

A

The precipitate that remains when FFP is thawed at 4C

102
Q

What are the components of cryoprecipitate?

A 
Factor VIII
Fibrinogen
Fibronectin
Factor XIII
von Willebrand factor
103
Q

When is cryoprecipitate used?

A

Replacement of factor XIII or fibrinogen
Bleeding in von Willebrand factor deficiency
Uremic bleeding

104
Q

What are AEs of all blood products?

A

Anaphylaxis
Transfusion-relate acute lung injury
Cause volume overload

Heme/Onc (20 decks)

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