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Nurs 575 Anesthesia Pharmacology > Coagulation-Procoagulants and Anticoagulants > Flashcards

Coagulation-Procoagulants and Anticoagulants Flashcards

1
Q

What three substances are important serine proteases that exert anticoagulant/anti-inflammatory actions?

A
  • Antithrombin
  • Protein C
  • Protein S

Stoeltings, pg. 622

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2
Q

Coagulation is closely linked to ___________ responses through complex networks of plasma and cellular components

A
  • inflammatory

Stoeltings, pg. 622

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3
Q

_________ is used to evaluate the extrinsic coagulation cascade

bold on PPT

A
  • Prothrombin time

bold on PPT

Stoeltings, pg. 622

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4
Q

_________ is used to evaluate the intrinsic coagulation cascade

bold on PPT

A
  • activated partial thromboplastin time (aPTT)

bold on PPT

Stoeltings, pg. 623

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5
Q

Describe the MOA of Tranexamic Acid (TXA)

A
  • Antifibrinolytic - competetively inhibits the activation of plasminogen to plasmin
  • Not prothrombotic but rather a clot stabilizer

bold on PPT

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6
Q

What is the usual dosing of TXA?

A
  • Trauma/Total Joints: 1g IV
  • Cardiac surgery: 50 mg/kg/dose IV

PPT, slide 12

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7
Q

What is the MOA of Desmopressin (DDAVP)?

A

V2 Agonist
* V2 analog of vasopressin that stimulates release of von Willebrand factor from endothelial cells

vWF necessary for platelet adherence to site of vascular injury

Stoeltings, pg. 642

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8
Q

________ mcg/kg of Desmopressin is given IV over ___________ minutes

A
  • 0.3 mcg/kg
  • 15-30 minutes

Stoeltings, pg. 642

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9
Q

What are the possible consequences of rapid administration of desmopressin?

A
  • Hypotension

stimulates endotelial release of vasoactive mediators (nitric oxide?)

Stoeltings, pg. 643

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10
Q

DDAVP affects what test in what population?

A

Shortens Bleeding time

  • vWF disease or Hemophilia A pts
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11
Q

Protamine is the only available agent to reverse ____________

bold on PPT

A
  • unfractionated heparin

bold on PPT

Stoeltings, pg. 642

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12
Q

What is the usual dosing of protamine?

A
  • 1-1.5 mg IV per 100 units of heparin

50 mg/dose MAX

PPT, slide 17

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13
Q

How does protamine chemically reverse UFH?

A
  • Protamine is 70% argenine (polycationic - alkaline)
  • UFH is a mucopolysaccharide (polyanionic - acidic)
  • They combine ionically to form a stable compound

PPT, slide 15

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14
Q

Adverse reactions associated with Protamine?

A
  • Anaphylaxis
  • Acute pulmonary vasoconstriction
  • R. ventricular HF
  • HoTN

PPT, slide 16

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15
Q

Pts at risk for Protamine adverse reactions?

A
  • NPH insulin user
  • Prior vasectomy
  • Multiple drug allergies
  • Previous protamine exposure

PPT, slide 16

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16
Q

Fibrinogen levels are normally 200-400 mg/dL - hypofibrinogenemia is best treated with ____________? Dose?

A

Cryoprecipitate

  • 1 unit per 10 kg increases levels by 50-70 mg/dL

Stoeltings, pg. 643
PPT, slide 21

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17
Q

It is preferable to give prothrombin complex concentrates(PCCs) which contain _________ for warfarin reversal

bold on PPT

A

all four vitamin K-dependent coagulation factors (i.e. Kcentra)

  • Factors II, VII, IX, X
  • Protein C (activated) & AT

bold on PPT

Stoeltings, pg. 645
PPT, slide 23

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18
Q

The partial thromboplastin time is used to monitor what, specifically?

A
  • Lower doses of UFH
  • ~1 unit/mL

Unfractioned Heparin

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19
Q

During cardiac surgery, higher doses of what drug are monitored via what test?

A
  • UFH
  • Activated Clotting Time (ACT)
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20
Q

What variables make up a thromboelastography? How are ea. variable measured ?

5

A
  • Coag. time (seconds)
  • Clot formation- rate of fibrin polymerization (seconds)
  • Angle (in degrees)
  • Maximum clot firmness (mm)
  • Lysis time (seconds) - used for diagnosis of premature lysis or hyperfibrinolysis
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21
Q

WTF is Idarucizumab? MoA?

A
  • Dabigatran (Pradaxa) reversal
  • Binds to pradaxa & it’s metabolites, neutralizing them
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22
Q

Idarucizumab Dose & Half-life?

A

5 mg IV x1
Half-life - 10.3 hrs

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23
Q

WTF is Andexanet alfa? MoA?

A
  • Reversal for Rivaroxaban & Apixaban
  • Binds & sequesters factor Xa inhbitor, inhibits TFPI
  • Reverses anti-Xa activity & restores Thrombin (IIa) generation
24
Q

Fibrinogen is a substrate for what three important enzymes?

A
  • Thrombin
  • Factor XIIIa
  • Plasmin
25
Q

At what Fibrinogen levels might you see changes on PT or aPTT? What cannot correct these levels @ this range?

A

< 100mg/dL

  • FFP
26
Q

Your patient is bleeding and needs a transfusion. What is the recommended increase for fibrinogen?

A

Increase levels 150-200 mg/dL

27
Q

What do Prothrombin Complex Concentrates contain (PCC)? Which factor do they contain mainly?

A

Factors:
* II
* VII
* IX <- this one
* X

28
Q

Some differences between PCCs?

A
  • Only FEIBA contains VIIa <- activated form
  • Profilnin & Bebulin only have low levels of VII
29
Q

Define the convoluted unit of UFH?

A
  • The volume of a UFH containing solution that will prevent 1mL of citrated sheep blood from clotting for 1 hr
  • after adding 0.2mL of 1:100 Calcium Chloride
30
Q

MoA of UFH?

A

Binds and activates AT III which inactivates:
* II
* IX
* Xa
* XI
* XII

31
Q

Common Dose & Half-life of UFH?

A
  • 2000-5000 units IV -> titrated based on ACT
  • Half-life: 0.5-2hr
32
Q

Mean molecular weights of LMWH?

A

4000-5000 Da

33
Q

Your patient is on enoxaparin, how long should surgery be delayed from their last dose?

A

12 hours from their last dose
Longer if they have renal dysfunction

34
Q

How long does it take for Protamine to neutralize LMWH?

A

It doesn’t neutralize LMWH

35
Q

Which drugs are Direct thrombin inhibitors?

A
  • Bivalrudin (Angiomax)
  • Argatroban
36
Q

Which direct thrombin inhibitor is a bivalent DTi? where does it bind to thrombin?

A

Bivalirudin
Catalytic & Fibrinogen binding site

37
Q

Which direct thrombin inhibitor is a univalent DTi? where does it bind to thrombin?

A

Argatroban
Catalytic binding site

38
Q

Dose & Half-Life of Bivalrudin?
(Bolus/Infusion)

A

Bolus: 0.75mg/kg IV
Infusion: 1.75mg/kg/hr for procedure
Half-life: 25 min

39
Q

Dose & Half-Life of Argatroban?
(Infusion)

A

Infusion: 15-30 mcg/kg/min
Half-life: 39-51 min

40
Q

How do you monitor Bivalrudin? Argatroban?

A
  • Bivalrudin - ACT
  • Argatroban - ACT & aPTT
41
Q

Mechanism by which thrombolytic drugs work?

This be bolded

A
  • Drugs act as plasminogen activators
  • converts endogenous plasminogen -> plasmin
  • Plasmin lysis clots & other proteins
42
Q

What is the goal for thrombolytic therapy?

A

Restore circulation

43
Q

What are some indications for Tissue plasminogen activator (tPA)?

Bolded

A
  • Acute ischemic Stroke
  • Acute MI
  • Acute massive PE for lysis
44
Q

When should Bivalrudin & Argatroban be stopped before surgery?

45
Q

When should Apixaban (Eliquis) & Rivaroxaban (Xarelto) be stopped before surgery?

A

Low bleed risk: 1-2 days
High bleed risk: 2-3 days

46
Q

When should Warfarin be held before surgery?

A

~5 days before
Bridge with Heparin if needed

47
Q

How long should Heparin be held before surgery?

A

4-6 hrs
* or reverse with protamine

48
Q

Which antiplatelet prevents the formation of thromboxane A2? by what pathway

A

Aspirin
* COX inhibition

49
Q

How long should aspirin be stopped prior to surgery?

50
Q

How long should LMWH be held prior to surgery?

A

At least 12 hrs, longer in renal dysfunction

51
Q

Which drugs are Platelet inhibitors?

A

Thienopyridines & Acetylsalicylate
* Clopidigrel
* Prasugrel
* Ticagrelor
* Aspirin

52
Q

Which Thienopyridines are direct acting or prodrugs?

A

Direct acting: Ticagrelor
Prodrugs: Clopidogrel & Prasugrel

53
Q

How long should Thienopyridines be held prior to surgery?

54
Q

MoA of Thienopyridines?

A

Irreversibly bind to P2Y-12 receptors
* block ADP binding
* inhibits (ADP mediated) platelet activation & aggregation

55
Q

Mean molecular weight of UFH?

A

3,000-30,000 Da

Nurs 575 Anesthesia Pharmacology (14 decks)

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