Coagulopathy Flashcards
What is the DVT ppx dose of lovenox for patients with BMI over 40?
.5 mg/kg q12h
What is the heparin dose for DVT ppx in patients with GFR <30?
5000 units SC q8h
What is your dosing of heparin for ACS? What is the intensity considered to be?
What do you want the aPTT to be?
-Low-intensity heparin
-60 U/kg bolus, then 12U/kg/hr
- aPTT 40-60
What is your dosing of heparin for DVT, PE, or ventricular thrombus? What is this intensity considered to be?
What do you want the aPTT to be?
- high-intensity heparin
- 80 U/kg bolus, then 18U/kg/hr
- aPTT 70-90
What is your lovenox dose for DVT, PE, ACS and ventricular thrombus?
What can you monitor for this and what do you want the level to be?
1 mg/kg SC q12h or 1.5 mg/kg SC qd
Anti-Xa level .6-1.2 U/mL
What do you want to use for anticoagulation in HIT?
Argatroban or Fondaparinux
Why do you give Calcium with MTP?
Citrate used in stored blood chelates ionized calcium
What labs do you need at the initiation of MTP?
CBC, PT/INR, aPTT, fibrinogen, type & crossmatch, ionized calcium, ABG, lactate, serum electrolytes, hepatic and renal function testing, thromboelastograph
What is the R-time in TEG?
- Reaction Time: time it takes for a clot to go from 0 to 2mm thick.
- driven by intrinsic & extrinsic pathway
- reflects availability of clotting factors and the ability for form thrombin
- normal is 5-10 min
What does a lower R-time mean?
What does a high than normal R-time mean?
- R-time lower than normal means hypercoagulability or rapid thrombin generation in setting of bleeding
- R-time higher than normal means deficiency of clotting factor; inhibition of clotting (heparin, thrombin inhibitors); consumptive coaulopathy
What is the K-time in the TEG?
- Kinetics Time: time it takes for the clot to go from 2 to 20 mm thick.
- due to the conversion of fibrinogen to fibrin, fibrin deposition, and cross-linking. Also somewhat dependent on platelet function
- normal K-time is 1-3 minutes
What is the alpha-angle in TEG?
- angle between the end of the R-time and the rate of maximal clot formation. Corresponds closely with K-time
- driven primarily by fibrinogen
- normal alpha-angle is 53-73 degrees
What does it mean if K-time is lower than normal and alpha angle is higher than normal
hypercoagulability; rapid clot formation in the setting of hemorrhage
What does it mean if the K-time is higher than normal and alpha angle is lower than normal
fibrinogen depletion; consumptive coagulopathy; dysfibrinogenemia; significant platelet deficiency of dysfunction
What is the MA in TEG?
- Maximal Amplitude: maximum thickness of the clot
- largely dependent on platelet function
- normal MA is 50-70mm
What does it mean when the MA (maximal amplitude) is lower than normal?
thrombocytopenia; thrombasthenia; platelet inhibition with medications; uremic platelet dysfunction
What does it mean when the MA (maximal amplitude) is higher than normal?
hypercoagulability
What is the LY-30 in the TEG?
What does a high LY-30 mean?
LY-30: percentage of clot that is lysed 30 minutes after reaching maximal amplitude
- normal is 0-8%
- high LY-30 means accelerated fibrinolysis; presence of activated plasminogen
When is TEG useful?
What are limitations of TEG?
- useful: MTP; patients who have coagulation derangements but may not actually have a high bleeding risk (cirrhotics)
- limitations: does not indicate specific coagulation factor deficiences or distinguish bt intrinsic and extrinsic pathway problems. Cannot be used to screen for DVT or PE.
**R-time may be normal in setting of warfarin, even with therapeutic INR.
What is in cryoprecipitate?
What is it used for? Dose?
- fibrinogen, Factor VIII, vWF. more concentrated source of fibrinogen than FFP
- could use 2 units in dabigatran reversal if fibrinogen <200
- really only used when factor concentrates or concentrated fibrinogen are unavailable
What is in Prothrombin Concentrate (PCC/Kcentra)?
What is it used for?
Dose?
- Factor II (prothrombin), factor VII, Factor IX, and Factor X
- warfarin reversal - depends on INR (25-50 U/Kg)
- in liver dz
- eliquis & xarelto reversal, actually recommended over andexenant still - 25-50 U/kg
What is the dosage of Kcentra reversal for warfarin?
INR 2-4: 25 U/kg
INR 4-6: 35 U/kg
INR >6: 50U/kg
or
fixed dose 1500 U
What is the reversal agent for apixaban and rivaroxaban? Dose?
andexanet - 400 mg bolus followed by 480 mg over 2 hours
- but really Kcentra is preferred reversal agent (25-50 U/kg)
