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Hem/Onc > Hemostasis Pharmacology and transfusion therapy > Flashcards

Hemostasis Pharmacology and transfusion therapy Flashcards

1
Q

What kind of blood transfusion would an anemia pt receive?

A

packed red blood cells

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2
Q

What kind of transfusion would a clotting factor deficiency pt need to receive?

A

fresh frozen plasma (coag factors)

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3
Q

If a pt donates their own blood ahead of a major surgery, this is _____ transfusion

A

autologous

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4
Q

____ is the universal recipient

A

AB+

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5
Q

____ is the universal donor

A

O-

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6
Q

Type vs screen: What does the type of blood mean?

A

Determines the ABO and Rh phenotype of the RECIPIENT’s blood

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7
Q

Type vs screen: What does the screen mean?

A

Identifies antibodies directed against other antigens by Mixes recipient’s blood with type O RBCs that contains major antigens of other blood group systems and observe for clumping

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8
Q

Pre-transfusion testing what does cross matching mean? When it is usually ordered?

A

Takes donor blood and mixes with recipient blood to make sure it is a “match”

Only ordered when there is a high likelihood that patient will receive PRBCs (packed red blood cells)

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9
Q

What type of blood is used in an emergency setting?

A

O-

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10
Q

Name 3 reasons why we would transfuse someone.

A

Replace acute blood loss
Oxygen delivery
Morbidity and mortality

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11
Q

When is a transfusion usually indicated?

A

in a pt with a Hbg less than 6 g/dL

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12
Q

1 unit of PRBCs should increase ____ in average sized adults without active bleeding or hemolysis; usually given over ____

A

Hgb 1 g/dL

1-2 hours

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13
Q

Does transfusion therapy require signed informed consent?

A

YES! Requires signed informed consent prior to non-emergency transfusions

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14
Q

When do transfusion reactions typically occur? What are the s/s?

A

during the transfusion or within 24 hours

fever, chills, pruritus, urticaria

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15
Q

**What is the most common risk of transfusions? What is one way to prevent it? What is the best treatment?

A

Febrile Non-hemolytic Rxn - MC

used leukocyte reduced PRBC

stop transfusion, Tylenol

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16
Q

**What is the most common cause of death associated with transfusion risks? Associated s/s?

A

Circulatory overload

swelling, SOB, decreased O2, difficulty breathing

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17
Q

What kind of pts are most at risk for circulatory overload?

A

renal failure, CHF, increased age, decreased ejection fraction or acute cardio syndrome (recent heart attack)

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18
Q

What is the treatment for circulatory overload?

A

diuretics

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19
Q

What is urticaria?

A

hives

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20
Q

Name some risks associated with transfusions?

A

Hemolytic Transfusion Reactions (incompatible blood 1/14,000)

Allergic Reactions ranging from urticaria to anaphylaxis

Infectious Complications
Septic Reactions
Viral Transmission

Transfusion Associated Graft Versus Host Disease

Post Transfusion Purpura

Iron overload

Hyperkalemia or other Electrolyte Toxicity

Hypothermia

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21
Q

When would you want to give a transfusion of whole blood?

A

Only in setting of massive hemorrhage, provides O2-carrying capacity and volume expansion

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22
Q

PRBCs increases the _____ in the anemic patient. Each unit has a total volume of approx. ____

A

oxygen-carrying capacity

200mL

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23
Q

What modifications can be made to a unit of PRBCs

A

Leukocyte reduced
Irradiated
Washed

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24
Q

What type of PRBCs: _______ used to reduce risk of immunologically-mediated effects, infectious disease transmission, reperfusion injury

A

Leukocyte reduced

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25
Q

What type of PRBCs: _______ to avoid the occurrence of graft-versus-host disease (GVHD) in patients who have immune deficiency states

A

Irradiated

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26
Q

What type of PRBCs: _______ to prevent or eliminate complications associated with infusion of proteins present in the small amount of residual plasma in red cell concentrates

A

washed

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27
Q

Whole blood is separated into ____ and ____

A

PRBCs

plasma

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28
Q

Plasma contains ____ and ____

A

platelets and proteins

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29
Q

The plasma is then centrifuged to give one unit of ____ and one unit of ____

A

platelets

fresh frozen plasma

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30
Q

____ is the universal plasma donor

A

AB

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31
Q

____ is the universal plasma recipient

A

O

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32
Q

FFP is separated from freshly drawn blood by removing the ____, _____ and _____

A

red blood cells

white blood cells

platelets

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33
Q

Name 6 things you can find in FFP

A

coagulation factors, fibrinogen, antithrombin, albumin, protein C and protein S

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34
Q

Once FFP has thawed, the plasma must be transfused within ____ hours or the concentrations of factor V and factor VIII begin to decline.

A

24 hours

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35
Q

____ is the most commonly used plasma product, in part because it can correct deficiencies of any of the circulating coagulation factors

A

FFP

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36
Q

What is cryoprecipitate made up of?

A

just clotting factors

von Willebrand factor, factor VIII, factor XIII, and fibrinogen.

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37
Q

What is the chief advantage to using cryoprecipitate vs FFP?

A

that it allows von Willebrand factor, factor VIII, factor XIII, and fibrinogen to be replaced using a much smaller volume than if those factors were replaced by transfusing FFP

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38
Q

A _____ contains a large amount of a specific clotting factor that has been produced with recombinant technology or collected from thousands of donors and pooled into a highly concentrated product.

A

factor concentrate

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39
Q

What is the major indication for factor concentrates?

A

to replace specific factor deficiencies (eg, hemophilia A and B) with minimal volume and without supplying extraneous proteins

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40
Q

** What are the four indications for platelet transfusion products?

A

-Patients with a platelet count <10,000 to prevent spontaneous hemorrhage.

-Patients with a platelet count <50,000 who are actively bleeding, are scheduled to undergo an invasive procedure, or have a qualitative intrinsic platelet disorder.

-Patients with a platelet count <100,000 who have a central nervous system injury, have multisystem trauma, or are undergoing neurosurgery

-Patients with a normal platelet count who have ongoing active bleeding and a reason for platelet dysfunction, such as a congenital platelet disorder, chronic aspirin therapy, or uremia

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41
Q

Each unit of transfused platelets should increase the platelet count by _____

A

5,000 to 10,000.

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42
Q

A patient develops an acute onset of shaking chills 10 minutes into a random donor platelet transfusion. Other than a mild fever, vital signs are normal and there is no evidence of rash, urticaria, or respiratory distress. What is the best course of action?

A

stop transfusion and administer acetaminophen

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43
Q

What are the four hemostasis promoting agents?

A

1) Protamine Sulfate
2) Vit K
3) Desmopressin
4) Thrombin

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44
Q

**______ neutralizes heparin and is the antidote for heparin overdose

A

Protamine sulfate

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45
Q

**How is protamine sulfate administered?

A

administered IV only

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46
Q

** What is the black box warning associated with protamine sulfate?

A

May result in severe hypotensive or anaphylactoid-like reactions

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47
Q

____ is the reversal agent for warfarin

A

Vit K

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48
Q

What is another name for Vit K?

A

phytonadione

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49
Q

____ Prevention and treatment of hypoprothrombinemia caused by vitamin K antagonist (VKA)-induced (warfarin) or other drug-induced vitamin K deficiency

A

Vit K

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50
Q

What is one cause of hypoprothrombinemia?

A

caused by malabsorption or inability to synthesize vitamin K

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51
Q

Where is Vit K metabolized?

A

in the liver

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52
Q

_____ increases plasma levels of von Willebrand factor, factor VIII, and t-PA contributing to a shortened activated partial thromboplastin time (aPTT) and bleeding time

A

Desmopressin (DDAVP)

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53
Q

____ is used for hemostasis may rarely lead to hyponatremia and extreme decreases in plasma osmolality, resulting in seizures, coma, and death

A

Desmopressin (DDAVP)

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54
Q

____ converts fibrinogen to fibrin directly at the site of bleeding.

A

topical thrombin

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55
Q

____ is used in various types of surgery to aid in hemostasis whenever oozing blood and minor bleeding from capillaries and small venules is accessible.

A

topical thrombin

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56
Q

What are the contraindications of topical thrombin?

A

patients with a known sensitivity to components of bovine origin

not for use in massive bleeding.

Must not be injected or allowed to enter large vessels.

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57
Q

What are the general contraindications for all anticoagulants?

A

Bleeding – current or past (not an absolute contraindication)

Most are cleared by kidneys so renal function is important to assess (Not Unfrac Heparin)

Allergic reaction to the drug

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58
Q

What are the 4 parenteral anticoagulants on the market?

A

(Unfractionated) Heparin

Low-molecular-weight heparin (LMWH) (Enoxaparin/Lovenox)

Bivalirudin (Angiomax)

Argatroban (Acova)

59
Q

**____ Binds to anti-thrombin (III) and enhances its inactivation of factor Xa and thrombin.

A

Unfractionated Heparin

60
Q

In what clinical setting do you usually find unfractionated heparin?

A

only given INpatient setting

61
Q

What routes is unfractionated heparin given?

A

Sq or continious IV only

62
Q

**_____ lab you must monitor for a pt on unfractionated heparin

A

activated partial thromboplastin time (aPTT)

63
Q

What are the adverse effects of unfractionated heparin?

A

bleeding, thrombocytopenia, osteoporosis, elevated levels of transaminases (LFTS, aka liver function)

64
Q

For Unfractionated Heparin, as the dose increases, the ????

A

risk of bleeding increases

65
Q

For Unfractionated Heparin pts, _____ and _____ are more prone to hemorrhage

A

Elderly women and renal insufficiency patients

66
Q

Osteoporosis caused by unfractionated heparin affects the activity of both ___ and _____

A

osteoblasts and osteoclasts

67
Q

What are the contraindications to unfractionated heparin?

A

HIT, hypersensitivity, active bleeding, hemophilia, significant thrombocytopenia (<50,000), purpura, severe hypertension

68
Q

Heparin-Induced Thrombocytopenia (HIT) affects ____ of those exposed to heparin and ___ of those exposed to LMWH

A

3%

0.6%

69
Q

Heparin-Induced Thrombocytopenia (HIT) is caused when ????

A

Heparin + PF4 form a neoantigen on the PLT surface, induces an immune antibody response resulting in PLT clearance

70
Q

Why is HIT particularly dangerous?

A

because it decreases PLT counts, but may also induce a hypercoagulable state

71
Q

**HIT can occur with ____ dose, ____ schedule, and _____ administration route

A

Any dose

any schedule

any administration route

72
Q

HIT is more common with ____ and _____

A

UFH, especially in surgical patients

females

73
Q

_____ is the most common manifestation of HIT, platelet count drops ____ of baseline

A

Thrombocytopenia

greater than 50% of baseline

74
Q

the typical onset of thrombocytopenia occurs ____ after the initiation of heparin therapy

A

5 to 10 days

75
Q

When does early onset of HIT occur?

A

may be seen if the patient has been exposed to heparin in the last few months and has circulating HIT antibodies

76
Q

How long does it take for the baseline platelets to return to normal?

A

5-7 days after the withdrawal of heparin

77
Q

____ occurs in up to 50% of individuals with HIT. Where is it most common?

A

Thrombosis

venous, leg veins, cardiac vessels, and small venules of the skin

78
Q

Where are arterial thrombosis due to HIT most likely to occur?

A

heart, central nervous system, limbs, and internal organs

79
Q

What are some common complications due to HIT induces thrombosis.

A

skin necrosis, limb gangrene (sometimes requiring amputation), and organ infarction

80
Q

When would you want to consult hematology if you suspect HIT?

A

New onset of thrombocytopenia (platelet count <150,000/microL)

A drop in platelet count of ≥50% from a prior value, even if absolute thrombocytopenia is not present

Venous or arterial thrombosis

Necrotic skin lesions at heparin injection sites

Acute systemic reactions (fever/chills, tachycardia, hypertension, dyspnea, cardiopulmonary arrest) occurring after IV heparin bolus administration

81
Q

What are the 4 Ts scoring system for assessing HIT

A
82
Q

If you suspect HIT, _____ is the most specific test. What other tests can you also order?

A

Serotonin release assay

HIPA
Heparin-PF4 Ab ELISA

83
Q

What is the HIT management plan?

A
  • STOP HEPARIN
  • begin immediate anticoagulation therapy
    -DO NOT GIVE PLATELETS
  • long term oral anticoag therapy is needed
  • must list “Heparin” allergy in the patient’s chart moving forward
84
Q

_____ is recommended following a HIT event, once the pt is stable and platelet count is higher than 150K

A

Warfarin (coumadin)

85
Q

______ enhance inhibition of factor Xa by AT III, has less direct inhibition of Xa and virtually no direct inhibition of thrombin.

A

Lovenox

86
Q

_____ must reduce dosing with CrCl <30; CONTRAINDICATED with ESRD

A

Lovenox

87
Q

**What is the best way to monitor Low-Molecular Weight Heparin (LMWH)?

A

anti–factor Xa levels must be measured because little effect on the aPTT

88
Q

______ is recommended in preg pts over heparin

A

Lovenox

89
Q

Under what 4 conditions would you want to use a levenox bridge?

A

Embolic stroke within past 3 months

Previous embolic stroke or VTE during interruption of chronic anticoagulation

Mechanical heart valve

Atrial fibrillation in pt with high stroke risk

90
Q

What are the 2 non-heparin thrombin inhibitor

A

Argatroban (Acova)

Bivalirudin (Angiomax)

91
Q

____ A direct, highly-selective thrombin inhibitor.
Reversibly binds to the active thrombin site of free and clot-associated thrombin.
Inhibits fibrin formation; activation of coagulation factors V, VIII, and XIII; activation of protein C; and platelet aggregation

A

Argatroban (Acova)

92
Q

What do you order on a pt, in order to adjust a Argatroban (Acova) dose?

A

measure aPTT to adjust dose

93
Q

______ A direct, highly-selective thrombin inhibitor.
Reversibly binds to the active thrombin site of free and clot-associated thrombin.

A

Bivalirudin (Angiomax)

94
Q

_____ alternative to heparin in patient undergoing percutaneous coronary intervention (PCI), especially if history of HIT

A

Bivalirudin (Angiomax)

95
Q

you order _____ on heparin pts, and _____ on warfarin pts

A

ptt

PT/INR

96
Q

______ is a Vitamin K antagonists

A

Warfarin (Coumadin)

97
Q

______ inhibits vit K oxide reductase complex subunit I, this inhibits factors II, VII, IX and X.

A

Warfarin (Coumadin)

98
Q

_____ kinetics are metabolized in the liver, primarily via CYP2C9, circulates bound to albumin.

A

Warfarin (Coumadin)

99
Q

What pregnancy category is Warfarin?

A

Preg category D

100
Q

______ is indicated prophylaxis and treatment of thromboembolic disorders (DVT/PE) and embolic complications arising from atrial fibrillation or cardiac valve replacement

A

Warfarin (Coumadin)

101
Q

______ No dosage adjustments with renal impairment

A

Warfarin (Coumadin)

102
Q

_____ Necrosis or gangrene of the skin and other tissue can occur (rarely, <0.1%) due to paradoxical local thrombosis; onset is usually within the first few days of therapy and is frequently localized to the limbs, breast, or penis

A

Warfarin (Coumadin)

103
Q

How does Warfarin interact with alcohol?

A

binge drinking) decreases the metabolism of oral anticoagulants and increases PT/INR.

Chronic daily ethanol use increases the metabolism of oral anticoagulants and decreases PT/INR.

104
Q

Warfarin and Vit E _____ warfarin effect

A

increase

105
Q

Warfarin and Cranberry juice may _____ warfarin effect.

A

increase

106
Q

What is an additional point to educate pts on Warfarin?

A

Take warfarin at the same time each day

Maintain a consistent diet

107
Q

What are the 4 direct oral anticoagulants?

A

Dabigatran (Pradaxa) – inhibits thrombin
Rivaroxaban (Xarelto) – inhibits factor Xa
Apixaban (Eliquis) – inhibits factor Xa
Edoxaban (Savaysa) – inhibits factor Xa

108
Q

_____, _____ and ______ all inhibits factor Xa

A

Rivaroxaban (Xarelto)
Apixaban (Eliquis)
Edoxaban (Savaysa)

109
Q

______ is a DOAC that inhibits thrombin

A

Dabigatran (Pradaxa)

110
Q

______ : Stroke prevention in nonvalvular atrial fibrillation, DVT/PE, and DVT/PE prophylaxis after hip or knee arthroplasty

A

Dabigatran (Pradaxa)
Rivaroxaban (Xarelto)

111
Q

What is the reversal agent for Dabigatran (Pradaxa)?

A

Praxbind (idarucizumab)

112
Q

Avoid taking ______ with taking grapefruit juice

A

Rivaroxaban (Xarelto)
Apixaban (Eliquis)

113
Q

What is the Rivaroxaban (Xarelto) reversal agent?

A

AndexXa (andexanet alfa)

114
Q

_____ Inhibits platelet activation and fibrin clot formation via direct, selective and reversible inhibition of free and clot-bound factor Xa

A

Apixaban (Eliquis)

115
Q

What is the reversal agent of Apixaban (Eliquis)?

A

AndexXa (andexanet alfa)

116
Q

_____ Factor Xa (FXa) inhibitor; inhibits platelet activation by selectively and reversibly blocking the active site of FXa without requiring a cofactor (antithrombin III) for activity

A

Edoxaban (Savaysa)

117
Q

Cannot use _____ if CrCl > 95 mL/min

A

Edoxaban (Savaysa)

118
Q

What is the reversal agent for Edoxaban (Savaysa)?

A

there is none :)

119
Q

What is the reversal of Heparin?

A

Protamine

120
Q

What is the reversal for Warfarin?

A

Vit K

121
Q

For DOACs, need to monitor _____ and possible reduce dose

A

kidney function

122
Q

_____ Inhibits COX-1 production, which is a critical enzyme in the biosynthesis of thromboxane A2.

A

Aspirin

123
Q

_____ Irreversibly acetylates COX enzymes (lasts the life of the platelet)

A

Aspirin

124
Q

When taking ASA and NSAIDs together, what is the dosing schedule?

A

ASA should be taken at least 60 minutes before or 8 hours after NSAIDs

125
Q

_____ inhibit ADP pathway of platelets. Irreversibly blocks the ADP receptor (P2y12).

A

Clopidogrel (Plavix)

126
Q

What drugs should be avoided while also taking Plavix?

A

Other drugs that inhibit CYP 2C19 (omeprazole, esomeprazole) should be avoided concurrently, as may reduce effectiveness of clopidogrel

127
Q

_____ the active metabolite irreversibly blocks the P2Y12 component of ADP receptors on the platelet

A

Prasugrel (Effient)

128
Q

Due to increased risk of CVA _____ is contraindicated if hx of TIA or CVA

A

Prasugrel (Effient)

129
Q

____ irreversibly blocks the P2Y12 component of ADP receptors, which prevents activation of the GPIIb/IIIa receptor complex, thereby reducing platelet aggregation

A

Ticlopidine (Ticlid)

130
Q

_____ may cause life-threatening hematologic reactions, including neutropenia, agranulocytosis, thrombotic thrombocytopenia purpura (TTP), and aplastic anemia.

A

Ticlopidine (Ticlid)

131
Q

What is the recommended monitoring for Ticlopidine (Ticlid)?

A

CBC with diff every 2 weeks starting the second week through the third month of treatment.

132
Q

____ reversibly and noncompetitively binds the adenosine diphosphate (ADP) P2Y12 receptor on the platelet surface which prevents ADP-mediated activation of the GPIIb/IIIa receptor complex thereby reducing platelet aggregation

A

Ticagrelor (Brilinta)

133
Q

The most common SE in clinical trials of _____ was dyspnea

A

Ticagrelor (Brilinta)

134
Q

What is the black box warning for Ticagrelor (Brilinta)?

A

Black box warning regarding reduced effectiveness with concomitant use of ASA above 100 mg daily

135
Q

_____ : reversibly and noncompetitively binds the adenosine diphosphate (ADP) P2Y12 receptor on the platelet surface which prevents ADP-mediated activation of the GPIIb/IIIa receptor complex thereby reducing platelet aggregation

A

Cangrelor (Kengreal)

136
Q

Where is the most common place you would find Cangrelor (Kengreal)?

A

in the cath lab

IV only

137
Q

____ and ____ work by Gp IIB/IIIA receptor inhibitor. Where would you find them?

A

Eptifibatide (Integrilin)
Abciximab (Reopro)

in the cath lab

138
Q

What is the goal of fibrinolytics?

A

to breakdown thrombi in the setting of life-threatening or massive thrombi

The goal of therapy is to produce rapid thrombus dissolution, thereby restoring blood flow.

139
Q

_______ act by converting plasminogen to plasmin, which then degrades the fibrin matrix of thrombi and produces soluble fibrin degradation products.

A

Fibrinolytics

140
Q

______ preferentially activate plasminogen that is bound to fibrin, which in theory confines fibrinolysis to the formed thrombus (thus avoiding systemic activation).

A

Alteplase (tPA)

141
Q

_____ is given IV for PE with hemodynamic instability, acute STEMI, severe DVT, and ascending thrombophlebitis.

A

Alteplase (tPA)

142
Q

____ a protein produced by streptococci that combines with the proactivator plasminogen. This enzyme complex catalyzes the conversion of inactive plasminogen to active plasmin.

A

Streptokinase

143
Q

_____ is given to heart attack pts only, NOT stroke pt (will increase bleeding)

A

Streptokinase

144
Q

Heparin binds to _____ in order to exert its anticoagulant effect

A

antithrombin III

Hem/Onc (14 decks)

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