Patient Assessment and Management Flashcards
What are the potential barriers to successful use of anticoag medication and management.
financial hardship transportation literacy health literacy communication language barrier
what anticoagulants can be used in pregnancy?
UFH
(LMWH over UFH except during the final wks of pregnancy for fast reversal for delivery)
Less info on Fonda/argatroban/danaparoid
Why cant you use warfarin in pregnancy
crosses the placenta and can cause miscarriage’s, embryopathy (early exposure), Fetal bleeding, Intracranial hemorrhage (late exposure)
why cant you use DOAC in pregnancy (what can it cause)
Miscarriages, embryopathy (facial dimorphism, limb deformity, cardiac defect)
when do you switch from LWMH to UFH when pregnant
at 36-37 wk gestation, to minimize the risk, or stop LMWH 24 hours prior to delivery
what anticoagulants can be used while breastfeeding
LMWH, UFH, Fonda, Warfarin
DO NOT USE DOAC
Pradaxa is the only DOAC that can be used in Children in what ages and for what indication has it been FDA approved
children 3 months to less than 12 years old with venous thromboembolism
what is the preferred anticoagulation therapy in children
LMWH Fragmin (Dalteparin ONLY one FDA approved)
although unfractionated heparin and warfarin remain frequently used. Other anticoagulants, including fondaparinux, direct thrombin inhibitors, and the newer target-specific oral anticoagulants are also discussed.
what are the advantages of using DOAC in children
oral dosage formulations, including oral suspension; minimal laboratory monitoring; predictable pharmacokinetics; and no food interactions
Preferred anticoagulant in elderly pts greater than 75
apixaban
what is the preferred Anticoagulant in pts with hepatic failure
warfarin
Then can consider dabigatran
what is the preferred anticoagulant in pts with renal failure
Unfractionated heparin (UFH)
can consider apixaban
what is the ISI when calculating INR?
ISI indicates how particular a batch of tissue factor compares to an international reference tissue factor
how does POC vs Venous testing affect the correlation between INR values
It loses correlation once INR is over 4 (or per manufacturer)
Define Prothrombin time (PT)
measures the time it takes plasma to clot when exposed to tissue factor (which assesses the extrinsic and common pathways of coagulation. Its performed by recalcifying citrated patient plasma in the presence of tissue factor and phospholipid and determining the time it takes to form a fibrin clot. The formation of a fibrin clot is detected by visual, optical, or electromechanical methods. The result is measured in seconds and reported along with a control value and/or an INR.)
what can an INR result be useful for?
INR is standardized and can be evaluated regardless of time/location
evaluation of bleeding in patient/ warfarin monitoring
assessment of liver synthetic function
Disseminated intravascular coagulation (DIC) is a serious disorder in which the proteins that control blood clotting become overactive.
what can prolong the INR
warfarin, DOACs, heparins, Vit K deficiency, liver disease, DIC, APLS HCT greater than 55%
Define Activated partial thromboplastin time (aPTT)
(not standardized - location specific)
measures the time it takes plasma to clot when exposed to substances that activate the contact factors, which assesses the intrinsic and common pathways of coagulation. It is performed by recalcifying citrated plasma in the presence of a thromboplastic material that does not have tissue factor activity (hence the term partial thromboplastin) and a negatively charged substance (eg, celite, kaolin [aluminum silicate], silica), which results in contact factor activation, thereby initiating coagulation via the intrinsic clotting pathway.
For heparin monitoring aPTT range should be what?
- 2-0.4 units/mL by protamine or
0. 3-0.7 anti-factor Xa units/mL
what is aPTT used for
Evaluating bleedign, DIC, UFH monitoring or DTI monitoring
what can prolong aPTT
DIC, vWB (von wildebrand factor), hemophilia A (def FVIII), and B (FIX), oritavacin (binds phospholipids), Lupus anticoag type inhibitors
Definite TT (Thrombin time) (not for initial screening but can be used to eval pts with prolonged PT and aPTT, inherited fibrinogen disorder)
measures the final step of coagulation, the conversion of fibrinogen to fibrin. It is performed by incubating citrated plasma in the presence of dilute thrombin (bovine [cow] or human) and measuring the time to clot formation
What can prolong TT (thrombin time)?
Heparin, LMWH, Bilval, argatroban, acquired fibronioge disorders, DIC, liver disease, hypoalbuminemia, paraproteinemias, bovine thrombin exposure
How is Anti-Xa assay performed?
adding patient plasma to reagent factor Xa and measuring the activity of factor Xa using an artificial factor Xa substrate that releases a colored compound when cleaved (ie, chromogenic assay) but NOT chromogenic factor Xa level!
Must be calibrated for specific agents
when do you use chromogenic assay of factor X
to monitor patients with antiphospholipid antibodies or other inhibitors that might interfere with INR. Or in patients on concurrent direct thrombin inhibitors that might interfere with INR
what does a heparin assay measure
indirectly measures the amount of heparin in a person’s blood by measuring its inhibition of factor Xa activity, one of the proteins involved in blood clot formation (known as heparin anti-Xa activity).
what does a hemoccult test measure?
that’s used to detect the presence of occult blood in your stool. Occult blood is blood in your stool that you can’t see in the toilet or on the toilet paper after you have a bowel movement. The hemoccult test is predominantly used as a diagnostic tool for colorectal cancer.
what does a hematocrit measure
measurement of the size and number of RBCs
what does a hemoglobin measure?
iron containing oxygen treansport metalloprotein in RBC
what does a d-dimer measure
measures D-dimer, which is a protein fragment that your body makes when a blood clot dissolves in your body. D-dimer is normally undetectable or only detectable at a very low level unless your body is forming and breaking down significant blood clots
What can increase levels of D-Dimer?
Arterial thrombosis (MI/Stroke/acute limb ischemia, afib, intracardiac thrombus) VTE, DIC, preeclampsia, use of thrombolytics CV Disease (HF) severe infection surgery/trauma, SIRS sickle cell cancer renal disease normal pregnancy venous malformations
what is the cut off for neutropenia ANC less than ___
500
what is ANC (absolute neutrophil count)
estimate of the bodys ability to fight infections
{(% neutrophils + bands) x WBC}/100
what tests do you use to monitor warfarin
PT/INR or factor X chromogenic assay if baseline INR is prolonged
what tests do you use to monitor Heparin (UFH)
vs (LMWH)
UFH: aPTT or anti Xa (good if prolonged baseline aPTT)
LMWH: dont require montioring but if you do you can do anti Xa levels calibrated and 4 hours after 3rd-4th dose of LMWH
what tests do you use to monitor argatroban?
aPTT (could use ECT)
what tests do you use to monitor dabigatran?
TT (thrombin time) or ECT
what tests do you use to monitor Apixaban, Rivaroxaban, Edoxaban?
Anti-Xa assay calibrated
what is the normal, therapeutic and critical value of PT
normal: 10-12 or 11-13 seconds
therapeutic: 2x normal value
critical > 36 seconds
what is the normal, therapeutic and critical value INR
normal: 1
therapeutic: 2-3 or 2.5-3.5
critical 4.9
what is the normal, therapeutic and critical value aPTT
normal: 21-35 seconds
therapeutic 1.5-2.5 x normal
critical:100 seconds
what is the normal, therapeutic and critical value Heparin
Therapeutic: 0.3 to 0.7 U/mL
Critical 1.5 Upper limit
what is the normal, therapeutic and critical value Anti-XA for heparin
For Heparin
therapeutic:0.6-1.0 units/mL
critical is any above 1
when should you collect anti Xa level when pt is receiving LMWH?
4hours after 3rd-4th dose of LMWH
when should you collect anti Xa level when pt is receiving apixaban? (peak vs trough)
2-4 hours after a dose (PEAK)
right before next dose for (TROUGH)
what should the trough level be for LMWH when measuring antic -Xa levels
less than 0.5 units/mL
higher troughs suggest impaired clearance - an increased dosing interval may be indicated
when should you measure factor Xa assay for pts on apixaban, dabi, Riva etc?
- assure absence of drug prior to invasive procedures
- assure absence of drug prior to use of thrombolytic therapy
(Not for compliance, possible overanticoag in cases of hemorrhage, or under anticoag in cases of treatment failure)
what is the therapeutic range for chromogenic facotor X (CHRF 10)
INR of 2-3.5
CFX 35%-25%
what is peak value and trough value of Dabigatran ASSY (DABIGL or dilute thrombin time)
peak: 64-443ng/ml
trough: 31 -225ng/ml
when would you use TTPAT (thrombin time to dectect direct thrombin inhibtors and DOXAS (direct Xa inhibitor scree) to detect presence of absence of direct Xa inhibitors>
assure absence of drugs prior to invasive procedures
assure absence of drugs prior to use of thrombolytic therapy
what are the therapeutic ranges for DTIs -argatroban and bivalirudin: (using the aPTT)
argatroban: 60-100 seconds
bivalirudin: 60-90 seconds
what are the PEAK and TROUGH values for Rivaroxaban using the RIVAR1 assay ( to measure anti-Xa levels)
both given 20mg daily
AFIB vs VTE
AFIB
Peak: 160-360
Trough: 4-96
VTE:
peak: 175-360
trough: 19-60
Rapid INR (at home point of care testing is not recommended for why type of patients?
- initiating warfarin and have not reached steady state
- variable responses to warfarin
- INR goal greater than 3.5
- LVAD
- HD pts
- cardioversion/ablation pts (weekly INR)
- pts with acute or chronic inflammatory conditions
- advance malignancy
- exposed to DTI in the last 24 horus or heparin in 48 hours or XA inhibitors in the past 5 days
- Non-compliant pts
what test would you want to preform in order to detect a hemorrhagic event?
CT/MRI/MRA
Glasgow coma score (only give reversal if score is greater than 7)
Age
Origin of hemorrhage
labs (antiXa, PT/INR, TT, CBC, aPTT, fibrinogen)
what are the immediate actions to take to stop bleeding?
compression of arterial bleeding
tamponade of nasal cavity
insertion of Sengstaken-Blakemore tube for esophageal variceal bleeding if urgent endoscopy is not available.
what can you do to counteract blood loss?
oxygen, IV fluids, blood transfusion
when do you administer tranexamic acid?
only for trauma related bleeding (ONLY pts that are not anticoagulated) dont use for hematuria cause it can cause clots
In patients with intracerbral hematoma(hemorrrage) when can you restart
Heparin/LMHW?
VKA?
Heparin/LMWH: 2-4 days after bleeding
after 10-14 days you can restart VKA
what are the 3 non-pharmacological methods for the prevention and treatment of thromboembolism (MOST to LEAST)
MOST; inferior vena cava filters
intermittent pneumatic compression (IPC)
graduated compression stockings
what are the risk factors for anticaog induced bleeding
older age female sex hx of bleeding peptic ulcer active cancer HTN Prior stroke renal insufficency alchol abuse liver disease
what are the risk factors for the development of thromboembolism?
age > 40 obesity hx of VTE cancer bed rest > 5 days major surgery CHF Varicose veins Fracture (hip/leg) estrogen treatment stroke multiple trauma childbrith MI
