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Haem/Onc > Thrombosis, ASPHO > Flashcards

Thrombosis, ASPHO Flashcards

1
Q

3 parts of virchow’s triad?

A

endothelial injury
hypercoagulability
venous stasis
–> blood clot

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2
Q

what are the vit k dep factors?

A

2,7,9,10

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3
Q

bimodal distribution of clots..peaks?

A

<1 year (particularly <1 month) and during adolescenece 11-18

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4
Q

acquired rfs for thrombosis…top 3? give 8 others

A

top 3= central venous catheters, cancer, cardiac disease…renal disease, liver diseae, rheum disease like lupus, IBD, DM, obesity, surgery, trauma, immonbility, infection, estrogen, dehydration, antiphospholipid syndrome

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5
Q

what does fondaprinux target?

A

Xa

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6
Q

what does heparin target?

A

Xa, IIa= thrombin

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7
Q

3 times when you should eval for thrombophilia?

A
  • non CVL-related clot
  • recurrent clot
  • acquired RF in pts with strong family hx of VTE (first degree relative <40 yrs or multiple relatives)
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8
Q

what should you check for thrombophilia eval?

A 
AT def
Prot C def
Prot S def
Factor V Leiden mutation
prothrombin G20210A mutation
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9
Q

mild common thrombphilias?

A

Factor V Leiden, prothormbin gene mut

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10
Q

severe rare thrombophilias?

A

prot c def, prot s def, at def

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11
Q

explain fvl

A

factor 5 mutant becomes insensitive to activated protein c= a natural anticoagulant–> f5 becomes overly active…most common thrombophilia we see, 5% in white population

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12
Q

explain G2021A mutatio in prothrombin

A

–> increase in prothrombin levels

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13
Q

factor v ledin: what % don’t get a clot?

A

95% of hetero

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14
Q

FVL: increase risk of clot from baseline?

A

4x higher

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15
Q

FVL and obsetrics?

A

may play a role in some cases of unexplained recurrent late preg loss

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16
Q

FVL hetero have a ___ recurrence risk

A

LOW…shouldn’t alter decision-making re: duration of AC

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17
Q

PT mutation: increase risk of clot over baseline?

A

4x higher

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18
Q

PT mutaiton: risk of VTE recurrence is ___

A

low

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19
Q

what does protein s do?

A

helper protein for protein C

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20
Q

what’s the most common? prot c, prot s, or at def?

A

Prot c def>prot s def> AT def

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21
Q

high -very high risk of recurrence for pts with what thrombophilias?

A

prot c def
prot s def
at def

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22
Q

typical prot c levels?

A

70-150%…<55%= problem

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23
Q

typical prot s levels?

A

60-120%…<35%= problem

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24
Q

typical AT levels?

A

110-140%…<40-60%= problem

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25
Q

which disorders are associate with warfarin skin necrosis? (2)

A

prot c def and protein s def

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26
Q

which disorder is asscoaited with hep resistance?

A

AT def

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27
Q

of protein c def, protein s def, adn AT def, which is most likely asscoaited iwth arterial clot?

A

prot c def

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28
Q

of protein c def, protein s def, adn AT def, which is most associate with preg-related VTE?

A

AT def

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29
Q

of protein c def, protein s def, adn AT def, which is most associated with fetal loss?

A

prot c def

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30
Q

of protein c def, protein s def, adn AT def, whihc is most asscoiated with VERY high risk of clot recurrence?

A

AT def

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31
Q

when does AT reach normal level?

A

age 6-12 mos

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32
Q

when does prot c reach normal level?

A

late teens/early 20s

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33
Q

when does prot S reach adult level?

A

6-12 months

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34
Q

how does homozygous prot c/prot s def present?

A

purpura fulminans

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35
Q

manage purpura fulmianns how?

A
  • send off prot c and s!
  • aggressive FFP replacment at time of presentation
  • long term AC, prot C replacmenet (we can’t replace prot S)
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36
Q

consier antiphospholipid antibody syndrome when?

A
  • unprovoked VTE

- new VTE in patient with underlying autoimmune disease

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37
Q

def’in of AAS?

A

persistent presence of antiphospholipid abs or lupus AC for at least 12 weeks in context of an acute thrombotic event

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38
Q

lab eval for AAS?

A

LAC, anticardiolipin abs, anti-beta 2 glycoprotein

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39
Q

how do you manage AAS?

A

long term ac

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40
Q

LAC: dx how?

A

dilute Russell viper venom tire (dRVVT), activated PTT or StaClot test…LA are characterized by correction fo the prolonged clotting time when you add phospholipid to the patient sample but NOT when you add control palsma, confirming that the coagulation inhibitor is phospholipid-dependent

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41
Q

4 signs/sx of DVT

A

acute swelling
pain/tenderness
red/purple discoloration
warmth

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42
Q

4 acute signs/sx of catheter related clots?

A

extremity sewlling
extremity pain
discoloration
line malfucntion

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43
Q

chronic signs of catheter-related clot? (3)

A

catheter occlusion
prominent chest wall veins
recurrent bacteremia

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44
Q

triad for PE?

A

chest pain, SOB, hypoxia…but only seen in 20% of kids with PE….also can get fever, cough, hemoptysis, rapid/irreg pulse

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45
Q

4 signs/sx of cerebral sinovenous thrombosis?

A

h/a
sz
cranial nerve palsies
papilledema

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46
Q

RFs for CSVT? 5

A 
dehydration
lymphadenitis
ear infection--> mastoiditis
jugualr vein catheterization
neonatal age group
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47
Q

3 anatomic variants associated with unprovoked VTE?

A

May Thurner syndrome
Thoracic outlet syndrome
IVC atresia/anomalies

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48
Q

May Thurnder: increased risk of VTE where?

A

left sided iliofemoral clots

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49
Q

what is May Thurner?

A

narrowed left iliac vein due to compression from right iliac artery

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50
Q

most commonly see May Thurner in which pts?

A

females in the 2nd adn 3rd decade of life

51
Q

throacic outlet syndrome aka?

A

paget-schroetter syndrome

52
Q

Thoracic outlet syndrome associated with DVTs where?

A

axillary, subclavian

53
Q

TOS due to?

A

compression of veins by extra rib, muscle group

54
Q

TOS associated with?

A

repeititve activity: baseball, softball, swimming, volleyball

55
Q

TOS: management?

A

first rib resection

56
Q

5 tx options for VTE?

A 
UFH
LMWH
fondaparinux
parenteral direct thormbin inhibitors
vit k antagonists
direct oral anticoagnats
thrombolysis
57
Q

UFH: binds reversibly to ___; after binding, increases ___’s ability to inhibit ___ and ____…does it bind other palsma proteins?

A

AT; AT; thrombin; Factor Xa; yes

58
Q

UFH: chains of varying lengths: sizes?

A

5k-40k Da

59
Q

LMWH size chains?

A

<8k Da

60
Q

LMWH binds to and accelerates the activity of ____ but with a preferenctial and longer-lasting effect on ___

A

AT; Xa…less able to inhibit thombin and bind to other plasma proteins thn UFH!

61
Q

fondaparinux binds to enhances activity of ___ by ___-fold…does it bind to other plasma proteins? does it have direct effect on thrombin?

A

AT; 300; no; no

62
Q

explain the mech of UFH

A

binds to and increases AT inhbiition of Factor 10A and thrombin

63
Q

explain the mech of LMWH

A

binds to and increases AT inhibition of 10 a and thormbin, BUT with a preferential and longer-lasting effect on Xa

64
Q

explain teh mech of fondaparinux

A

binds to adn STRONGLY enhances actvity of AT, only inhibits 10A with NO DIRECT EFFECT on THROMBIN

65
Q

other activity of UFH?

A

binds non-specifically to a variteyt of other palsma protiens

66
Q

other activity of LMWH?

A

less able to bind other plasma proteins

67
Q

other activity of fondaparinux?

A

does not bind to tohter plasma proteins

68
Q

UFH: monitoring?

A

PTT, ACT, anti-Xa

69
Q

LMWH monitoring?

A

Anti-Xa

70
Q

fondaparinux monintroing?

A

anti-Xa that’s calibrated for fonda

71
Q

act stands for?

A

activated clotting time

72
Q

Adv of UFH?

A

good first choice for pt who is unstable or may need a procedure soon; short half life of 30 min; reversible with protamine

73
Q

disadv of UFH?

A

continuous infusion

74
Q

LMWH advs?

A

SC injection
easier to use in stable pt
more predictable pharmacokinetics
longer half life: 4-7 hrs

75
Q

disadv of LMWH?

A

requires good renal functon

incomplete reversal with protamine

76
Q

monitor UFH how often?

A

daily, and 4 hours after any dose changes

77
Q

PTT target in UFH?

A

65-80, or 1.5-2.5x baseline

78
Q

PTT sensitive to what?

A

improper collection, anemia, low plts, factor defs, LAC, pt age

79
Q

preferred way to monitor UFH?

A

anti-xa, has most consistnet results

80
Q

ACT: sensitive to?

A

plt counts and function, factor defs, ambient temp, hypothermia, LAC

81
Q

anti-10a target?

A

0.3-0.7

82
Q

anti-10a affected by?

A

hemolysis, high bili, high triglycerides

83
Q

LMWH: obtain anti-10a level how many hours after dose? goal range? goal range for ppx?

A

4-6 hours

  1. 5-1
  2. 1-0.3
84
Q

infant <3 months need ___ doses of heparin and more ___ ___ due to a ___ ___ __ ____

A

higher; frequent monitoring; larger volume of distribution

85
Q

heparin affects what when drawing sample from central cath? (2)

A

thrombin time, PTT…you could do a PTT HEPARINASE to see if that PTT prolongation was due to heparin

86
Q

RFs for HIT?

A

PICU, NICU, heart surgery…has been receiving heparin for several days

87
Q

what causes HIT?

A

due to formation of auto-antibodies against endogenous platelet factor 4…development of auto-ab takes about 5 days

88
Q

do what if suspect HIT?

A

stop heparin! start direct thrombin inhibitor…test for HIT Ab (ELISA) and confirm with functional assay= serotonin release…AVOID plt transfusions unless severe hemorrahge

89
Q

give 2 direct thrombin inhibitors. do they have reversal agents?

A

argatroban, bivalirudin…no

90
Q

argatroban and bival: bind thrombin reversibly or no?

A

arg: reversible; bival: partially reversible

91
Q

half life of argatroban?

A

45 min

92
Q

bival half life?

A

25 min

93
Q

elimination argatroban?

A

hepatic

94
Q

bival elim?

A

renal

95
Q

monitor bival how?

A

aPTT, ACT

96
Q

argatroban: monitor how?

A

aPTT, ACT

97
Q

antidote for bival and argatroban?

A

none

98
Q

mech of warfarin?

A

inhibitors hte synth of vit k dependent clotting factors= 2, 7, 9, 10…..will also inhibit prot c and s because also vit k dependent–> actually leads to HYPERCOAGULABLE state at first because protein c and s decrease FIRST! this is why you need bridging

99
Q

warfarin must be given with another AC for at lesat __ days until a therpeutic inr is reached

A

5

100
Q

typical dose of warfarin?

A

0.1 mg/kg/day

101
Q

what is INR?

A

ratio fo the patient’s pt= prothrobin time and the rnomal mean PT

102
Q

what can interact with warfarin? 8

A

antibiotics, gastroenteritis, anticonvulsants, anti-fungals, antacids, febrile illness, liver disease, vit k containing foods, infant formulas (have lots of vit k), mango, avocado, fish oil, soy milk, grapefruit

103
Q

how to reverse warfarin?

A

vit k, FFP, PCC= prothormbin complex concentrate

104
Q

adv of direct oral anticoag?

A

less bleeding than warfarin with similar efficacy

105
Q

Xa inhibiting doacs to know?

A

apixaban, rivaroxaban

106
Q

direct thrombin inhibitor?

A

dabigatran

107
Q

which doac has phase 3 in kids?

A

rivaroxaban…liquid not yet available

108
Q

give half lives of dabigatran, rivaroxaba, apixaban

A

dab: 11-14 hours (BID)
riva: 5-9 hours (QD)
apix: 9-14 (BID)

109
Q

clearance of dabigatran?

A

renal

110
Q

clearance of riva?

A

renal

111
Q

clearance of apix?

A

mainly liver

112
Q

provoked VTE: tx for how long?

A

if RF is reversbile, 3 months (6 weeks in neonataes)…if RF is chronic: 12 mos to lifelong

113
Q

idiopathic VTE tx for how long?

A

6-12 mos

114
Q

recurrent VTE tx for how long?

A

reversible RF: 6-12 mos

chronic RF: 12 mos- lifelong

115
Q

4 reasons for thrombolysis?

A

life threatening art thormb
intracardiac thrombus
PE with right heart strain or hypotension
extensive DVT (SVC syndrome, occlusive IVC thrombosis with renal compromise, large iliofemoral clot)

116
Q

when NOT to do thrombolysis?

A
  • active major bleeding
  • significant potential for uncontrolled local bleeding
  • surgery within preceding 10 days (neurosurgery 60 days)
  • neurosurgery
  • intracranial neoplasm/cerebral vascular lesion
  • seizures within 48 hours
  • sepsis
  • uncontrolled severe htn
  • contrast allergy
117
Q

ways to give tPA?

A

catheter-driected
low-dose systemic 24-96 hours
high-dose systemic 6 hours

118
Q

laboratory monitoring and goals in thrombolysis?

A
  • fibirnogen: 100-200 (hsould decrease by 20-50%)
  • d-dimer (elevatd)
  • PTT (50-70), becuase give UFH at same time usually
  • hgb stable
  • plts >100k…think of thrombolysis= just like DIC!
119
Q

post-thrombotic syndrome causes? 2

A

residual venous outflow, venous valvular insufficiency

120
Q

RFs for PTS? (5)

A 
adolescents
obesity
extesnive DVT (multiple vessels)
idiopathic or efffort-related upper extrem DVT
lack fo DVT resolution
121
Q

PTS incidence?

A

25% in thsoe with extremity DVT

122
Q

symptoms/signs of PTS?

A

pain, paresthesia, dialted vessels, swelling….also decreased QoL if mod-severe

123
Q

how to prevent PTS?

A
  • consider thromboprophylaxis is those with prolong hospitalization/immobilization/prescence of CVL/infection/chronic inflamm/prothromb chronic disease
  • timely dx and initiation of therapy for VTE
124
Q

4 ways to manage PTS?

A
  • elastic compression stockings
  • phys therpay
  • elevating the affected extrem at rest
  • mantaining a healthy wt

Haem/Onc (30 decks)

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