Anticoagulant Acute Injectable Flashcards by Eresi Obewu

What is the virchow’s triad

Vascular wall injury

Venous stasis

Hypercoaguability

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What can cause vascular wall injury

Surgery

Trauma

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What compromises of venous stasis

Vericose veins

Immobility

Travel (Serena williams)

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What can cause hypercoaguability

Thrombophilia

Pregnancy

Cancer

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What complications can arise from DVT

Pulmonary embolism

Postphlebitic syndrome

Loss of limb

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DVT that occurs above the knee is called

Proximal

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DVT that occurs below the knee is called

Distal

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What are the complications of pulmonary embolism

Hypertension

Death

Shock

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Which form of pulmonary embolism is serious

Saddle embolism

Lobar embolism

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What veins are VTE most likely to occur

illiac

Popliteal

Subclavian

Superior and inferior vena cava

Femoral

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What are the risk factors for VTE

Age

History of VTE (strongest risk factor)

Venous stasis

Vascular wall injury

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Some patient are prone to clotting (thrombophilia) what is the hereditary basis for this pathology

Protein C deficiency

Protein S deficiency

Antithrombin III deficiency

Factor V Leiden: protein C resistance

Prothrombin gene mutation

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Some patient are prone to clotting (thrombophilia) what is the acquired basis for this pathology

Antiphospholipid antibody syndrome

                    - Lupus anticoagulant
                     - Beta 2 glycolprotein antibodies
                      - Anticardiolipin antibody

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What are the clinical signs of DVT

Unilateral pain and tenderness

Palpable cord ( thrombus )

Unilateral swelling and discoloration

Positive homan’s sign

Often silent

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What is a positive homan’s sign

Pain upon dorsiflexion of the foot

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What two imaging tool allow for DVI diagnosis

Venography (gold standard)

Ultrasonography (good sensitivity and specificity for proximal DVT)

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Why is the D-dimer lab test done for DVT

To exclude diagnosis of DVT or PE

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What are the clinical signs and symptoms PE

Nonspecific

Sudden onset:
Cough

Tachycardia

Dyspnea

Pleuritic chest pain

Tachypnea

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What are the more serious signs of PE

Hemoptysis

Cardiovascular collapse

Acute right heart failure

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What imaging tool are used for PE diagnosis

Pulmonary angiography (gold standard)

CT pulmonary angiography (high sensitivity and specificity)

V/Q scan (radioactive albumin)

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What are the goals of VTE

reduce recurrence
prevent post thrombotic syndrome
reduce thrombus extension
prevent PE development
decrease mortality

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Which patient population are at risk of developing VTE

Hospitalized

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What are the non-pharmacologic intervention

Early ambulation

Graded compression socks

Intermittent pneumatic compression

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What are the pharmacology interventions for VTE

Heparin

LMWH

Factor Xa inhibitors

Oral DTI

Warfarin

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What are the two LMWH used in prophylaxis of VTE

Enoxaparin Daltepairin

How is enoxaparin dosed prophylaxis

30 mg SC every 12 hours initiated 12 hours - 24 hours after surgery -Hip and knee replacement 40 mg SC every 24 hours: - Acute medical illness - Initiated 12 hours before hip replacement surgery Or -Initiated 2 hours before abdominal surgery

What is the post operative dose of dalteparin giving prophiylatically before hip replacement surgery

2500 units SC 4-8 hours after surgery followed by 5000 units SC every 24 hours

How is dalteparin dose prophylactically the evening before a hip replacement surgery

5000 units SC 10-14 hours before 2500 units 4-8hours after followed by 5000 units every 24 hours

How is dalteparin dose prophylactically the day of a hip replacement surgery

2500 units SC 2 hours prior to surgery 2500 units 4-8 hours after surgery followed by 5000 units every 24 hours

How is fondaparinux dosed prophylatically for total hip and knee replacement and hip fracture surgery

2.5mg SQ every 24 hours

How is Apixaban dosed prophylatically for total hip and knee replacement

2.5 mg twice daily

How is dabigatran dosed prophylatically for total hip and knee replacement

110-220mg initially followed by 220mg daily

How is rivaroxaban dosed prophylatically for total hip and knee replacement

10mg daily

How is unfractionated heparin dosed prophylatically for total hip and knee replacement and hip fracture surgery

5000 units SQ every 8 - 12 hours

How is warfarin dosed prophylatically for total hip and knee replacement and hip fracture surgery

Dose adjusted

How is aspirin dosed prophylatically for total hip and knee replacement and hip fracture surgery

Low dose

True or false: anticoagulant therapy is used both inpatient and outpatient

True

When is anticoagulant therapy considered safe for outpatient treatment

- patient is hemodynamically stable - no comorbidity that would cause hospitalization - no recent trauma or surgery - no current hemodialysis or active bleeding

When is heparin alternatives to VTE treatment considered

Allergy or HIT

Patient with high mortality risk are not first treated with anticoagulant, when is a patient considered high mortality risk

Hemodynamics instability ( SBP < 90 mmHg or vasopressor use) sPESI ≥1: 80 yrs, cancer, chronic pulmonary disease, pulse ≥ 110, SBP < 100, oxygen < 90% Right ventricular dysfunction Elevated cardiac troponins

What therapy is used in high mortality risk patient or rescue for hemodynamic deterioration despite anticoagulants

Thrombolytic agents: Alteplase or streptokinase Or Thrombectomy(Surgery) (Surgery)

What medications falls under the antithrombotic class indirect thrombin inhibitor

Unfractionated Heparin or LMWH

What medication make up LMWH

Enoxaparin Dalteparin Tinzaparin

What medications of antithrombotic agent falls under the class Factor Xa Inhibitor

Fondaparinux Apixaban Endoxaban Rivaroxaban Betrixaban

What medications of antithrombotic agent falls under the class direct thrombin inhibitor

Argatroban Bivalirudin Desirudin Dabigatran

What medications of antithrombotic agent falls under the class vitamin K antagonist

Warfarin

Which antithrombotic are considered DOACs

Betrixaban Edoxaban Apixaban Rivaroxaban Dabigatran

In the treatment of VTE with heparin,fondaparinux or LMWH when should a switch be done to dabigatran or Edoxaban

After the first 5 days switch to: Dabigatran 150 mg PO twice daily through maintenance and prevention Or Edoxaban 60 mg PO daily through maintenance and prevention

In the treatment of VTE with heparin,fondaparinux or LMWH when should an overlap with warfarin be done

After 5 days and INR > 2.0 and dose adjust to INR target of 2.5 through maintenance and prevention

In VTE treatment how is Apixaban dosed

First 7 days: 10 mg twice daily Day8-prevention: 5 mg twice daily After the first 6 months: 2.5 mg twice daily

In VTE treatment how is rivaroxaban dosed

First 21 days: 15 mg twice daily Day 22 till prevention: 20 mg daily After the first 6 months; 10 mg daily

What is the target INR for warfare dosing

2.0-3.0

When patient has transient risk factor (stasis): immobility, surgery or estrogen use, how long should duration of therapy be

3 months

When patient has unprovoked DVT or PE (i.e no underlying cause) how long should duration of therapy be

3 months to long term

For patients with DVT or PE and cancer after the first 3-6 months initial treatment, how long should treatment be extended

Indefinitely or after cancer resolves

For patients with recurrent VTE or continuous risk factor such as thrombophilias, how long should therapy last

Extended

What therapy is preferred when term is considered

DOACs

What is the basis for heparin dosing during the acute phase treatment

Weight

What is heparin loading dose during acute phase treatment

70-100 units/kg

What is heparin maintenance infusion rate during acute phase treatment

15-25 units/kg/hr

How's heparin dose adjusted

Based on aPTT

How is infusion rate adjusted for heparin

Use Nomogram

For acute phase treatment how is enoxaparin dosed

1 mg /kg SQ every 12 hrs or 1.5 mg/kg SQ every 24 hrs

For acute phase treatment how is dalteparin dosed

200 IU/kg SQ every 24 hours

What is the basis for LMWH dosing and what if patient is obese

A) weight B) use actual body weight

When patient has renal insufficiency (CrCl <30 ml/min) what is the preferred treatment

Heparin over LMWH

How is unfractionated heparin and LMWH dosed prophylaxis

UH: lower doses SQ BID or TID LMWH: lower doses SQ daily or BID

How is heparin monitored

Measure aPTT 6 hours after initiation and after any dose adjustment

How is LMWH monitored

Not routinely done

For pregnant patient what therapy is preferred

LMWH over heparin

How is hemorrhage managed for patient on heparin or LMWH

Use protamine to reverse hemorrhage

How's protamine dosed

1 mg for every 100 units of heparin 1 mg for 60% LMWH

When is a patient on heparin experiencing HIT

Platelet <100,000 or drop by >30 -50% If its 5-10 days of heparin therapy Thrombosis is present No other explanation for low platelet

How is HIT managed

Discontinue Heparin Consider switching to DTIs, fondaparinux or DOACs

For direct thrombin inhibitors, which should PTT be monitored

Argatroban

Which have long half life

Factor Xa inhibitors

Anticoagulant Acute Injectable Flashcards

(76 cards)