Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
173 Cards in this Set
- Front
- Back
|
What are the 5 steps of hemostatis
|
Vascular constriction
Formation of Platlet Plug Activation of Clotting cascade Formation of clot Clot dissultion |
|
|
What are the 3 phases of cell-based thrombosis
|
1. Iniation phase
2. Amplication phase 3. Propgation phase |
|
|
Examples of Vichow's Triad---Best rest
|
venous statis
|
|
|
Estrogen therpay
|
hypercoagulability
|
|
|
All types of surgery
|
vascular damage, hypercoagubility, venous statis
|
|
|
Inflammatory bowel disease
|
vascular damage, hypercoagablity
|
|
|
HF
|
venous stais, hypercoagulibty
|
|
|
Factor 5 Ledien
|
hypercoagability
|
|
|
Malihancy
|
hypercoag, statis
|
|
|
Obesity
|
Statis
|
|
|
Chemotherapy
|
vascular damage
|
|
|
Antithrombin deficiency
|
hypercoaglablity
|
|
|
Long distance travel
|
statis
|
|
|
What is route of administration for UFH
|
IV, or sub-q, IM-run risk of hematoma
|
|
|
When is onset of UFH
|
IV--immediaite
SC 1 hr |
|
|
Half-life of UFH
|
1 hr--but dose dependent
|
|
|
Adverse effect of UFH
|
BOOAT--bleeding, osteoporosis, occasial hyperkalemia, allergic reactions, and thrombocytopenia
|
|
|
What is the STANDARD of care for DOSING UFH
|
weight based nonograms, and rapdi theraptuetic antigoad in the 1st 24hrs is effective in decreasing recurrence
|
|
|
What are indications for UFH
|
DVT Prophylaxis
DVT/PE ACS Acute MI w/ thrombolysis |
|
|
What is dose of DVT prophylaxis
|
5000 U SQ q8hrs
|
|
|
What is 2 routes of administration for DVT/PE
|
IV
Sub-Q |
|
|
What is dose for DVT/PE IV (monitored)
|
Bolus 80units/kg
Continous infusion of 18units/kg/hr |
|
|
What is dose for sub-q DVT/PE (unmonitored)
|
Inital 333 units/kg
Then 250 units/kg BID |
|
|
What is ACS and aterial thromboembolism
|
Actue contary syndrome, and atrial fibraillation, and mechanical valve
|
|
|
What is dosing of ACS sand atrial fibraillation IV
|
Bolus: 60-70 units/kg
Continous: 12-15 units/kg/hr |
|
|
What is dosing of Acute MI with thombolytics
|
BolusL 60 units/kg
Continous 12 units/kg/hr |
|
|
Dose adjustment of heparin should be
|
weight based
|
|
|
What is monitoring of UFH
|
aPPT
|
|
|
Why does the aPPT time vary from one institution to another
|
different reagents, and different labs and personnel
|
|
|
The therapetuci range is often defined as 1.5-2.5 x control value, but
|
THIS is NOT a good way to describe
|
|
|
Each LAB should establish an aPPT rang that corresponds to a UFH plasma conc of
|
0.2-0.4 units/ml for protamine, and 0.3-0.7 for anti-factor Xa
|
|
|
What is only time do you NOT monitor aPPT for UFH
|
VTE prophylaxis
|
|
|
What reverses haprin effect, and ratio
|
protamine 100units to 1 mg protamine
|
|
|
For patietns with IV, give 1mg of protamine for every 100 units of UFH given in
|
last 3 hours
|
|
|
Two main benefits of LMWH
|
1. increase bioavailbility
2. longer half-life |
|
|
What is route of administration of LMWH (in general)
|
Sub-q, can be given as a bolus
|
|
|
What is onset of LMWH
|
3-5 hours
|
|
|
What is half-life of LMWH
|
2-4x longer than UFH
|
|
|
What are adverse effects of LMWH
|
bleeding, thrombocytopenia (less than UFH)
|
|
|
What are indications of LMWH--
|
same as UFH
Prophylaxis for DVT DVT/PE ACS/ atrial fib, mechical value Acute MI with thrombylotic |
|
|
What are prophylaxis dose of enoxaparin
|
30mg SQ BID
or 40mg SQ once daily |
|
|
WHat is treatment dose of enoxaparin
|
1mg/kg BID or 1.5 mg/kg QD
|
|
|
What is PCI treatment of Enoxaparin
|
PCI – on current therapy
0.3 mg/kg IV bolus if last dose > 8 hours ago |
|
|
What is dose of enoxaprin of PCI if no previous therapy
|
0.75 mg/kg IV bolus if no previous therapy
|
|
|
What is prophylaxis of Dalteparin
|
2500-5000 units SQ QD
|
|
|
What is treatment of Dalteparin
|
100 units/kg SQ twice daily or 200 units/kg SQ once daily
|
|
|
What is prophylasic of Tinzaparin
|
3500-4500 units SQ qd
|
|
|
What is treatmetn of Tinzaparin
|
175 units/kg QD
|
|
|
What is only LMWH you can dose adjust for renal dysfuciton
|
enoxaprin
|
|
|
When do you dose adjust for renal failure in enoxaprin
|
<30ml/min with URINE OUTPUT
|
|
|
WHat is prophylaxis dose for enoxaprin in renal dysfuction, and treamtnet dose
|
pro--30mg qd
treatment 1.0mg/kg qd |
|
|
What is monitoring for LMWH
|
generally not needed
|
|
|
What can be monitored in LMWH in special popualtion
|
anti-Xa levels
|
|
|
Anti-Xa levels are monitored in what special popuations for LMWH
|
Body weight extereme
Renal dysfuction w/ prolong adminisration, change in Vd (preg) |
|
|
LMWH are adjusted for body size <50kg (increase risk of bleeding, >150kg or BMI >40 enoxaparin prophylaxis is increased to
|
40mg BID
|
|
|
What is Goal peak levels of anti-Xa BID dosing for
|
0.5-1.0 units
|
|
|
What is Goal peak levels of anti-Xa for qd dosing
|
1.0-1.2 units/ml
|
|
|
Reversal of LMWH is not as effective as heparin, but what can be ratio
|
1mg protamine, 1 mg enaxaprin
|
|
|
What are synthetic Pentassacharides
|
fondaparinux
|
|
|
Fondaparinux only inhibits
|
Xa
|
|
|
What is Route of administration of fondaparinux
|
sub-q
|
|
|
What is onset of Fondaparinux (synthetic pentasaccharide
|
3-4 hours
|
|
|
What is half-life of fondaparinux
|
17-21 hours---much longer
|
|
|
benfit of fonaparinux 17-21 half-life
|
once daily dosing
|
|
|
Fondaparinux is contraindicated in
|
<30ml/min renal dysfuction
|
|
|
What is prophylaxis treatment of fondaparinux
|
2.5 mg qd
|
|
|
What is treamtnet of ACS for fonaparinux
|
2.5 mg qd
|
|
|
What is treatment of VTE for fondaparinux
|
Treatment ACS : 2.5 mg QD
Treatment VTE: 5 mg (< 50 kg), 7.5 mg (50-100 mg), 10 mg (> 100 kg) |
|
|
Monitoring for fondaparinux
|
not needed
|
|
|
Can you reverse fondaparinux
|
NO reversal agent--supportive care
|
|
|
What are 3 direct thrombin inhbitiors
|
Lepitrudin
Argatroban Bivalirudin |
|
|
What is type of products of Lepirudin, Argatroban, and Bivalirudin
|
lepirudin-recombinant
agatroban/bivalirudn-synthetic |
|
|
What Direct thormbin inhbitor is irrversible
|
lepirudin--increased risk of bleeding, and recombinant allergic reaction is possible
|
|
|
What is route of adminstiration of Direct thrombin inhibitors
|
IV
|
|
|
What is clearnace of Lepirudin, Argatroban, Bivalirudin
|
Lepirudin--renal
Argatroban-Hepatic Bivalirudin-proteolyic cleavage--good for pts with both heaptic and renal dysfuction |
|
|
What is indictions of Lepirudin, Argatroban, and Bivalirudin
|
Lepirudin/Argatroban--HIT
Bivalirudin--ACS/PCI |
|
|
What Direct thrombin inhibtior has shorterst half-life
|
bivalirudin
|
|
|
What is Direct thrombin inhibtior that may form anti-bodies
|
lepirudin
|
|
|
CrCL <60 mg/min should avoid
|
Lepirudin
|
|
|
What is typical dosing for Argatorban, and dosing for critcally ill
|
Argatroban
Typical dose 2 ug/kg/min Critically ill – 1.0 ug/kg/min |
|
|
Special dosing for Lepirudin in critically ill pts
|
omit bolus
|
|
|
What is Dosing of Bivaliruin in ACS
|
ACS – 0.1 mg/kg bolus, 0.25 mg/kg/hr infusion
|
|
|
What is dosing of Bivalirudin in PCI
|
PCI – 0.75 mg/kg bolus, 1.75 mg/kg/hr infusion
|
|
|
What is monitoring required for DTI
|
aPPT
|
|
|
How do you calculate goal aPPT for Lepirudin
|
1.5-2.5x the pts control value is goal range
|
|
|
What is goal aPPT values in Argatroban/Bivalirudin
|
1.5-3.0 the pts control values (baseline)
|
|
|
Can you reverse the effects of Direct Thrombin inhibtiors--is it a problem
|
no reversal agent--but short-acting--supportive care only short time
|
|
|
What are only 2 meds that monitor aPPT
|
DTI, and Heparin
|
|
|
Warfarin is the only oral anti-coagulant what is MOA
|
inhibits the snythesis of NEW clotting factors
|
|
|
Does wararin do anything to exisiting clotting factors
|
NO
|
|
|
Wafarins onset of action depends on
|
the half-life of the clotting factors
|
|
|
What is warfarins peak activity
|
48 hrs, has long duration of action
|
|
|
What is warfarins absoprtion
|
rapid and complete
|
|
|
What is warfarins distribution
|
highly protein bound--can lead to displacment
|
|
|
WHat is warfarins metabolism
|
by liver cyp2c9 and cyp3A4
|
|
|
What is warfarins excretion
|
as inactive metabolites in urine
|
|
|
What are indications of warfarin
|
HAMS EAT
Heart values Acute MI STroke Elective cariovesion Atrial Fib Treat/prevent of VTE |
|
|
what is monitoring of warfarin
|
INR
|
|
|
What is target INR for all indications expect one
|
2.5 (2-3)
|
|
|
What indication has a different INR goal
|
presthetic mechanical heart value other than aortic position
|
|
|
What is prostehtic Mechical heart value (i.e mitral)
|
3.0 (2.5-3.5)
|
|
|
What are 5 main things that lead to varied warfarin response
|
FAG DD
Foods Alcohol Genetics Disease states Drug |
|
|
How do you conseul pts in regards to food
|
don't tell them to AVOID vit K dependent foods, rather eat them consistently
|
|
|
What is main disease state that affects warfarin
|
liver
|
|
|
What are effects of binge drinking, vs consistent intake of alcohol
|
1. binge drinking increases INR
2. consistent have lower INR |
|
|
55% of variance in warfarin can be explained by (*2*3 alleges
|
VKORC1
CYP2C9 Age, hegiht, body weight, interacting medication *2*3--have lowest enzymatic activity (need lowest dose of warfarin |
|
|
Should a loading dose be used to start warfarin
|
NEVER
|
|
|
What are 3 ways to iniate warfarin
|
Nomogram
Flexible iniation (should use) Utilizaiton of gentic info |
|
|
What is standard maintence dose of warfarin
|
5mg
|
|
|
When should individuals start at 2.5 mg
|
HIM LS
>60, HF, Inhibiting medication, malnoushied, liver disease , surgery |
|
|
Young healthy patients reasonable to start at higher doses
|
7.5-10
|
|
|
Must we counsel our pts that some bruising and bleeding may occur
|
unsafe in urine/feces or does not stop
|
|
|
Wafarin has a long half-life so we should make a change in dosing based on
|
the weekly dose
|
|
|
What is the max % change in the weekly dose
|
10-20%
|
|
|
When is most of the effect of warfarin seen
|
after 7 days of therapy
|
|
|
When is the maximal effect of warfarin seen
|
after 14 days
|
|
|
Why can't you increase a pts dose from 5mg qd to 7.5 mg qd
|
greater than 10-20 change in the weekly dose
|
|
|
What 3 options to reverse warfarins anticoagulation effect
|
DC or hold dose
Vit K FFP (fresh frozen plasma) |
|
|
What are 2 ways the Vit can be given
|
only ORAL and IV
|
|
|
Why dont you give Vit K SC
|
erratic, unpredictable
|
|
|
If someone is on chronic therapy of warfarin--why should you not given an excessive Vit K dose
|
Vit K is a fat solbule vit, can create a reseve,
|
|
|
Minor/no signifigant bleeding and an INR <5 how do you manage
|
lower or omit the dose, and monitor more frequently
|
|
|
How do you treat an INR 5-8
|
Omit dose and give Vit K if as risk for blleeing, and check INR In 24hrs
|
|
|
What happens if INR is still high 24hrs after giving 2.5-5mg of Vit K
|
give additiona vitamin K 1-2mg orally
|
|
|
How do you treat an >9 or equal to
|
HOld dose give Vit K 5-10mg rehcheck in 24hrs
|
|
|
The reversal of oral Vit K occurs
|
within 24hrs
|
|
|
The reversel of IV Vitk occurs wihtin
|
6 hours
|
|
|
Whenever ther is Serious bleeding on warfarin how do you treat
|
Hold dose, and give vitk 5-10mg IV by slow infusion
|
|
|
When do you use Fresh Frozen plasam or prothrombin complexes
|
for life threatineing blleds
|
|
|
When can vitamin K be administration be repeated
|
q 12hrs
|
|
|
Oral Vitamin K is ALWAYS the preferred route b/c
|
IV can cause hypersensitive reactions or anaphylaxis
|
|
|
What is the fastest you may infuse vit K
|
Do NOT exceeds 1mg/min
|
|
|
How long does the Vit K infusion typically last
|
30-60minutes
|
|
|
If you administer high doses of Vit K, can it lead to a breify period of warfarin resistance
|
YES
|
|
|
Platlet adhesion to collagen, thrombin, Epi, ADP and TXA all lead to
|
platelt activation though GP IIb/IIIa activtion--leading to platlet aggretion and thrombus formation
|
|
|
What are main indications for Oral antiplatelet agents
|
limited to ATERIAL thromelbic disorders
|
|
|
What are aterial thromboembolic disorders
|
arterial clots, ACS, stroke CAD, Peripheral VASCULAR disease
|
|
|
What is ASA MOA
|
irreversible inhibition of COX enzyme preventin TXA formation
|
|
|
What is actue dosing of ASA
|
160-325mg qd
|
|
|
What is chronic dosing of ASA
|
81-325mg qd
|
|
|
What is dosing of ASA for AVD prevnetion
|
81mg qd
|
|
|
ASA doing for PCI plus BMS
|
325mg x1month, then 81 qd
|
|
|
ASA dosing for PCI plus DES
|
325 for 3-6 months then 81 mg a day
|
|
|
Dose an increase dose of ASA lead to increasing efficacy
|
NO--rather increased risk of bleeding
|
|
|
MOA of Clopidogrel
|
Inhibits APD activation of platelts
|
|
|
What is Acute dosing of Clopidogrel
|
300-600mg loading dosing
|
|
|
What is chornic dosing of Clopidogrel
|
75mg qd
|
|
|
What is dosing of Clopidogrel for PCI plus BMS
|
75mg x 1 month
|
|
|
What is dosing of Clopidogrel for PCI plus DES
|
75mg x 1 year
|
|
|
What is primary choice for pts intolerant to ASA
|
Clopidogrel
|
|
|
What is MOA of Dipyraimole
|
inhibtion fo Phosphodiesterase leading to increase cAMP, and platelt inhibitions (may also result in vasodialtion
|
|
|
What is Chronic dosing for Dipyradimole
|
200mg qd
|
|
|
What are limited indications of dipradimole
|
stroke, and poorly tolerated with primary adverse effects of HA and Fluch
|
|
|
What are INDICATIONS for IV Antiplatelt agents
|
limited to ACUTE aterial clots--ACS, PCI
|
|
|
What are is most potent Antiplatlet agents
|
Glycoprotein IIb/IIIa antagonsts
|
|
|
Glycoprotein IIb/IIIa antaoginsts lead to
|
blockage of final common pathway in platelt aggregation and formation of a stable clot
|
|
|
What are Glycoprotein IIb/IIIa anatagoinsts
|
Abciximanb, eptifbatide, and tirofiban
|
|
|
What are the recombinatns/synthetic GP IIb/IIIa inhibitors
|
abciximac-recombinant
eptifabtide and tirofiban are synthetic |
|
|
Which Glycoprotein IIb/IIIa antagoinst is irrversile binding (non-competivie)
|
abciximab
|
|
|
What Glycoprotein IIb/IIa inhbitios are cleared renally
|
eptifabtide, and tirofiban
|
|
|
What is elmination of Abciximab
|
unbound drug rapdily cleared from plasma by proteloyic breakdown
|
|
|
What Duration of action for abciximab
|
12-24 hrs
|
|
|
What is Duration of action for eptifibatide, and tirofiban
|
4-6 hours
|
|
|
What is monitoring for Glycoprotein IIb/IIIa inhibitiors
|
thrombocytopenia
|
|
|
What are Fibinolytic agents used
|
tPA, TNK and Reteplase
|
|
|
What are indications of Fibrinolytic agents
|
ACS, Acute Ischemic stroke, Acute PE/DVT, and Cathether clearance
|
|
|
What agent is most selvetive for fibrin
|
TNK
|
|
|
What agent has the short half life in minutes
|
Tpa 4-8 minutes
|
|
|
TPA and TNK and Reteplase are all indicated for
|
ACS
|
|
|
What is only agent indicated for stroke
|
TPA
|
|
|
What is risk of bleeding for fibrinolytic agents
|
EXTREMLY HIGH risk of bleeding---1 in 100 experiecne intracrainal bleeding
|
|
|
Is there inclusion and exclusion criteia that must be met in order to administer an fibrinolytic agent
|
YES
|
|
|
Fibrinolytic agents activate plasmin which dissolves clots, what else is need when having these agents
|
need adjunt threapy to PREVENT clot formation
|
