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73 Cards in this Set

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Heparin: How Available?
injection various concentrations
Heparin: Description
functional class - anticoagulant
Heparin: Mechanism of Action
prevents conversion of fibrinogen to fibrin and prothrombin to
thrombin by enhancing inhibitory effects of antithrombin III -
HAS NO EFFECT ON EXISTING CLOTS ONLY PREVENTS OR
SLOWS DOWN FORMATION OF NEW CLOTS
Heparin: Metabolism, distribution and
Excretion
not absorbed from GI tract, must be given parenterally
Heparin: Indications & Dosing
• DVT
• MI
• Pulmonary embolism
• Open heart surgery
• Catheter flush
Heparin: Adverse Effects
hemorrhage, prolonged clotting time, thrombocytopenia,
hypersensitivity reactions, anaphylactoid reactions
Heparin: Precautions &
Contraindications
contraindicated in patients with active bleeding, blood
dyscrasias, or bleeding tendencies, suspected cerebral
hemorrhage
Heparin: Drug Interactions
• oral anticoagulants and platelet inhibitors - increase
anticoagulant effects
• antihistamines, cardiac glycosides, nicotine - may
counteract anticoagulant effects
Heparin: Assessment
• assess for Hct/Hgb, blood in stools
• monitor PTT
• monitor platelet count
• assess for bleeding gums, petechiae, ecchymosis, black
tarry stools, hematuria
• monitor for hypersensitivity
Heparin: Implementation
• give IV loading dose followed by maintenance
• give subcutaneously
Heparin: Patient Education/Info
• advise patient against OTC products may contain
products such as aspirin increase risk of bleeding
• caution patient to use soft bristle toothbrush to preserve
gums, avoid IM injections, contact sports and use electric
razors
• advise patient to get MedicAlert bracelet
• advise patient to report any signs of bleeding - gums,
under skin, urine, stools, nose, or unusual bruising
Enoxaparin (Lovenox): Description
low molecular weight heparin
available in prefilled syringes
Enoxaparin (Lovenox): Mechanism of Action
accelerates formation of antithrombin III-thrombin complex and
deactivates thrombin, preventing conversion of fibrinogen to
fibrin. It has a higher anti-factor Xa to anti-factor IIa activity
that unfractionated heparin
Enoxaparin (Lovenox):Indications & Dosing
• prevention of DVT post hip, knee, or abdominal surgery
• systemic anticoagulation
• recurrent systemic embolism prevention
• Can be used for already formed clots
Enoxaparin (Lovenox):Adverse Effects
thrombocytopenia, hemorrhage, rash, hives, angioedema,
neurologic injury when used with spinal or epidural puncture
Enoxaparin (Lovenox):Precautions &
Contraindications
• contraindicated in patients with hypersensitivity to
heparin or pork products, thrombocytopenia, major
bleeding
• use cautiously in patients at increased risk of
hemorrhage – bacterial endocarditis, ulcer disease, GI
disease, hemorrhagic stroke, concurrent treatment with
NSAIDs
Enoxaparin (Lovenox):Drug Interactions
• other anticoagulants, antiplatelet agents, NSAIDs –
increased risk of bleeding
• valproic acid – cause hypoprotrombinemia and inhibit
platelet aggregation
Enoxaparin (Lovenox):Assessment
• monitor Hct/Hgb, occult blood in stools
• monitor platelets, possible thrombocytopenia
• assess patient for bleeding
• assess for neurosymptoms for patients that have
received spinal anesthesia
Enoxaparin (Lovenox):Implementation
• administer in abdomen subcutaneously
• give to recumbent patient and rotate sites
Enoxaparin (Lovenox):Patient Education/Info
• advise patient to report any signs of bleeding, bruising –
gums, nose, under skin, urine, and stools
• caution patient about OTC products – may contain
aspirin or other salicylates
• advise patient to use soft bristle toothbrush, electric
razor, avoid contact sports and IM injections
Enoxaparin (Lovenox) – advantages over heparin.
Has a more predictable anticoagulant effect
Low molecular weight heparins
Enoxparain (Lovenox)
Dalteparin (Fragmin)
Danaparoid (Orgaran)
Tinzaparin (Innohep)
Ardeparin (Normiflo)
Fondaparinux (Arixtra)
Protamine sulfate
Anticoagulation Antagonist – Heparin/Low molecular wt heparin
Protamine sulfate: Description
functional class - heparin antagonist
chemical class - low-molecular weight protein
Protamine sulfate: Mechanism of Action
binds heparin, making it ineffective
Protamine sulfate: Metabolism, distribution and
Excretion
forms a heparin-protamine complex
Protamine sulfate: Indications & Dosing
heparin overdose
Protamine sulfate: Adverse Effects
decrease in blood pressure, circulatory collapse, pulmonary
edema, acute pulmonary hypertension, anaphylaxis,
anaphylactoid reactions
Protamine sulfate: Drug Interactions
none significant
Protamine sulfate: Assessment
• monitor Hct/Hgb, platelets
• monitor APTT
• monitor vitals
• assess for skin rash, urticaria, dermatitis
• assess for fish allergy, use cautiously
Protamine sulfate: Implementation
• give by direct IV after dilution
• give by intermittent infusion
Protamine sulfate: Patient Education/Info
• explain reason for medication
• Advise patient to refrain from contact activities
Warfarin (Coumadin)
- anticoagulant
Warfarin (Coumadin): How Available
tablets, injectable
Warfarin (Coumadin): Description
coumarin derivative
Warfarin (Coumadin): Mechanism of Action
inhibits vitamin K dependent activation of clotting factors II, VII,
IX, X which are formed in the liver. It has no direct effect on
established thrombi and can’t reverse ischemic tissue
damage. It may prevent additional clot formations,
extension of formed clots and secondary complications of
thrombosis
Warfarin (Coumadin): Metabolism, distribution and Excretion
• absorption is complete and reaches a peak concentration
in 90 minutes
• half life 36-42 hours. Steady state may not be achieved
in elderly patient for up to 2 weeks
• metabolized by cyt-P-450 2C9, 3A4
• 99% bound to albumin
Warfarin (Coumadin): Indications & Dosing
• prevention pulmonary emboli
• prevention deep vein thrombosis
• MI
• Rheumatic heart disease w/ heart valve damage
• Atrial arrhythmias
Warfarin (Coumadin): Adverse Effects
• diarrhea
• rash
• fever
• hemorrhage
Warfarin (Coumadin): Precautions & Contraindications
contraindicated in pregnant women, patients with bleeding
tendencies, GI ulcerations, severe renal/hepatic disease
Warfarin (Coumadin): Drug Interactions
• amiodarone, cimetidine, metronidazole, sulfonamides –
increased anticoagulant effect
• erythromycin, salicylates, cefotetan, allopurinol, vitamin
E – increase anticoagulant effect
• alcohol – may increase or decrease INR - unpredictable
Warfarin (Coumadin): Assessment
• monitor blood tests – Hct/Hgb, PT/INR (NOT aPTT)
• assess for bleeding – gums, nose, black tarry stools,
petechiae
Warfarin (Coumadin): Assessment
• monitor blood tests – Hct/Hgb, PT/INR (NOT aPTT)
• assess for bleeding – gums, nose, black tarry stools,
petechiae
Warfarin (Coumadin): Implementation
may be given with IV heparin until warfarin is at steady state
Warfarin (Coumadin): Patient Education/Info
• advise pt to keep green leafy vegetable intake consistent
– asparagus, broccoli, cabbage, lettuce, turnip greens,
spinach, watercress, fish, beef/pork liver, green tea,
tomatoes.
• advise patient to avoid OTC products containing
salicylates  may increase risk of bleeding
• advise patient to use soft bristle toothbrush, avoid
contact sports, use electric razor, avoid IM injections
• advise patient to report signs of bleeding – gums, stool,
urine, under skin
Warfarin (Coumadin): How to Dose Warfarin:
must bridge therapy with either heparin 5000 U SQ BID or TID or
low molecular weight heparin Lovenox 30mg SQ BID for adequate anti-coagulation.
Warfarin (Coumadin): DOSING INCREMENTS (STEPS)–
10 mg
7.5mg
**** 5mg*****
4mg
3mg
2.5mg
2mg
1mg
Start off at 5mg step
Then you either decrease or increase steps based upon other factors in patient’s life at the
time.
Factors that increase INR response
Blood dyscrasias
Cancer
Collagen vascular disease
CHF
Diarrhea
Fever >102
Vitamin deficiency
Hepatic disease
Hyperthyroidism
Poor nuitrition
Steatorrhea
Factors that decrease INR
Hypothyroisism
Nephrotic syndrome
Hereditary syndrome
Antiphospholipid syndrome
Protein C deficiency
Protein S deficiency
Indication Goal INR
Orthopedic Surgery (hip & knee) 2-2.5
DVT, PE, Stroke, A fib, Porcine valve 2-3
Mechanical Heart Valve 2.5-3.5
Phytonadione (AquaMEPHYTON, Vitamin K)
Anticoagulant Antagonist for Coumadin
Phytonadione (AquaMEPHYTON, Vitamin K)
Description functional class
– vitamin K, fat soluble vitamin
Phytonadione (AquaMEPHYTON, Vitamin K)
Mechanism of Action
promotes hepatic formation of active prothrombin and several
other coagulation factors ( factors II, VII, IX, and X)
Phytonadione (AquaMEPHYTON, Vitamin K)
Metabolism, distribution and Excretion
• requires presence of bile salts to be absorbed from GI
tract
• IV injection has more rapid onset of action, but IM or SC
has longer duration of action
Phytonadione (AquaMEPHYTON, Vitamin K)
Indications & Dosing
• prevention of hypoprothrombinemia secondary to oral
anticoagulants
• vitamin K malabsorption
• prevention of hemorrhagic disease of newborn
Phytonadione (AquaMEPHYTON, Vitamin K)
Adverse Effects
arrhythmias, bronchspasm, anaphylaxis, anaphylactoid reactions,
fatal kernicterus
Phytonadione (AquaMEPHYTON, Vitamin K)
Precautions & Contraindications
contraindicated in patients with hypersensitivity to drug
Phytonadione (AquaMEPHYTON, Vitamin K)
Drug Interactions
• broad spectrum antibiotics – cefamandole, cefoperazone,
cefotetan – may interfere with Vitamin K actions
• oral anticoagulants – antagonizes anticoagulant effect
Phytonadione (AquaMEPHYTON, Vitamin K)
Assessment
• monitor PT/INR
Indication Goal INR
Orthopedic Surgery (hip & knee) 2-2.5
DVT, PE, Stroke, A fib, Porcine valve 2-3
Mechanical Heart Valve 2.5-3.5
• assess nuitritional status – beef liver, spinach, tomatoes,
coffee, asparagus, broccoli, cabbage, lettuce, greens
• assess for bleeding/bruising
Phytonadione (AquaMEPHYTON, Vitamin K)
Implementation
IV – must be diluted – give 1mg/min (emergency usually –
deaths have occurred)
Clopidogrel (Plavix)
platelet aggregation inhibitor
Clopidogrel (Plavix)
Mechanism of Action
inhibits the binding of adenosine diphosphate (ADP) to its
platelet receptor and the subsequent ADP-mediated activation of
glycoprotein IIb/IIIa complex, thereby inhibiting platelet
aggregation. It irreversibly modifies the platelet ADP receptor –
therefore, those platelets exposed to drug are affected for their
life span
Clopidogrel (Plavix)
Metabolism, distribution and Excretion
extensively metabolized by liver
Clopidogrel (Plavix)
Indications & Dosing
reduce atherosclerotic events – MI, CVA, vascular death in
patients with atherosclerosis documented by recent CVA, MI or
peripheral arterial disease. May give loading dose 150-300 mg
Clopidogrel (Plavix)
Adverse Effects
flulike symptoms, chest pain, rash, pruritis, rhinitis, bronchitis,
upper respiratory infection, pupura, hypercholesterolemia, UTI
Clopidogrel (Plavix)
Precautions & Contraindications
• contraindicated in patients with pathologic bleeding –
ulcer/intracranial hemorrhage
• caution in patients with increased risk of bleeding
Clopidogrel (Plavix)
Drug Interactions
• aspirin, NSAIDs – increase risk for GI bleed
• heparin, warfarin – safety not established – use
cautiously
Clopidogrel (Plavix)
Assessment
• monitor liver function tests
• monitor CBC, Hct/Hgb, PT, platelets
• can be an alternative for patients who are allergic to
aspirin
Clopidogrel (Plavix)
Implementation
• can give with or without food. With food to decrease GI
upset
Clopidogrel (Plavix)
Patient Education/Info
• advise patient to report signs of bleeding
• drug should be stopped 7 days prior to surgery if
antiplatelet effect is not desired
Antiplatelet agents
• Aspirin (Bayer, Ecotrin)
• Ticlopidine (Ticlid)
• Clopidogrel (Plavix)
• Dipyridamole (Persantine)
• Abiciximab (ReoPro)
• Dipyridamole/aspirin (Aggrenox)
• Eptifibatide (Integrilin)
• Anagrelide (Agrylin)
• Tirofiban (Aggrastat)
Thrombolytic Agents
– dissolve blood clots at sites of intravascular injury.
Alteplase (tPA) (Activase)
Reteplase (Eliminase, Retavase recombinant)
Streptokinase (Streptase)
Urokinase (Abbokinase)
Peripheral vascular dilators
– decreases blood viscosity, improves erythrocyte flexibility,
increases leukocyte deformability, and inhibits neutrophil adhesion and activation. Improves
blood flow through microcirculation and increases tissue oxygenation to affected area.
Pentoxifylline (Trental, Pentoxyfylline ER)