S2 Ch 9 H/o 2-3

Front 1

367. What can be given if severe bleeding occurs for pts on either warfarin or heparin?

Back 1

a. FFP

Front 2

368. LMWH has a longer half-life than standard heparin, so it takes longer for the effects to fade.

Back 2

368. LMWH has a longer half-life than standard heparin, so it takes longer for the effects to fade.

Front 3

369. MOA of LMWH?

Back 3

a. LMWHs most inhibit factor Xa (equivalent inhibition of factor Xa as standard heparin) but have less inhibition of factor IIa (thrombin) and platelet aggregation.
b. They cannot be monitored by PT or PTT bc they do not affect either!!!

Front 4

370. Why are LMWHs being used more now?

Back 4

a. Bc of their greater convenience compared w/standard heparin, as well as ↓’d risk of side effects (HIT, osteoporosis).
b. They are given subq (no IV admin)
c. PTT monitoring is not necessary.
d. They are easier to use as an outpt- the pt may be discharge if stable and the pt can continue LMWH until the level of long-term anticoag (warfarin) is therapeutic)

Front 5

371. How are LMWHs excreted?

Back 5

a. Via kidneys.

Front 6

372. Negative of LMWHs?

Back 6

a. Much more expensive than standard heparin, but often more cost-effective in the long run due to reduced testing, nursing time, and hospital length of stay.

Front 7

373. 3 options for DVT prophylaxis?

Back 7

1. LMWH
2. Low-dose unfractionated heparin
3. Pneumatic compression boots

Front 8

374. MOA of Warfarin?

Back 8

a. Vit K antagonist: Leads to a ↓ in Vit K-dependent clotting factors (II, VII, IX, and X) and protein C and S.
b. Causes prolongation of PT (and ↑ in INR)

Front 9

375. Downside of using warfarin?

Back 9

a. Takes 4-5 days for the anticoag effect to begin. Therefore, start heparin as well if the goal is acute anticoag bc heparin has an immediate effect.
b. Once warfarin is therapeutic (checking INR), then stop the heparin and continue warfarin for as long as necessary.

Front 10

376. Indications for use of warfarin?

Back 10

a. Same as heparin but used for long-term anticoagulation.

Front 11

377. How is warfarin administered?

Back 11

a. Orally.

Front 12

378. How do you bridge warfarin from heparin?

Back 12

a. As soon as PTT is therapeutic, initiate warfarin. Continue heparin for at least 4 days after starting warfarin.
b. Once INR is therapeutic on warfarin, stop the heparin.
c. In most cases, an INR of 2-3 is therapeutic.

Front 13

379. AE of warfarin?

Back 13

a. Haemorrhage
b. Skin necrosis is a rare but serious complication. It is caused by rapid ↓ in protein C (a vit K-dependent inhibitor of factors Va and VIIIa).
c. Teratogenic- avoid during pregnancy!!!!
d. Should not be given to alcoholics or to any pt who is prone to frequent falls bc an intracranial bleed in a pt on warfarin can be catastrophic.

Front 14

380. How do you reverse the affects of warfarin?

Back 14

a. Administer Vit K.
b. It normally take 5 days to correct the effects of warfarin on stopping the medication. Vit K infusion corrects an abnormal PT w/in 4-10 hours if the pt has normal liver function.
c. Giving Vit K makes it difficult to return the pt to therapeutic INR levels if anticoag is to be continued.

Front 15

381. What should you give if rapid reversal of acute bleeding for warfarin is indicated?!?

Back 15

a. FFP!!!

Front 16

382. What is Multiple Myeloma?

Back 16

a. A neoplastic proliferation of a single plasma cell line that produces monoclonal immunoglobulin.
b. This leads to enormous copies of 1 specific Ig (usually IgG or IgA).

Front 17

383. In whom is multiple myeloma most common?

Back 17

a. Incidence is ↑’d after 50.
b. 2x as common in blacks.
c. Etiology is unclear.

Front 18

384. How does Multiple Myeloma progress and what does it result in?

Back 18

a. As the disease process advances, bone marrow elements are replaced by malignant plasma cells.
b. Therefore, anaemia, leukopenia, and thrombocytopenia may be present in advanced disease.

Front 19

385. What values w/respect to hemoglobin, calcium, serum protein, and renal function suggest multiple myeloma?

Back 19

a. Low Hb
b. High Ca
c. High serum protein
d. Poor renal function.

Front 20

386. 5 clinical features of Multiple Myeloma symptoms?

Back 20

1. Skeletal manifestations
2. Anaemia (normocytic/normochromic)
3. Renal failure
4. Recurrent infections
5. Amyloidosis: Develops in 10% of pts (usually clinically insignificant).

Front 21

387. Skeletal manifestations of Multiple Myeloma?

Back 21

a. Bone pain due to osteolytic lesions, fractures, and vertebral collapse- occurs especially in the low back or chest (ribs) and jaw (mandible)
b. Pathologic fractures
c. Loss of height secondary to collapse of vertebrae

Front 22

388. How is the anaemia of Multiple Myeloma characterized and why does it occur?

Back 22

a. Normocytic/normochromic
b. Present in most pts due to bone marrow infiltration and renal failure.

Front 23

389. What is Renal failure in Multiple Myeloma due to?

Back 23

a. Myeloma nephrosis: Immunoglobulin precipitation in renal tubules leads to tubular casts of Bence Jones protein.
b. Hypercalcemia also plays a role in renal decompensation.

Front 24

390. What are the recurrent infections in Multiple Myeloma due to?

Back 24

a. 2º to deprivation of normal immunoglobulins.
b. Therefore, humoral immunity is affected.
c. Most common cause of death!!!! Up to 70% of pts die of infection (lung or urinary tract most common).

Front 25

391. What serum and urine markers are used to diagnose Multiple Myeloma?

Back 25

a. Serum and urine protein electrophoresis detecting:
1. Monoclonal spike due to a malignant clone of plasma cells synthesizing a single Ig (usually IgG) called a monoclonal protein (M-protein)
2. Serum monoclonal protein is present in 85% of pts, and 75% have a urine monoclonal protein.

Front 26

392. What do plain radiographs reveal in Multiple Myeloma?

Back 26

a. Detect lytic lesions.
b. An MRI may be needed to detect lesions that are not apparent on plain films.

Front 27

393. What does bone marrow biopsy reveal in Multiple Myeloma?

Back 27

a. At least 10% abnormal plasma cells.