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74 Cards in this Set
- Front
- Back
Venous Thromboembolism & HIT incidence ___ with each ___ > ___
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Incidence doubles w/ each decade over the age of 50
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Do patients show symptoms of Venous Thromboembolism & HIT
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Lots of patients are asymptomatic
Some patients never express any symptoms |
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What Ethinicities are at risk of DVT and HIT?
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African Americans > Caucasian > Hispanic Americans
Very low incidence in Asian Americans and Pacific Islanders |
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What the #1 risk factor Venous Thromboembolism & HIT
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Prior history of DVT/PE is #1 risk factor
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What are Risk factors for VTE?
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Age
Hx of VTE--> strongest risk factor for VTE Venous Stasis--> obsity, CHF, Post-MI Vascular Injury--> major surgery, Trauma DRug therapy--> BC, SERM, HIT |
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How do VTE Present?
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Hallmark: lower extremeties. One large will be large red and swollen, other one will be fine
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What are symptoms of DVT?
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Unilateral swelling ( one leg, not both)
Pain Redness Heat Ulceration Cord-like obstruction( can feel in calf, feels like rope in there leg) |
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What are symptoms of PE?
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Cough
Chest pain/tightness Hemoptysis (<30%) (coughing up blood) Dyspnea Tachypnea Tachycardia Cardiovascular collapse cyanosis shock oliguria Need immediate help, may need stronger drugs than coagulations |
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What are LAB tests for VTE?
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↑ D-dimer ( bi-product of fibrinolysis) (can measure these levels)
IF patient comes in with a PE or DVT-->D-dimer will be high. - d-dimer will rule it out ↑ ESR, WBC Time it takes fr the erythrocytes to pool WBC maybe elavated, non-specific |
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What 2 imaging test are used for DVT?
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Ultrasound most common, to look at the veins and look for flow through the veins
Venography (gold standard) Not used that much, because it is risky, inject radio pink dye, and take an xray, and see where blood is flowing and where its not |
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What are 3 imaging tests for PE?
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Ventilation-perfusion (V/Q) scan: measures distribtion between air and blood flow in the lungs. Number 1 test for PE
Spiral CT scan-->detecs emboli in the lungs Pulmonary angiography (gold standard) |
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What is the Pre-test Probability for DVT?
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Risk Factor:
Tenderness=1 Swelling of entire leg=1 > 3cm difference between one leg to the her circumference difference=1 Pitting edema=1 Collateral superficial veins=1 Risk factors= -2 Active cancer Immobility Recent surgery or medical illness Alternative diagnosis likely ≥ 3 = high (>60%) 1-2 = moderate (35%) ≤ 0 = low (<5%) |
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What is the Pre-test Probability for PE
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Risk Factors:
DVT suspected Clinical features of DVT=3 Recent immobility or surgery=1.5 Active cancer=1 History of DVT/PE=1.5 Hemoptysis=1 HR >100 bpm=1.5 No alternative for SOB or CP=3 ≥ 6 = high (>60%) 2-6 = moderate (35%) ≤ 1.5 = low (<5%) |
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Describe Rating Scale for 1A, 1B, 1C
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Strong, high-quality evidence
Apply to most patients in most circumstances; further evidence unlikely to change recommendation Strong, moderate-quality evidence (limitations) Apply to most patients in most circumstances; further evidence would help confirm/change recommendation Strong, low or very low-quality evidence (many limitations in RCTs) Apply to most patients in most circumstances; higher-quality evidence would support or change recommendation |
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Describe Rating Scale for 2A, 2B and 2C
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Weak, high-quality evidence
best action may differ depending on circumstance, patient, society; further evidence will not change Weak, moderate-quality evidence Best action may differ depending on circumstance, patient, society; further evidence will support/change recommendation Weak, low or very low-quality evidence Other alternatives equally reasonable; higher-quality evidence would support/change recommendation |
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What do you do first when patient comes into the hospital?
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Screening at admission to assess:
Risk factors Pre-test probability of DVT/PE |
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What is nonpharmacological Prophylaxis of VTE?
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1: Walk around, if patient is mobile and complying on compression to move the blood that is good
2: graduated compression stockings--> reduce VTE rate by 60% 3: Intermittent Pneumatic Compression (IPC)--> reduced vte by 60%--> must be used with pharm TX 4. Inferior Vena Cava (IVC) filter |
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what is Pharmacologic Prophylaxis for VTE
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The use of UFH, LMWHs, fondaparinux should be used first-line for hospitalized patients (1A) according to manufacturer’s dosing recommendations (1A)
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What Pharmacologic Prophylaxis should not be used as a primary agent?
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Aspirin should not be used as primary agent (1A)
Also, other antiplatelet drugs |
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What are Low level Risk patient risk factors?
% for DVT, PE and Fatal PE? Prevention stratgey for Low risk? |
Low
Minor surgery, age <40 yrs, no RF DVT-2 PE-0.2 Fatal PE- 0.002 Ambulation |
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What risk factors make a patient Moderate level of risk
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Moderate
Major/minor surgery, age 40-60, no RF Major surgery, age <40 yrs, no RF Minor surgery, clinical RF present Acutely ill (MI, ischemic stroke, CHF exacerbation), no RF present |
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For moderate risk patients, what % chance do they have of getting DVT, PE and Fatal PE?
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10-20
1-2 0.1-0.4 |
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What are prevention strategies for Moderate risk patients
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UFH 5,000 units SC q12h
Dalteparin 2,500 units SC q24h Enoxaparin 40mg SC q24h Tinzaparin 3,500 units SC q24h IPC Compression stockings |
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What risk factors make a patient high level of risk?
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High
Major surgery, age >60 yrs, no RF Major surgery, age 40-60, clinical RF present Acutely ill (MI, ischemic stroke, CHF exacerbation), clinical RF present |
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For high risk patients, what % chance do they have of getting DVT, PE and Fatal PE?
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20-40
2-4 0.4-1.0 |
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What are prevention strategies for high risk patients
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UFH 5,000 units SC q8h
Dalteparin 5,000 units SC q24h Enoxaparin 40mg SC q24h Fondaparinux 2.5mg SC q24h Tinzaparin 75 units/kg SC q24h IPC |
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What risk factors make a patient highest level of risk?
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Highest
Major lower-extremity orthopedic surgery Hip fracture Multiple trauma Major surgery, age >40 yrs, prior Hx of VTE Major surgery, age >40 yrs, malignancy Major surgery, age >40 yrs, hypercoagulable state Spinal cord injury or stroke with limb paralysis |
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For highest risk patients, what % chance do they have of getting DVT, PE and Fatal PE?
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40-80
4-10 0.2-5 |
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What are prevention strategies for highest risk patients
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Adjusted dose UFH SC q8h (aPTT >36s)
Dalteparin 5,000 units SC q24h Desirudin 15mg SC q12h Enoxaparin 30mg SC q12h Fondaparinux 2.5mg SC q24h Tinzaparin 75 units/kg SC q24h Warfarin (INR 2-3) IPC with UFH 5,000 units SC q8h |
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For Orthopedic Surgery, which therapires should be used?
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(LMWH, fondaparinux, or warfarin) for 10 days (1A)
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For total hip replacement therapy how long should it be extended?
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therapy should be extended to 10-35 days (1A)
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Total knee replacement therapy should be for how long?
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therapy should be 10 days (1A); extended therapy here is 2B
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Hip fracture surgery - therapy should be extended to ?
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10-35 days (1A)
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What is Dabigatran (Pradaxa®)
used for? What is the dosing for them? |
Approved for use in Canada for postoperative ppx
220mg PO daily for 10 days (TKR) or 28-35 days (THR) |
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Rivaroxaban (Xarelto®) is used for what? What is the dosing for?
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Approved for use for postoperative ppx
10 mg PO daily for 12-14 days (TKR) or 35 days (THR) |
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What studies was Rivaroxaban studied in? What did they show?
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RECORD1, RECORD2, RECORD3
All showed non-inferiority of rivaroxaban against enoxaparin Increased rates of bleeding in rivaroxaban groups |
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Case Study 1 DF is a 63 year old, morbidly obese woman who presents for elective abdominal surgery for diverticulitis. She has a significant medical history for hypertension, type 2 diabetes mellitus, peripheral vascular disease, and chronic kidney disease. Her current home medications include enalapril 10mg BID, metformin 500mg BID, and glipizide 10mg daily. Her blood pressure reading in the pre-op area was 135/85 mmHg. She reports that her blood sugar at home is normally in the low 100’s. Her A1c is 6.4. Labs reveal CKD with a calculated CrCL of 46 mL/min.
What else do you want to find out about? |
History of VTE
History of hypercoaguable state |
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Case Study 1
What are DF's risk factors for VTE? |
Obesity,
major surgery, venous stasis- PVD, Age greater then 60 |
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Case Study 1
What nonpharmacologic interventions do you want to make (if any)? |
intermittent pneumatic compression devices while int he hospital
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Case Study 1
What pharmacologic interventions do you want to make (if any)? |
UFH 5,000 units sc q8h is the best choice
LMWH- caution with renal impairment Fondaparinux also an option renail impairment and long t1/2 BE careful because patients has chronic kidney disease CRCL: 46-> cut off is 30 |
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For acute treatment of DVT/PE what would you use?
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Use LMWH, fondaparinux, UFH, or SC adjusted dose UFH (1A)
The dose of UFH should maintain an aPTT that corresponds to anti-Xa level of 0.3-0.6 IU/mL (1C) LMWH is preferred in patients with cancer (1A) |
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Duration of acute treatment for DVT/PE?
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UFH, LMWH, or fondaparinux should be overlapped for ≥ 5 days until INR is >2.0 (1A)
Patients with cancer should be treated for 6 months (1A) A longer period of 10 days of heparin therapy should be used for patients with massive PE or severe iliofemoral thrombosis (1C) |
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Long-term anticoagulation for treatment of DVT/PE
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Oral anticoagulation (INR 2.0-3.0) should be continued for at least 3 months (1A)
Patients with idiopathic VTE, hypercoagulable state, or antiphospholipid antibodies should be treated indefinitely (1A) Patients with continuing risk factors should be treated for at least 12 months (1C) |
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Treatment of DVT/PE with UFH is given how? What is the dosing?
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Given as bolus and continuous infusion
Dosing: 80 units/kg bolus 18 units/kg/hr infusion thereafter titrated to aPTT corresponding to 0.3-0.7 IU/mL anti-Xa activity |
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Treatment of DVT/PE with UFH monitoring parameters?
Level of evidence? |
aPTT
CBC Bleeding 1A |
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What is the advantage of LMWH compared to UGH when treating DVT/PE?
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no need for frequent monitoring
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Treatment of DVT/PE with LMWH, what are the agents and dosing?
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Enoxaparin 1 mg/kg SC q12h OR 1.5 mg/kg SC q24h
Dalteparin 100 units/kg SC q12h OR 200 units/kg SC q24h Tinzaparin 175 units/kg SC q24h |
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What is monitored when treating DVT/PE with LMWH
level of evidence? |
Monitoring:
Bleeding SCR 1A |
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Treatment of DVT/PE with Fondaparinux has what kind of dosing and administration?
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Fixed dose of 7.5 mg SC daily
10 mg SC daily if ≥100kg 5 mg SC daily if <50kg |
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Treatment of DVT/PE with Fondaparinux monitoring parameters?
What is the level of evidence? |
Monitoring:
Bleeding SCR Level of evidence: 1A |
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IS warfarin used for acute TX of DVT/PE?
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NO
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How is warfarin dosed for chronic DVT/PE?
How long to treat general patients for? Level of evidence? |
Dosing:
It’s an art! Most patients start at 5mg daily IF they are over 65 start at 2.5 mg Titrate to goal INR: 2.0-3.0 3-6 months 1A |
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What kind of patients should thrombolysis be used?
When does throbomlysis used the best? |
Reserved for use in patients with PE and evidence of shock
Systolic bp is going down, HR is going up Early 1B |
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What are approved thrombolysis agents for PE patients?
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Streptokinase 250,000 units IV over 30 minutes, then 100,000 units/hr x 24h
Not a thrombin specific plasminagen activator Risk of bleeding is higher Urokinase 4,400 units/kg IV over 10 minutes, then 4,400 units/kg/hr x 12-24h Alteplase 100 mg IV over 2 hours |
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For Pregnant patients DVT/PE treatment consists of what?
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UFH or LMWH can be used
LMWH may be preferred - UFH linked to osteoporosis and multiple injections |
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What can be used in Pediatrics with VTE?
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UFH or LMWH can be used
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What is dosing for Pediatrics with VTE?
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UFH or LMWH can be used
UFH 75-100 units/kg bolus, then 28 units/kg/hr (age 2-12 months) or 20 units/kg/hr (age >1 year) LMWH dosed to anti-Xa activity (less evidence) Overlap with warfarin Starting dose 0.2mg/kg titrated to INR 2.0-3.0 |
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What DVT/PE treatment would you use in cancer patients? Dosing/duration?
What is not used? |
LMWH is preferred agent
Enoxaparin 1 mg/kg SC q12h Dalteparin 200 units/kg SC q24 Duration of 3-6 months WARFARIN IS CONTRAINDICATED |
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For HAT, type 1 HIT, what does the platelet count drop to? which days is it seen between?
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Platelet nadir = 100K between days 2-4
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For HIT; Type 2 HIT
What does the platelet cont drop to? Between which days? |
Platelet nadir = 20k-150k between days 7-14
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How does HIT typically present?
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Venous thrombosis
Proximal DVT PE (25% of patients) sometimes you can get an arterial thrombosis (MI,Stroke) Heparin-induced skin necrosis Platelet fall >50% |
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How do you diagnosis HIT?
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4-T test
thrombocytopenia Timing of platelet nadir Thrombosis or other sququelae Other causes for TCP |
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What are the scoring parameters for thrombocytopenia?
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2 points= Platelet fall >50% and nadir ≥20k
1 point =Platelet fall 30-50% or nadir 10-19k o point = Platelet fall <30% or nadir <10k |
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What are the scoring parameters for timing of platelet nadir
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2 points =Clear onset 5-10 days or platelet fall ≤1 day (prior exposure w/in 30 days)
1 point= Consistent with days 5-10 but not clear; onset after day 10; or fall ≤1 day (prior exposure 30-100 day) 0 points= none |
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What are the scoring parameters for Thrombosis or other sequelae
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2 points= New confirmed thrombosis; skin necrosis; acute reaction pos IV bolus
1 point = Progressive or recurrent thrombosis; non-necrotizing skin lesions; suspected unproven thrombosis 0 points =none |
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What are the scoring parameters for other causes for TCP
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2 points= none apparent
1 point = possible 0 points= definite |
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What are the risk categories for HIT?
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6-8 points = high-risk (HIT probable)
4-5 points = intermediate risk (HIT possible) 0-3 points = low risk (HIT unlikely) |
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Can 4T's test confirom or completely rule out HIT alone?
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NO
Does have 99.5% negative predictive value |
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What is used along with 4T's test?
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Functional Assays
Serotonin-release assay (SRA) Washed platelet assay 95% sensitivity much more labor intensive |
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what are 5 steps of managment of HIT?
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Stop all heparin products immediately!
Treatment doses Prophylactic doses Heparin coated IVs/Catheters Heparin flushes Begin alternative anticoagulant Obtain confirmatory lab assessment (if not done already) ± surgical extraction of thrombus Start long-term anticoagulation when ready |
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What are alternative anti-coagulation drugs for HIT? What is FDA approved for it? What is not FDA approved but is still used? What dont you use?
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FDA approved for HIT:
Lepirudin 0.4 mg/kg bolus, then 0.15 mg/kg/hr infusion titrated to aPTT 1.5-2.5x control Argatroban 2 mcg/kg/min infusion titrated to aPTT 1.5-3x control Not FDA approved, but used Bivalirudin 0.15-0.2 mg/kg/hr infusion titrated to aPTT 1.5-2.5x control DONT USE LMWH |
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What do you monitor with DTIs for HIT
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CBC
aPTT SCr LFTs-argatroban |
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When do you begin warfarin in long term management?
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Begin warfarin therapy when platelets >150k
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How do you dose warfarin in long term HIT?
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Overlap with DTI for at least 5 days
2 consecutive days of INR in TR (2.0-3.0) |