Term
| Definition of anticoagulants |
|
Definition
| drugs that delay or prevent the clotting of blood (no effect on clot after it is formed) |
|
|
Term
| what is this- prevents clot formation or extension of existing clot? |
|
Definition
| anticoagulants (Warfarin, Heparin) |
|
|
Term
| 4 examples of antiplatelet agents |
|
Definition
| ASA, Plavix, Ticlid, Aggrenox |
|
|
Term
| what is the definition of antiplatelet agents? |
|
Definition
| reduce platelet aggregation, prevent stroke, MI, TIA |
|
|
Term
| What is the definition of direct thrombin inhibitors? |
|
Definition
|
|
Term
| what is an example of a direct thrombin inhibitor (Brand and Generic) |
|
Definition
|
|
Term
|
Definition
| interferes with normal adhesion and aggregation of platelets |
|
|
Term
| True or false, fibronolytics possess inherent fibrinolytic effects or enhance the body's fibrinolytic system |
|
Definition
|
|
Term
| At which tissue factor does the coagulation cascade merge together? |
|
Definition
|
|
Term
| What is the extrinsic pathway? |
|
Definition
|
|
Term
| Where in the cascade does LMWHeparin work? |
|
Definition
|
|
Term
| Where in the cascade does Heparin work? |
|
Definition
| II to IIa (Prothrombin to Thrombin) |
|
|
Term
| what happens immediately after damage to a blood vessel? |
|
Definition
| platelets adhere and release chemicals to attract even more platelets |
|
|
Term
| what happens after platelet plug forms? |
|
Definition
| clotting factors, cause strands of fibrin to stick together and seal the inside of the wound |
|
|
Term
| what 3 things does clot formation require? |
|
Definition
| vascular endothelium, platelets, plasma-mediate hemostasis |
|
|
Term
| is tissue factor the intrinsic or extrinsic pathway? |
|
Definition
|
|
Term
| is factor XI intrinsic or extrinsic pathway? |
|
Definition
|
|
Term
| which pathway initiates plasma- mediated hemostasis and which amplifies the response? |
|
Definition
| tissue factor (extrinsic) initiates plasma mediate hemostasis and factor XI (intrinsic) amplifies the response |
|
|
Term
| what 3 ways do platelets participate in clot formation? |
|
Definition
| 1. anchor sites for coagulation factor activation 2. delivery vehicles releasing hemostatically active proteins 3. major structural components of the clot |
|
|
Term
| true or false, coag studies are the most effective means for identifying bleeding and thrombotic tendencies |
|
Definition
| false, "a carefully performed history" |
|
|
Term
| What 2 hypercoagulable states require anticoag? |
|
Definition
| 1. factor V leiden homozygous 2. antiphospholipid antibody syndrome |
|
|
Term
| How long is normal bleeding time? |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| Heparin enhances _____ times the ability of antithrombin to inactivate a number of coagulation enzymes |
|
Definition
|
|
Term
| heparin helps to inactivate a number of coagulation enzymes (5 examples are...) |
|
Definition
| thrombin, factor X, XII, IX, XI |
|
|
Term
| How does Heparin function as an anticoagulant? |
|
Definition
| accelerating the normally occuring antithrombin induced neutralization of activated clotting factor |
|
|
Term
| where does Heparin exist endogenously (3)? |
|
Definition
| basophils, mast cells and liver |
|
|
Term
| true or false, heparin think hepatic |
|
Definition
|
|
Term
|
Definition
| classic intrinsic and final common pathways |
|
|
Term
| Heparin is lipid soluble, true or false |
|
Definition
| false, poor lipid solubility |
|
|
Term
| is there an assay for heparin? |
|
Definition
| no, must monitor biologic activity |
|
|
Term
| if you increase the dose of heparin, what are you increasing? |
|
Definition
|
|
Term
| 100units/kg IV elimination 1/2 time |
|
Definition
|
|
Term
| 400 units/kg IV elimination 1/2 time |
|
Definition
|
|
Term
| true or false, hyperthermia increases elimination half time |
|
Definition
| false, decrease in body temp prolongs elimination 1/2 time |
|
|
Term
| why is it important to know that hypothermia prolongs heparin? |
|
Definition
|
|
Term
| what is the goal aPTT for Heparin? |
|
Definition
| 1.5-2.5 times pre drug value (30-35 seconds) |
|
|
Term
| when do you check ACT levels? |
|
Definition
| baseline, 3-5 minutes post administration, and 30min to 1 hour intervals post administration |
|
|
Term
| is Heparin metabolism reliable? |
|
Definition
| some people met Heparin faster |
|
|
Term
| what 4 things influence ACT? |
|
Definition
| hypothermia, thrombocytopenia, aprotinin, coagulation deficiences |
|
|
Term
| Control ACT is usually ______ |
|
Definition
|
|
Term
| What is the goal ACT for CPB? when is it inadequate? |
|
Definition
| >400 seconds, <180seconds |
|
|
Term
| When is unfractionated heparin used? |
|
Definition
| when cost is an issue (Heparin is cheaper than Lovenox) |
|
|
Term
| What is the half life of UFH? |
|
Definition
|
|
Term
| what is the onset of action of heparin? |
|
Definition
|
|
Term
| what is the SQ dose of Heparin? |
|
Definition
|
|
Term
|
Definition
| 5000units/ml or 10,000units/ml |
|
|
Term
| How does the size of Enoxaparin compare to the size of Heparin? |
|
Definition
| Enoxaparin is 1/3 the size of Heparin |
|
|
Term
| Why does Enoxaparin have more bioavailability? |
|
Definition
|
|
Term
| why does Enoxaparin have a longer elimination 1/2 time? |
|
Definition
| less binding to epithelial cells |
|
|
Term
| why is lovenox more convenient for patients? |
|
Definition
|
|
Term
| which is more expensive- heparin or lovenox? |
|
Definition
|
|
Term
| Which is more predictable (pharmacokinetic response)- Heparin or Lovenox? |
|
Definition
|
|
Term
| which has fewer effects on platelet function? |
|
Definition
|
|
Term
| HIT is less likely with _____ |
|
Definition
|
|
Term
| What is the Heparin dose for DVT Prophylaxis? |
|
Definition
| 5,000 units SC every 8-12 hours |
|
|
Term
| What is the goal aPTT for DVT treatment? |
|
Definition
|
|
Term
| How long before surgery should patient stop Coumadin? |
|
Definition
|
|
Term
| when does the patient start weight based dose of lovenox? |
|
Definition
|
|
Term
| what does the patient take morning of surgery? |
|
Definition
|
|
Term
| when does the Coumadin get restarted? |
|
Definition
|
|
Term
| True or false, the day after surgery, restart LMWH, continue until INR therapeutic |
|
Definition
|
|
Term
|
Definition
|
|
Term
| What types of cases get DVT prophylaxis? 2 |
|
Definition
|
|
Term
| What is the dose of Heparin given during aortic purse string sutures are placed during cannulation? |
|
Definition
|
|
Term
| How do you give Heparin? (route) |
|
Definition
|
|
Term
| patients that have antithrombin deficiency- how does this affect Heparin? what do you do? |
|
Definition
| resistant to heparin bc there is nothing for heparin to bind to. Give 2 units FFP so Heparin can bind |
|
|
Term
| HIT- how does it cause thrombocytopenia? |
|
Definition
|
|
Term
| If patient has a history of HIT- you can never give Heparin true or false |
|
Definition
| false, if remote history and no longer has antibodies, Heparin is safe |
|
|
Term
| What is the platelet drop after Heparin in HIT? |
|
Definition
|
|
Term
| What is the % chance of developing HIT after 5 days of Heparin? |
|
Definition
|
|
Term
| 3 alternative coagulants if patient has HIT |
|
Definition
| hirudin, bivalirudin, agatroban |
|
|
Term
|
Definition
|
|
Term
| If a patient receiving Heparin also takes ____, they are at higher risk for hemorrhage |
|
Definition
|
|
Term
| large doses of heparin can cause hypertension, true or false |
|
Definition
|
|
Term
| chronic exposure of heparin leads to what? |
|
Definition
| reduction of antithrombin activity |
|
|
Term
| important risk factor for epidural hematoma |
|
Definition
| length and intensity of anticoag |
|
|
Term
|
Definition
|
|
Term
| protamine is negatively charged and heparin is positvely charged- they form a stable complex, true or false |
|
Definition
| false, protamine positive |
|
|
Term
| how is the heparin-protamine complex removed? |
|
Definition
| reticuloendothelial system |
|
|
Term
| how do you dose protamine? |
|
Definition
| 1mg for every 100units (1mg) of Heparin |
|
|
Term
| How do you inject protamine? |
|
Definition
| in PIV slowly over 5 minutes |
|
|
Term
| do not exceed _____mg of Protamine Sulfate in any ____ minute period |
|
Definition
|
|
Term
| protamine- rapid IV push causes what? |
|
Definition
| HPN from histamine release, facial flushing, tachycardia |
|
|
Term
| How does protamine lead to Pulm HTN? |
|
Definition
| protamine heparin complex can result in complement activation and thromboxane release = pulmonary constriction |
|
|
Term
| If patients take ____ they are more likely to be allergic to protamine, why? |
|
Definition
| NPH insulin, chronic exposure produces antibodies against protamine |
|
|
Term
| there are approx ____mg protamine per ___units of isphane NPH insulin |
|
Definition
|
|
Term
| allergic reactions to protamine if ____ and ____ |
|
Definition
| fish allergies, vasectomies/infertile males (antisperm antibodies) |
|
|
Term
| protamine comes from the sperm of salmon and other fish, true or false |
|
Definition
|
|
Term
| patient is allergic to protamine and needs CPB, what do you do? |
|
Definition
| pretreat, avoid protamine, admin alternative anticoag |
|
|
Term
| fondaparinux- what type of drug? what's it's other name? |
|
Definition
|
|
Term
| Where does argatroban bind? is it reversible? |
|
Definition
| thrombin active site, yes it's reversible |
|
|
Term
| does argatroban require antithrombin III? |
|
Definition
|
|
Term
| how does argatroban exert its anticoag effects? |
|
Definition
| by inhibiting thrombin- catalyzed or induced reactions, including fibrin formation; activation of coag factors, protein C and platelet aggregation |
|
|
Term
| what is the bolus dose of argatroban? |
|
Definition
| 350mcg/kg over 3-5 minutes |
|
|
Term
| what is the antidote to argatroban? |
|
Definition
|
|
Term
|
Definition
| 1. hirudin 2. ximelagatran 3. argatroban |
|
|
Term
| when might you use a DTI? |
|
Definition
| CPB patients that have developed heparin resistance or HIT |
|
|
Term
|
Definition
| an antifibrinolytic used for bleeding prophylaxis |
|
|
Term
|
Definition
| repeat operations, jehovahs, high risk of post op bleding, coagulopathies, long complicated procedures |
|
|
Term
| aprotinin preserves platelet function (Adhesion & aggregation), true or false |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| Is Amicar an antiplatelet? |
|
Definition
|
|
Term
| dose of Amicar (bolus & infusion) |
|
Definition
| 5-10g followed by 1g/hour |
|
|
Term
| what's the normal Coumadin dose? |
|
Definition
| 5-10mg orally *dose varies among patients |
|
|
Term
| Coumadin competitively inhibits ____ |
|
Definition
| Vitamin K dependent coagulation proteins |
|
|
Term
| What factors does Coumadin inhibit? |
|
Definition
|
|
Term
| What labs measure Coumadin coag? |
|
Definition
|
|
Term
| What is the goal INR for Coumadin? |
|
Definition
|
|
Term
| why can't you use Coumadin in parturient? |
|
Definition
|
|
Term
|
Definition
|
|
Term
| duration of single dose of coumadin |
|
Definition
|
|
Term
|
Definition
|
|
Term
| when are coumadin effects seen in INR? why? |
|
Definition
| 8-12 hours due to depletion of factor VII |
|
|
Term
| when are the full effects of coumadin seen? |
|
Definition
|
|
Term
| How do you calculate INR? |
|
Definition
|
|
Term
|
Definition
|
|
Term
| the INR is repeated every ___ weeks |
|
Definition
|
|
Term
| Goal INR is 2-3 for which conditions? |
|
Definition
| AFib, Treatment of VTE, Treatment of PE, Prevention of VTE in high risk surgery, tissue heart valves |
|
|
Term
| Goal INR is 2.5-3.5 for which conditions? |
|
Definition
| mechanical heart valve, prevention of recurrent MI, history of VTE with INR 2-3 |
|
|
Term
| For minor surgery- when do you DC Coumadin for PT 20% within baseline? |
|
Definition
|
|
Term
| How do you reverse Coumadin for immediate surgery or active bleeding? |
|
Definition
| Vitamin K, 10-20mg orally or 1-5mg IV at a rate of 1mg/min |
|
|
Term
| after Vit K, PT to normal range within ____ hours |
|
Definition
|
|
Term
| if the bleeding with Coumadin is an emergency- what is the treatment? |
|
Definition
|
|
Term
| what are thrombolytics used for? |
|
Definition
| restore circulation through a previously occluded vessel (ST elevation, CVA) |
|
|
Term
|
Definition
| streptokinase, urokinase, alteplase |
|
|
Term
| tpa- converts ______ to ______ |
|
Definition
| plasminogen to the active form, plasmin |
|
|
Term
|
Definition
| breaks down fibrin into fibrin degredation split products |
|
|
Term
| antithrombotics- what do they do? |
|
Definition
| suppress platelet function (inhibit platelet aggregation) |
|
|
Term
| 3 examples of antithrombotics |
|
Definition
| ASA, Dipyridamole, Dextran 70 |
|
|
Term
|
Definition
| inhibits thromboxane synthesis and release of adenosine diphasphate by platelets |
|
|
Term
| what is the life of a platelet? |
|
Definition
|
|
Term
|
Definition
| renders it non-functional, acetyl group of ASA causes acetylation of cyclooxygenase |
|
|
Term
| What does the ACETYLATION OF CYCLOOXYGENASE cause? |
|
Definition
| COX to be rendered non-functional |
|
|
Term
|
Definition
| the rate-limiting enzyme in the conversion of arachidonic acid to thromboxane A |
|
|
Term
| what is ASA primary and secondary prophylaxis? |
|
Definition
| primary is in the absence of diagnosis and secondary is treatment in the presence of overt CV disease or conditions |
|
|
Term
| How should primary ASA be used periop? |
|
Definition
| should be continued up to and day of but it may be held by surgeon for a few days prior |
|
|
Term
| when is primary ASA held? |
|
Definition
| intracranial, middle ear, posterior eye or intramedullary spine surgery, possibly in prostate surgery |
|
|
Term
| How should secondary ASA be used periop? |
|
Definition
| same as primary- stopping ASA for patients that need it requires an explicit discussion |
|
|
Term
|
Definition
| inhibits platelet aggregation |
|
|
Term
| what class of ADP platelet receptors does Plavix work on? |
|
Definition
|
|
Term
| How is Plavix metabolized? |
|
Definition
| CYP450 enzymes to produce the ACTIVE METABOLITE that inhibits platelet aggregation |
|
|
Term
| How do NSAIDs work to depress platelets? |
|
Definition
|
|
Term
| nsaids are more temporary- what is the doa? |
|
Definition
|
|
Term
| DDAVP causes release of _______ |
|
Definition
| endogenous stored von willebrands |
|
|
Term
| what is the dose of DDAVP? |
|
Definition
| 0.3mcg/kg IV infusion over 10-20 minutes |
|
|
Term
| after DDAVP- platelet adhesion increases within ____ minutes |
|
Definition
|
|
Term
| DDAVP wears off in _____ hours |
|
Definition
|
|
Term
|
Definition
|
|
Term
| what are the 2 pathways of factor VII |
|
Definition
| 1. site of tissue injury combine with Tissue Factor 2. platelet surface |
|
|
Term
| why is factor VII good for trauma? |
|
Definition
| localizes to the site of injury |
|
|
Term
| what is the MOA of factor VII? |
|
Definition
| activates extrinsic pathway- forms a complex with tissue factor at the site of injury and activating factors IX and X |
|
|
Term
| Factor VIIa lowers the _______ |
|
Definition
|
|
Term
| You can use Factor VIIa in hemophilia A, B or C, true or false |
|
Definition
|
|
Term
| What is the drug name for Factor VII? |
|
Definition
|
|
Term
| what is the main benefit to Factor VII? |
|
Definition
| reduces the need for blood transfusion |
|
|
Term
| Factor VII comes with its own diluent- reconstitute with specific volume of ____ diluent |
|
Definition
|
|
Term
| what is the bolus dose for Factor VII? |
|
Definition
|
|
Term
| how frequently can you re-dose Factor VII? |
|
Definition
|
|
Term
| when do half of the spinal hematomas associated with heparinization occur? |
|
Definition
| at the time of catheter removal |
|
|
Term
| Heparin should be D/C'd ____ hours before catheter manipulation |
|
Definition
|
|
Term
| How soon after catheter removal can you restart Heparin? |
|
Definition
|
|
Term
| are patients that receive SQ heparin with 5000 units twice daily at risk for neuraxial techniques? |
|
Definition
| no, there is no contraindication |
|
|
Term
| remove catheters with INR < ____ |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| decrease oral anticoag dose |
|
|
Term
|
Definition
|
|
Term
| true or false, all the herbals inhibit platelets but only ginkgo increases fibrinolysis |
|
Definition
| false, only garlic increases fibrinolysis |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| how soon after catheter removal before LMWH? |
|
Definition
|
|
Term
| when do you d/c ticlid and plavix? |
|
Definition
| ticlid 14 days, plavix 7 days |
|
|
Term
| when do you d/c GP IIb-IIIa ? |
|
Definition
|
|
Term
| SQ lovenox- if patient got single 40mg SQ dose, the epidural cath can't be removed until _____ |
|
Definition
| 10-12 hours after the last dose |
|
|
Term
| before placing epidural cath, coumadin should be stopped _____ |
|
Definition
|
|
Term
| before placing epidural cath, coumadin INR should be _______ |
|
Definition
|
|
Term
| anticoags should not be restarted for _ hours after removing the epidural cath |
|
Definition
|
|
Term
|
Definition
| 1. tensile strength of the clot 2. platelet aggregation/fibrin polymerization |
|
|
