Pharmville

• Stage 1—formation of platelet plug
• Platelet aggregation (want to prevent this during surgery)
• Stage 2—coagulation
• Intrinsic system
• Extrinsic system

• Rapid acting anticoagulant
• Accelerates binding of Antithrombin III to the clotting factors:
• --Thrombin
• --Factor Xa

• Heparin will not breakdown existing clots. Will only prevent clots from forming. Therefore, give as prophilactic.

• Arteries
• White clot
• Platelets
• Veins
• Red Clots
• Fibrin

• Coagulation cascade
• intrinsic
• activated when blood comes in contact with injured vessel wall
• Extrinsic
• Activated when vessels walls releases tissue factor--> causes adherence, activation and aggregation of platelets
• Final common pathway
• Factor x is acrivated
• Prothrombin-->thrombin
• Fibrinogen-->fibrin

• Inhibits both thrombin and factor xa
• uses: treat venous thrombosis ie prevent further formation.

• Inhibits Factor Xa 
• Has little effect on Thrombin

• Uses:  Prophalactically after OR to prevent thrombus development
• Subq: DO NOT give IV or IM
• Does not require monitoring of PTT (partial thromboplastin time)

• Mixture of Heparin sulfate, Dermatan Sulfate and Chondroitin Sulfate (Heparin + antiinflamatory)
• Derived from porcine intestinal mucosa (contraindicated for pts with allergic rxn or religious intolerence of pork products).
• Even less inhibition of Thrombin than LMW heparin….but does inhibit Factor Xa
• Uses:  Prophalactic prevention of post-op thrombus
• Black Box Warning!: Epidural and Spinal Hematomas. LMW Heparin would be a better choice for such pts.

• Uses
• PE
• STroke
• Vein thrombosis

• Adverse effects
• Hemorrage
• Thrombocytopenia
• Hypersensitivity rxn.
• Heparin Induced Thrombocytopenia (HIT)

• Immune mediated process
• Antibodies to heparina and platelets are produced
• Leads to thrombus formation
• Indications: DVT, Platelet count less than 100K or 50% below baseline
• Treatment
• Direct thrombin inhiitors: do not affect platelets, ie Lepirudin, argatroban

• Prior to and during  therapy:
• --CBC
• --Platelet count
• --Hgb and Hct
• --PTT or a aPTT
• activated Partial thromboplastin time
• Values 1.5-2.5 times baseline
• Obtaining specimens

• Arm band identification
• For IV use, use an infusion pump and check patency
• Double check all doses (need 2 RNs)

• Sub-q dose
• --Always use stomach, anywhere except 1 inch around umbilius.
• --Don’t aspirate (pull back on plunger)
• --Don’t massage. Doing either --> brusing (hematoma)
• IV
• Maintain pressure on venapucture sites for ~ 5 minutes to prevent hematomas. Check for epidural and spinal hematomas.

Antagonist - Protamine sulfate. Antitode for too much heparin when pt can no longer clot at all and keeps on bleeding.

• Oral anticoagulant
• Affects synthesis—factors VII, IX, X, 
and prothrombin
• Peak effect ~ 36-72 hours
• Duration of action 4-5 days
• Is highly protein bound
• Uses:
• Prevents thrombosis formation
• Adverse effects
• Hemorrhage
• Gingival
• Occult (bloody poops, sounds demonic-->occult)

Will be taking concurrently with Heparin until pt can be weened off heparin.

• PT  Prothrombin time
• --Normal 11-13 secs
• --2-3.5 x baseline

• INR (International Normalized Ratio)
• --Normal  0.7 - 1.8
• --2-3.5 unites

• Antagonist ~ Vitamin K (found in dark green leafies). Give if INR/PT times are unusually high.
• Check for bruising and bleeding, esp occult blood

Always given in afternoon/evening because need a PT level before given, but need a baseline to compare. Baselines should be available my afternoon/evening.

• Antagonizes the action of factor Xa
• Common Pathway
• Prevention of DVT in Orthopedic surgical procedures
• Subq admin
• Admin 1x/day.
• No coagualtion testing needed

Nursing Implications: watch for bleeding.

• Selectivly inhibits factor Xa
• Slightly more effective than enoxaparin (LMW Heparin)
• Taken as a pill
• Nursing implications: monitor creatinine Clearance prior to beginning
• Doesn't require lab monitoring, but does alter INR
• Usually started 6-10 hours after OR and continued for 12 days.

• Aspirin (ASA)
• Inhibition of cyclooxygenase
• Ticlopidine (Ticlid) ADP receptor antagonistsTirofiban (Aggrastat) - GP IIb / IIIa receptor antagonists Clopidogrel (Plavix) ADP receptor antagonist. Used as an alternative to ASA.

• related to Hirudin found in leech saliva
• Interact directly with thrombin (circulating, clot bound)
• Used for those with HIT, and only a treatment for HIT because there is no antidote.
• Monitor aPTT
• Hgb and Hct
• There is no antidote.

• Inhibits thrombin
• 2x/day oral dosing
• don't interact with food
• Should not take with otc meds, nsaids
• blood tests are not necessary
• take capsule whole and not given via feeding tube
• check Cr Cl before giving.
• Impedes coagulation cascade in a few hours and effects last about 5-9 hrs
• Risk for MI and GI bleeding
• Epidural and spinal hematomas
• there is no antidote
• Ecarin clotting time (ECT) or aPTT.
• Proposed as coumadin repacement.
• Indications: atrial fibrilation--> stroke, MI, DVT, PE.

• Wear a medic alert bracelet
• Discuss ways to derease risk of falls
• Avoid sharp toolsa nd knives. Use an electric razor
• Regular lab monitoring
• Contact HCP prior to dental work or surgery
• Take med at same time every day
• Possibilityof bleeding
• Consistent intake of vit K
• Altered effects of alcohol on INR making INR labs meaningless, so no booze.
• NO OTC meds, ie no asparin and/or tylenol.

• Inactivates plasminogen
• Dissolves thrombi after they form
• Best results if given early in treatment
• For MI’s not longer than 6 hours, best if given within an hour of MI.

• Uses
• Myocardial infarction
• Deep vein thrombosis
• Massive pulmonary emboli
• Adverse effects
• Bleeding
• Hypotension
• Fever

• Active internal bleeding
• Aneurysm
• Surgery or trauma within past 2 months
• History of CVA with unknown cause
• Brain neoplasms
• Severe, uncontrolled hypertension (>160 SBP)

• Streptokinase
• Onset ~  immediate
• Peak ~ 30-60 min
• Duration ~ 4-12 hrs
• Alteplase (tPA) (drug of choice)
• Onset ~  immediate
• Peak ~ 5-10 min
• Duration ~ 2.5-3 hrs
• Reteplase (Retavase)
• Onset ~  immediate
• Peak ~ 5-10 min
• Duration ~ Unknown
• Half-life ~ 13-16 min

Need combo therapy along with antihrombolytics beccause thrombolytics treat clots while antithrombolytics prevent them.