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Pharmacology Hemo
| Question | Answer |
|---|---|
| The reason these drugs are given is ALWAYS | Prevent blood clot (Thrombi)_______ _Prevent clumping of platelets (aggregation)______ _Dissolve clots_____________ _Replace blood components to maintain hemostasis____ _Prevent anemia____________________ |
| Basic steps in hemostasis | blood vessel injury blood vessel spasm Platelets adhere-causes plug Insoluble fibrin strands form and coagulate |
| warfarin INR levels for For A-fib, AMI, PE, DVT, or tissue heart valves | ____2.0-3.0_______ |
| warfarin INR levels for mechanical heart valve or recurrent systemic emboli | 3.-4.5 |
| Activated partial thromboplastin time (aPTT or PTT) | Used to monitor patients on _heparin therapy________ |
| Activated partial thromboplastin time (aPTT or PTT) Normal time | Normal time ranges from _25__ to _36_ seconds |
| PT-Lab for what drug | Coumadin |
| PTT-Lab for what drug | Heparin |
| D-Dimer is a breakdown product of | fibrinolysis |
| D-Dimers are frequently used to screen patients who present with | signs and symptoms of __DVT___ or ___PE__________ |
| A negative D-Dimer generally rules out | __DVT__ and __PE__ |
| Patients with __DVT_ or a _PE_ almost always have | positive D-Dimer. |
| Anticoagulant therapy can cause a false | negative D-dimer. |
| A positive D-Dimer can mean other things | …therefore, you need to have assessed your patient and other tests may be needed! |
| Prevent clot formation | Inhibit specific clotting factors Anticoagulants |
| Prevent clot formation | Antiplatelets Inhibit platelet action |
| Remove existing clot | Thrombolytes Dissolve clots |
| Promote clot formation | Inhibit fibrin destruction-hemostatics |
| Prototype: Heparin: | Doesn’t lyse or break up the clot, it just delays the formation |
| Prototype LMWH: Enoxaparin (Lovenox) | Drug of choice to __prevent DVT after surgery |
| Administration: Heparin | = _IV_ or __SQ__ |
| Administration: Lovenox | LMWH = _SQ__ |
| Heparin Action | Works by activating antithrombin which indirectly inactivates both |
| Lovenox Action | Action: Very similar to heparin |
| Lovenox Advantage: | longer duration of action produces a more stable response can be given at home less likely to cause thrombocytopenia |
| Heparin | – often used as a continuous infusion that is titrated according to patient lab values. “Weight-based protocol”. |
| Nursing Considerations for Heparin | Must use _infusion pump Initial dose is a generally a _bolus_, followed by a drip in a rate adjusted for _units/kg/hour Monitor rate every 30 to 60minutes Double check dose with another RN Monitor PTT every 4 to _6_ hours per hospital protocol Based |
| DO NOT GIVE Anticoagulants: parenteral | patient has active _internal bleeding_____ __bleeding____ disorders severe hypertension recent trauma, intracranial hemorrhage. |
| Caution Anticoagulants: parenteral | caution in liver disease. Contraindicated if _platelet___ count low (<_100,000___). |
| Adverse Reactions Anticoagulants: parenteral | __Bleeding____is the biggie (hemorrhage); anaphylaxis can occurred, thrombocytopenia |
| DDI: Drug to Drug Interactions | Nicotine, digoxin, tetracycline, antihistamines: _inhibits__drug effect. Ginkgo or Vitamin E may __increase______bleeding |
| Anticoagulants Coumadin/Warfin: oral Purpose | antagonize Vitamin K which is used in the liver to produce clotting factors _VII_, IX, _X_, and prothrombin__. |
| Anticoagulants Coumadin/Warfin: Administration: | Oral – long half life: _1_ to _3__ days |
| Anticoagulants Coumadin/Warfin: Watch out | Watch Out! Clients with __liver__ or __renal__ impairment or __alcohol__ dependence. Presume that it interacts with every other drug out there (i.e., ALWAYS check!) |
| Coumadin/Warfin Absolute contraindications: | Absolute contraindications: Neurosurgery/Eye surgery. Pregnancy category _X_ Adverse Reaction: __Bleeding___!(Effects of drug may persist _10__days). |
| Coumadin/Warfin Adverse reaction | Adverse Reaction: __Bleeding___!(Effects of drug may persist _10__days). |
| Coumadin Lab | PT INR |
| Heparin Lab | PTT |
| Dabigatran (Pradaxa): | Reduces stroke risk for patients with atrial fib BETTER than warfarin. Far fewer drug/food interactions. Excreted primarily in __urine_, which means caution in _dialysis__patients It is NOT _reversible_ No blood monitoring |
| Anticoagulants Heparin : treating overdose | Prototype for heparin OD: __Protamine Sulfate______ Works by binding to heparin. |
| Anticoagulants Coumadin: treating overdose | Vit K _Aquamephyton (“Mephyton”)_____ Give slow & dilute before administration Watch for anaphylaxis Oral route is safest |
| Antiplatelets | Aspirin (Ecotrin) Glycoprotein inhibitors: abciximab (ReoPro), eptifibatide (Integrilin), tirofiban (Aggrastat) ADP inhibitors: Clopidogrel (Plavix), ticlopidine (Ticlid) Arterial vasodilators: pentoxifylline (Trental); dipyridamole (Persantine), |
| Administer Antiplatelets | Administration: oral (only exception is abciximab -REOPRO). |
| Antiplatelets Watch out | Watch Out! Additive risk for bleeding with other NSAIDs, heparin, warfarin. Pregnancy risk “D” = don’t use. Contraindicated with peptic ulcer disease, several renal/hepatic disorders. Adverse Reactions: Bleeding! |
| ASA __325__ mg | is given during acute MI; prevention accomplished with ___81__mg daily ASA therapy. |
| Clopidogrel (Plavix) Purpose | Prevent platelet aggregation (clumping) |
| Clopidogrel (Plavix) Watch Out! | Do not give to clients with active bleeding. Pregnancy category B. Adverse Reactions: Flu-like syndrome, headache, dizziness, rash (adverse effects generally are mild). Discontinue ___7__ days before surgery |
| Clopidogrel (Plavix) Administration | : Oral |
| Thrombolytics names | Prototype: Streptokinase (Streptase) Representative Names: Alteplase (Activase, tPA) Drug of choice for __ischemic_stroke____ Tenecteplase (TNKase) Reteplase (Retavase) |
| Thrombolytics Purpose | _Dissolving existing clots |
| Alteplase (Activase, tPA) Drug of choice for | __ischemic_stroke____ |
| Thrombolytics Nursing Consideration | Watch Out! Serious risk of bleeding – avoid venipunctures, I.M.s etc. during infusion. Apply pressure to any puncture sites. Monitor carefully for hemorrhage. |
| Thrombolytics use | USE: strictly prescribed by protocols, generally no more than __6__ hours after a cardiac event occurs and no more than __3__ hours after ischemic stroke. Before administration for stroke patient: MUST get a ___scan___ to rule out __hemorrhagic stroke__ |
| Hemostatic name | Prototype: Aminocaproic Acid (Amicar) |
| Hemostatic Purpose | Purpose: _Promote clot formation______ |
| Aminocaproic Acid (Amicar) | Administration: IV only during acute phase; oral tablet after. |
| Aminocaproic Acid (Amicar) Watch out | Watch Out! NEVER use in DIC states or when there is severe renal impairment. Adverse Reactions: Mild hypotension infusion. Headache/skin rash. |
| Aminocaproic Acid (Amicar) caution | Must be used cautiously when patients have history of thrombolytic states – remember, this stuff promotes __clots____ so watch for signs of “bad clots”! |
| Biologic Response Modifiers | Natural hormones that promote some aspect of blood formation are as a general term called hematopoietic growth factors i.e., they “grow” blood. |
| Biologic Response Modifiers Erythropoetic Growth Factors | Epoetin alfa (Epogen, Procrit) These factors stimulate erythrocyte, leukocyte or platelet production. This is why they are also called “Biologic Response Modifiers”. |
| Erythropoetic Growth Factors | Epoetin alfa (Epogen, Procrit) |
| Epoetin alfa (Epogen, Procrit) Administer | Administration: Preferred: __SQ__; _IV__ is an alternative route. Given 3x/week until therapeutic response seen. Shaking vial deactivates drug…so don’t! |
| Epoetin alfa (Epogen, Procrit) Watch Out! | A “no no” in view of uncontrolled hypertension. Adverse Reactions: ___Headache_____ ___fever____ ___NVD_______ ___Edema_______ ___Hypertension______ |
| Leukopoetic Growth Factors | |
| Leukopoetic Growth Factors Purpose and Names | Purpose: Stimulate WBC production: __Neutophils___ ONLY Prototype: Filgrastim (Neupogen) “LGF” Representative Names: Pegfilgrastim (Neulasta) |
| Filgrastim (Neupogen) “LGF” Pegfilgrastim (Neulasta) Administer | Administration: SQ or slow IV infusion |
| Filgrastim (Neupogen) “LGF” Pegfilgrastim (Neulasta) Watchout | Watch Out! Hypersensitivity to foreign proteins; existing myeloid cancers such as leukemia (may proliferation of bad cells). Adverse Reactions: _Bone pain____is common. _Flu-like symptons____ _fever___ _dyspnea_______ _hypertension_____ _Alle |
| When to STOP Filgrastim (Neupogen) “LGF” Pegfilgrastim (Neulasta) Watchout | If WBC >50,000 , ANC >20,000 or platelets >500,000…D/C or reduce treatment! |
| Colony Stimulating Growth Factors Purpose Sargramostim (Leukin) | Purpose: Stimulate __WBC____ production. |
| Colony Stimulating Growth Factors Sargramostim (Leukin) | Watch Out! Same as previous but add: cautious use with heart disease, hypoxia, peripheral edema, pleural/pericardial effusion. Contraindicated if patient allergic to yeast. Adverse Reactions: Diarrhea, rash, bone pain. |
| D/C or reduce treatment of Colony Stimulating Growth Factors Sargramostim (Leukin) | If WBC >50,000 , ANC >20,000 or platelets >500,000…D/C or reduce treatment! |
| Thrombopoietic Growth Factors Oprelvekin (Interleukin II, Neumega) | Purpose: Stimulate production of __platelets____ Administration: Like the others -don’t shake! |
| Thrombopoietic Growth Factors Oprelvekin (Interleukin II, Neumega)Watch out for | Started 4 to 6 hours after chemo & given once/day Watch Out! Caution if patient has: heart failure, pleural effusion, history of cardiac arrhythmia, bone marrow cancer. Adverse Reactions: Fluid retention. Conjunctival irritation, blurred vision, papil |
| What lab do you monitor (Oprelvekin (Interleukin II, Neumega) to see if it is working? | Monitor Platelets |
| What would your patientson (Oprelvekin (Interleukin II, Neumega) with a low platelet count look like? | thrombocytopenia-bruising bleeding |
| What improvement would you see (Oprelvekin (Interleukin II, Neumega) ? | increased platelet production no bleeding |
| Replacement: Blood & Blood Products – Whole Blood purpose | Purpose: To replace BOTH plasma volume and RBCs to improve __O2__ carrying capacity. |
| Replacement: Blood & Blood Products - PRBCs Packed Red Cells (PRBCs) | Purpose: Red blood cells are indicated for patients with a symptomatic deficiency of oxygen-carrying capacity or tissue hypoxia due to an inadequate circulating red cell mass. |
| The ABO type of the donor should be compatible with | the recipient’s |
| . Type A can receive from | type A or O, type O. |
| type B from | B or O, |
| type AB can receive from | types A, B, AB, or O |
| type O only from | type O |
| Replacement: Blood & Blood Products – Platelet concentrate Purpose | Purpose: Use to treat bleeding due to decreased circulating platelet counts or functionally abnormal platelets. Use prophylactically to prevent bleeding at pre-specified low platelet counts |
| Replacement: Blood & Blood Products - FFP Purpose Fresh frozen plasma (FFP) | Purpose: Indicated for use in patients with : 1. Active bleeding due to deficiency of multiple coagulation factors, or risk of bleeding due to deficiency of multiple coagulation factors. 2. Severe bleeding due to warfarin therapy, or urgent reversal of |
| Replacement: Blood & Blood Products: Pheresed granulocytes | Purpose: Replace neutrophils/granulocytes (neutrophils, basophils, eosinophils). Severe neutropenia (ANC <500) Life-threatening bacterial/fungal infections Neonatal sepsis Prototype: Pheresed granulocytes |
| Replacement: Blood & Blood Products: Albumin | Purpose: Rapid expansion of circulating volume. Primary conditions include: Hypovolemia Hypoalbuminemia Burns Prototype: Albumin Does not require type & x-match |
| The major cause of acute transfusion-related death is | The major cause of acute transfusion-related death is error in identification. Patient identification is the most important step in the transfusion procedure. |
| Whole Blood Administration Notes | ABO must be identical & Rh compatible Infuse: as fast as possible |
| PRBCs Administration Notes | ABO & Rh must both be compatible Infuse: < 4 hours per unit |
| Platelet concentrate Administration Notes | ABO compatible preferred but not absolute; Rh compatible. Infuse: as fast as possible but < 4 hours per unit |
| FFP Administration Notes | ABO compatible; Rh compatible preferred but not strictly required. Infuse: <4 hours per unit & within 24 hours of thaw. |
| Pheresed granulocytes Administration Notes | ABO & Rh must both be compatible Infuse: over 2 – 4 hours (usually faster…) |
| Albumin Administration Notes | No compatibility testing required (No ABO present). Infused: ATI says “slow” -Comes in 5% and 25% solutions; 5% given faster, 25% given slow. |
| Hemolytic Reaction | Chills, fever, low back pain, tachycardia, tachypnea, hypotension |
| Febrile “non-hemolytic” Reaction | Chills, fever, headache |
| Anaphylactic reaction | Anxiety, urticaria, wheezing, shock, cardiovascular collapse |
| Mild allergic reaction | Flushing, itching, urticaria (common and is why Benedryl may be given prophylactically) |
| Circulatory overload | Cough, dyspnea, crackles at lung bases, hypertension, tachycardia, JVD |
| Sepsis | Rapid onset of chills and fever; vomiting, diarrhea, hypotension, shock – generally not “immediate |
| Complications & Nursing Management | Circulatory Overload: Transfuse blood slowly to prevent circulatory overload. |
| Symptoms of Circulatory overload | Signs include dyspnea, orthopnea, cyanosis, or sudden anxiety. If the transfusion is continued, severe dyspnea and coughing of pink, frothy sputum can occur. Neck vein distention, crackles at the base of the lungs, and rise in central venous pressure will |
| Treatment of Circulatory overload | Position the patient with the feet in a dependent position Discontinue the blood transfusion Notify the physician. Keep the IV line patent with very slow infusion of normal saline to retain access to the vain in case IV medications are necessary. |
| Febrile Reaction: | May occur because of the presence of bacterial pyrogens, sensitivity to leukocytes or platelets, hemolytic episodes, or unknown factors. If contaminated blood is infused, the patient develops fever, and shaking chills within 30 minutes, and shock soon f |
| Febrile Reaction Treatment | Even if the cause of this reaction is recognized early, mortality is high. Discontinue the transfusion Keep the IV line is kept open with normal saline. Notify the physician and blood bank Monitor the patient's temperature is monitored for 30 minu |
| Allergic Reaction: | Signs and symptoms include urticaria (hives) or generalized itching or, wheezing or anaphylaxis. MILD: These respond to antihistamine. If uticaria is the only symptom, the transfusion can sometimes be continued at a slower rate. SEVERE (ANAPHYLACTIC |
| Septic Reaction: | This is a severe reaction that results from transfusion of blood or components contaminated with bacteria. Preventative measures include administering blood within a 4 hour period before warm room temperatures promote bacterial growth, inspecting bloo |
| Hemolytic Reaction: | This is the most dangerous type of all of the reactions because the donor blood is incompatible with that of the recipient. Symptoms consist of chills, low back pain, headache, nausea, or chest tightness followed by fever and hypotension and vascular c |
| SHOCK | Inadequate blood flow to meet body's needs Considered medical emergency Can lead to irreversible organ damage and death Collection of nonspecific signs and symptoms Affects the nervous, renal, cardiovascular systems |
| Symptoms of Shock | Most types have symptoms in common Pallor; cold, clammy skin Feeling of sickness and weakness Restlessness, anxiety, confusion, depression, apathy B/P low, heart rate may be rapid with weak pulse Breathing usually rapid and shallow Unconsciousness |
| Treatment of Shock | ABCs of life support Airway Breathing Circulation Identify underlying cause, then start more specific treatment Connect to a cardiac monitor, and apply a pulse oximeter |
| Drugs to Treat Shock | Blood or blood products May be administered to restore fluid volume Whole blood for acute, massive blood loss (more than 30% of total volume) Blood or blood products Replace plasma volume and supply red blood cells Components Whole blood, plasma pro |
| Drugs to Treat Shock | Colloid Agents Mechanism of action: to maintain plasma osmotic pressure; transport substances through blood Primary use: restoration of plasma volume and blood proteins Examples of blood colloids Normal human serum albumin, plasma protein fraction, se |
| Drugs to Treat Shock | Digoxin Dobutamine Dopamine Epinephrenine Norepinephrine Phenylephrine |
| Treatment of Anaphylaxis | Prevention by knowledge of triggers, carrying EpiPen or Auvi-Q Sympathomimetics, antihistamines, glucocorticoids Therapy is symptomatic To support cardiovascular system To prevent further hyperreaction of immune system Give oxygen immediately Ant |
| Sympathomimetic/Anaphylaxis epinephrine (Adrenalin) Action | Mechanism of action: for use as nonselective adrenergic agonist Primary use: to treat anaphylaxis, shock, cardiac arrest |
| Sympathomimetic/Anaphylaxis epinephrine (Adrenalin) Adverse effect | Adverse effects: hypertension and dysrhythmias |
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