anticoagulation reversal may 11, 2013. objectives develop an approach for treating patients with...
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Patient Care Medical Knowledge Practice-Based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems-Based Practice ACGME Competencies AddressedTRANSCRIPT
Anticoagulation Reversal
May 11, 2013
Objectives
• Develop an approach for treating patients with iatrogenic coagulopathy
• Understand recent changes in STEMI care• Review the ICH treatment protocol
Patient Care
Medical Knowledge
Practice-Based Learning and ImprovementInterpersonal and Communication Skills
ProfessionalismSystems-Based Practice
ACGME Competencies Addressed
Tissue factor pathway
Contact activation pathway
Tissue factor pathway
Contact activation pathway
Haemophilia A
Haemophilia B
What is the mechanism of action of warfarin?
What is the mechanism of action of warfarin?
• Inhibits Vitamin K epoxide reductase
The American College of Chest Physicians guideline for the reversal of anticoagulation
therapy (8th ed.).
Vitamin K epoxide reductase
What clotting factors are affected by warfarin?
78 year old with history of PE presents with weakness and UTI. INR = 8.
58 year old with history of atrial fibrillation and HTN on warfarin presents with ICH. GCS = 6 and INR = 4.
67 year old with pmh atrial fibrillation on warfarin presents with brisk nose bleed. INR = 6.
What is the universal donor FFP type?
What is the universal donor FFP type?
• AB
One unit plasma replaced what percent of clotting factors?
One unit plasma replaced what percent of clotting factors?
• 2.5%
How low can you get the INR with FFP?
How low can you get the INR with FFP?
• 1.5
Name two problems with FFP
Name two problems with FFP
• Time• Volume
PCCWhat types of PCC are there?
PCCWhat types of PCC are there?
• 3 factor• 4 factor
3 Factor PCCProfilnine
• II• IX• X• Very small amount of VII
Kcentra
• 4F-PCC– II– VII– IX– X
What is the mechanism of action of Xabans?
What is the mechanism of action of Xabans?
• Xa inhibitor
Xabans-rivaroxaban (Xarelto)
How would you treat major bleeding in someone on Rivaroxaban?
How would you treat major bleeding in someone on Rivaroxaban?
• PCC (?)
XabansRivaroxaban (Xarelto)
• Xa inhibitors• PCC
Dabigatran (Pradaxa)
• What is mechanism of action?
dabigatran(Pradaxa)
Dabigatran (Pradaxa)
• Renal metabolism• Can not be monitored• Normal PTT helpful, but abnormal PTT not
helpful• PCC?• FEIBA (Factor eight inhibitor bypass activity)?
What is the mechanism of action of heparin?
Heparin
• Activates Antithrombin III
HeparinActivates Antithrombin III
You have a patient in the ED with a non-STEMI. You put them on heparin. They develop a severe headache and you diagnose an ICH.
What do you do?
How do you treat a patient with major bleeding on heparin?
• Protamine
LMW Heparin
Low Molecular Weight Heparin
• Blocks Xa• Protamine causes partial reversal
Tissue Plasminogen Activator
• Cryoprecipitate• Platelets• FFP• Heparin reversal if on heparin
TissuePlasminogenActivator
Safest central line site for a patient with an elevated INR
Safest central line site for a patient with an elevated INR
• Internal Jugular
What should the INR be before dong an LP?
What should the INR be before dong an LP?
• 1.5
ICH Protocol
Antiplatelet Therapy
• Cyclooxygenase Inhibitors• P2Y12 receptor antagonists (ADP)• GP Iib/IIIa antagonists
How does aspirin work?
How does aspirin work?
• Irreversible inhibition of COX-1 (cyclooxygenase 1)
• Blocks TXA2 production (thromboxane A2)?
Treatment of major bleeding for a patient on aspirin?
Treatment of major bleeding for a patient on aspirin?
• Platelet transfusion• DDAVP (analog of vasopressin)
1 unit of single donor (pheresis) platelets = how many units of pooled donors?
1 unit of single donor (pheresis) platelets = how many units of pooled donors?
6-10
What is Aggrenox?
What is Aggrenox?
• Aspirin• Dipyridamole
What is the half life of clopidogrel?
What is the half life of clopidogrel?
• 6-7 hours• Binds P2Y12 receptor irreversibly
P2Y12 Inhibitors
• Clopidegrel (Plavix)• Prasugrel• Ticagrelor
What are two drug classes you may want to avoid for patients on clopidogrel?
What are two drug classes you may want to avoid for patients on clopidogrel?
• PPIs• Macrolides
Which P2Y12 inhibitor should you avoid in a patient with a history of TIA or CVA
• Prasugrel
How do you treat a patient on clopidogrel with major bleeding?
How do you treat a patient on clopidogrel with major bleeding?
• Platelets – 2 units• DDAVP?• fFVII?
GPIIbIIIa Inhibitor
• Abciximab (ReoPro)• Triofiban (Aggrastat)• Eptifibatide (Integrillin)
STEMI Protocol
What antiplatelet is given to STEMI patients at SJH and MMC?
What antiplatelet is given to STEMI patients at SJH and MMC?
Ticagrelor (Brilinta)
Ticagrelor
• "David Griffen" wrote: Frank, Could you please refresh my memory - what was the rationale regarding replacing Plavix with ticagrelor for the STEMI orders?
• It's proven clinical superiority in head-to-head ACS clinical trial (PLATO) for which it has received a Class I recommendation in the 2013 ACC/AHA STEMI guidelines and is preferred over plavix in the 2012 European STEMI guidelines.
What has just replaced heparin in the STEMI (Star 80) at MMC?
What has just replaced heparin in the STEMI (Star 80) at MMC?
• Angiomax (bivalirudin)• Revisable inhibitor of thrombin• it is a synthetic congener of the naturally
occurring drug hirudin (found in the saliva of the medicinal leech Hirudo medicinalis
Anticoagulant Therapy to Support Primary PCI
For patients with STEMI undergoing primary PCI, the following supportive anticoagulant regimens are recommended:
• UFH, with additional boluses administered as needed to maintain therapeutic activated clotting time levels, taking into account whether a GP IIb/IIIa receptor antagonist has been administered; or
• Bivalirudin with or without prior treatment with UFH.
I IIa IIb III
I IIa IIb III
Anticoagulant Therapy to Support Primary PCI
In patients with STEMI undergoing PCI who are at high risk of bleeding, it is reasonable to use bivalirudin monotherapy in preference to the combination of UFH and a GP IIb/IIIa receptor antagonist.
Fondaparinux should not be used as the sole anticoagulant to support primary PCI because of the risk of catheter thrombosis.
I IIa IIb III
I IIa IIb III
Harm
Why I get confused
• Aggrenox• Angiomax• Aggrastat
Objectives
• Learn strategies for treating patients with iatrogenic coagulopathy
• Understand recent changes in STEMI care• Review the ICH treatment protocol
• Dr. J. Wall on coagulopathy in trauma June 6th.
Recommended preparation
• CAEP 2012 Annual ConferenceJune 3- June 6, 2012– What's New in the Management of the Massively
Bleeding Trauma PatientDr. Sandro Rizoli