Transcript Heparin
Heparin – Lovenox - Coumadin
Charnelle Lee, RN, MSN
Heparin
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Anticoagulant
Does not dissolve clots
Interrupts the clotting process
Helps the body stop the size of the clot from
increasing
• Takes 6 weeks for an existing clot to dissolve
• Of course this is dependant on the size and
patient condition
Heparin Antidote
• Heparin® Antidote Protamine Sulfate
• Protamine sulfate is a heparin antidote that works against
the anti-coagulating effects of heparin by binding to the
drug and making it ineffective.
• Originally derived from the sperm of salmon, protamine
sulfate can only effectively counteract heparin if 1mg of
protamine sulfate is administered for every 100 IU of active
heparin received.
• It's important to note that Vitamin K, which is effective at
promoting blood clotting, is not an effective heparin
antidote, as Vitamin K cannot stop heparin from working
(like protamine sulfate does).
Protamine Sulfate
• Unfortunately, using protamine sulfate to stop the
effects of heparin can have its own complications,
including:
• constricting the lung's airways (bronchoconstriction)
• dramatically increasing or decreasing blood pressure
• severe allergic reaction, characterized by facial or
tongue swelling, breathing difficulties and/or skin rash
• promoting anti-coagulation (if large enough doses are
administered)
Side Effects
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Abdominal or stomach pain or swelling
Back pain or backaches
Bleeding from the gums when brushing teeth
Blood in the urine
Constipation
Coughing up blood
Dizziness
Headaches, severe or continuing
Heavy bleeding or oozing from cuts or wounds
Joint pain, stiffness, or swelling
Menstrual bleeding, unexpected or unusually heavy
Unexplained bruising or purplish areas on the skin
Unexplained nosebleeds
Vomiting of blood or material that looks like coffee grounds
Heparin-Induced hrombocytopenia (HIT)
• Description
– Two distinct types
• Type I HIT
– Most common type
– Non-autoimmune condition
– Transient, often resolves spontaneously
• Type II HIT
– Less common, more severe
Etiology of Type II HIT
• Immune-mediated response to the
administration of heparin
– Observed in 3% to 5% of patients treated
with unfractionated heparin
– Also occurs after exposure to low–
molecular-weight heparin (less common)
• Characterized by severe thrombocytopenia
during heparin therapy
• Onset 5 to 14 days after first exposure to
heparin, can be within hours of re-exposure to
heparin
• Mortality rates as high as 30%
Assessment and Diagnosis of Type II HIT
(Continued)
• Laboratory findings
– Key indicator is platelet count
• Platelet count <50,000/mm3
• Sudden drop of 30% to 50% from patient’s
baseline platelet count
– Assays to assist in confirming diagnosis
• Heparin-induced platelet aggregation
• Serotonin release assay
Medical Management of Type II HIT
• Early identification is critical to managing
effects of Type II HIT
• Focus of medical management revolves
around:
– Identification of Type II HIT
– Discontinuation of heparin therapy
– Alternative form of anticoagulation if needed
Nursing Management of Type II HIT
• Nursing priorities in the management of
the patient with HIT are focused toward:
– Ensuring that all heparin is discontinued.
– Maintaining surveillance for complications.
– Providing comfort and emotional support.
Laboratory monitoring: platelet count
• Check PLT count daily to detect heparin induced
thrombocytopenia (HIT)
• If count drops 30-50%, consider HIT, withdraw
heparin, start alternative anticoagulant, order
confirmatory test for HIT
• Overdose of UFH
• Stop heparin and monitor PTT. Heparin half-life is
approximately 30 minutes. If bleeding is severe,
consider protamine sulfate (1 mg/100 units
heparin)
• FFP does not reverse heparin effect
Coumadin
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Warfarin (Coumadin) Indications for warfarin
Treatment of arterial and venous thrombosis to prevent clot propagation
Prevention of thromboembolic disease in thrombophilia, atrial fibrillation,
mechanical heart valves, and high-risk surgery
Mechanism of action for warfarin
Prevents the vitamin K dependent gamma-carboxylation of factors II, VII, IX, and X,
proteins C and S, slowing thrombin production
Dosage of warfarin
5-10 mg/day with no loading dose. Must be monitored due to unpredictable halflife.
Affected by many drugs and dietary variation
Requires 2-7 days to reach therapeutic levels. To achieve immediate
anticoagulation, begin with heparin
Laboratory monitoring: The INR
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Laboratory monitoring: The INR
PT generates the international normalized ratio (INR) by this formula:
INR = (Patient PT/MRI PT) ISI
Where…
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PT = prothrombin time in seconds
MRI = geometric mean of reference interval
ISI = international sensitivity index supplied by reagent manufacturer
Target INRs
Post-myocardial infarction, most therapy and prophylaxis: INR 2.0-3.0
Mechanical heart valves: INR 2.5-3.5
Laboratory monitoring sequence
Daily until INR is therapeutic twice at least 24 hours apart
Twice a week for 2 weeks, then once a month until therapy is complete
Minor bleeding
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Warfarin dosage
INR 2-3.5
Decrease, look for site
INR 3.5-5
Stop drug, reinstitute at lower dose
INR 5-8
Stop drug, give 2.5 mg K PO or 1 mg SQ
INR 5-8, thrombotic risk high
Stop drug, do not give K
INR > 8
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Stop drug, give 5 mg K PO or 2-5 SQ
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Consider 10 mL/kg FFP or 25 U/kg PCCs (p. 36)
Managing warfarin overdose
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No bleeding
Warfarin dosage
INR 3.5-5
Decrease, do not stop drug
INR 5-8
Decrease, consider 1 mg K PO
INR 5-8, bleeding risk high
Decrease, give 2.5-5 mg K PO or1 mg SQ
INR > 8
Stop drug, give 2.5-5 mg K PO or 2-3 mg SQ
INR > 8, bleeding risk high
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Stop drug, give 5 mg K PO or 3-5 mg SQ
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Consider 10 mL/kg FFP or 25 U/kg PCCs (p. 36)
Major bleeding
• Warfarin dosage
• INR 2-3.5
• Stop drug, give 5 mg SQ K or IV, repeat as necessary, look for
bleeding site
• INR 3.5-5
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Stop drug, give 5-10 mg K SQ or IV, repeat
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Consider 10-15 mL/kg FFP or 25-50 U/kg PCCs (p. 36)
• INR 5-8
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Stop drug, give 5-10 mg K SQ or IV, repeat
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Give 15 mL/kg FFP or 25-50 U/kg PCCs (p. 36)
• INR >8
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Stop drug, give10 mg K SQ or IV, repeat 6h
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Give 15 mL/kg FFP or 25-50 U/kg
Antidotes
• Heparin –
• Coumadin–1
–2
LMWH
• What is Lovenox?
• Lovenox is an anticoagulant (blood thinner) that prevents
the formation of blood clots.
• Lovenox is used to treat or prevent a type of blood clot
called deep vein thrombosis (DVT), which can lead to blood
clots in the lungs (pulmonary embolism). A DVT can occur
after certain types of surgery, or in people who are bedridden due to a prolonged illness.
• Lovenox is also used to prevent blood vessel complications
in people with certain types of angina (chest pain) or heart
attack.
• Lovenox may also be used for other purposes not listed in
this medication guide
Difference between Heparin and
Lovenox
• Lovenox is a brand name for the prescription
medication enoxaparin, which, like heparin, is
prescribed for the treatment of blood clots.
Lovenox is actually derived from heparin and has
molecules with a lighter weight than its parent
drug.
Read more at Suite101: Lovenox vs. Heparin:
Differences Between Anticoagulant Medications |
Suite101.com
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