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 ID: 390215
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Slide1
Anticoagulation Reversal
May 11, 2013Slide2
Objectives
Develop an approach for treating patients with iatrogenic coagulopathy
Understand recent changes in STEMI care
Review the ICH treatment protocolSlide3
Patient Care
Medical
Knowledge
Practice-Based
Learning and ImprovementInterpersonal and Communication SkillsProfessionalismSystems-Based Practice
ACGME Competencies AddressedSlide4Slide5
Tissue factor pathway
Contact activation pathway Slide6
Tissue factor pathway
Contact activation pathway
Haemophilia
A
Haemophilia BSlide7
What is the mechanism of action of warfarin?
Slide8
What is the mechanism of action of warfarin?
Inhibits Vitamin K
epoxide
r
eductase Slide9
The American College of Chest Physicians guideline for the reversal of anticoagulation therapy (8th ed.).Slide10
Vitamin K epoxide
reductaseSlide11
What clotting factors are affected by warfarin?Slide12Slide13
78 year old with history of PE presents with weakness and UTI. INR = 8. Slide14Slide15
58 year old with history of atrial fibrillation and HTN on warfarin presents with
ICH. GCS =
6 and INR = 4. Slide16Slide17
67 year old with
pmh
atrial fibrillation on warfarin presents with brisk nose bleed. INR = 6.Slide18
What is the universal donor FFP type?Slide19
What is the universal donor FFP type?
ABSlide20
One unit plasma replaced what percent of clotting factors?Slide21
One unit plasma replaced what percent of clotting factors?
2.5%Slide22
How low can you get the INR with FFP?Slide23
How low can you get the INR with FFP?
1.5Slide24
Name two problems with FFPSlide25
Name two problems with FFP
Time
VolumeSlide26
PCC
What types of PCC are there?Slide27
PCC
What types of PCC are there?
3 factor
4 factorSlide28
3 Factor PCC
Profilnine
II
IX
XVery small amount of VIISlide29Slide30Slide31
Kcentra
4F-PCC
II
VII
IXXSlide32Slide33Slide34
What is the mechanism of action of
Xabans
?Slide35
What is the mechanism of action of
Xabans
?
Xa
inhibitorSlide36
Xabans
-
rivaroxaban
(
Xarelto)Slide37
How would you treat major bleeding in someone on
Rivaroxaban
?Slide38
How would you treat major bleeding in someone on
Rivaroxaban
?
PCC (?)Slide39
Xabans
Rivaroxaban
(
Xarelto
)Xa inhibitorsPCCSlide40
Dabigatran (
Pradaxa
)
What is mechanism of action?Slide41
d
abigatran
(
Pradaxa
)Slide42
Dabigatran
(
Pradaxa
)
Renal metabolismCan not be monitoredNormal PTT helpful, but abnormal PTT not helpfulPCC?FEIBA (Factor eight inhibitor bypass activity)?Slide43
What is the mechanism of action of heparin?Slide44
Heparin
Activates
Antithrombin
IIISlide45
Heparin
Activates
Antithrombin
IIISlide46
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?Slide47
How do you treat a patient with major bleeding on heparin?
ProtamineSlide48
LMW HeparinSlide49
Low Molecular Weight Heparin
Blocks
Xa
Protamine causes partial reversalSlide50
Tissue Plasminogen
Activator
Cryoprecipitate
Platelets
FFPHeparin reversal if on heparinSlide51
Tissue
Plasminogen
ActivatorSlide52Slide53
Safest c
entral
l
ine site for a patient with an elevated INRSlide54
Safest c
entral
l
ine site for a patient with an elevated INR
Internal JugularSlide55
What should the INR be before dong an LP?Slide56
What should the INR be before dong an LP?
1.5Slide57
ICH ProtocolSlide58
Antiplatelet Therapy
Cyclooxygenase Inhibitors
P2Y12 receptor antagonists (ADP)
GP
Iib/IIIa antagonistsSlide59Slide60Slide61
How does aspirin work?Slide62
How does aspirin work?
Irreversible inhibition of COX-1 (cyclooxygenase 1)
Blocks TXA2 production (thromboxane A2)?Slide63Slide64Slide65
Treatment of major bleeding for a patient on aspirin?Slide66
Treatment of major bleeding for a patient on aspirin?
Platelet transfusion
DDAVP (analog of vasopressin)Slide67
1 unit of single donor (
pheresis
) platelets = how many units of pooled donors?Slide68
1 unit of single donor (
pheresis
) platelets = how many units of pooled donors?
6-10Slide69
What is Aggrenox?Slide70
What is Aggrenox?
Aspirin
DipyridamoleSlide71Slide72
What is the half life of clopidogrel
?Slide73
What is the half life of clopidogrel
?
6-7 hours
Binds P2Y12 receptor irreversiblySlide74Slide75
P2Y12 Inhibitors
Clopidegrel
(Plavix)
Prasugrel
TicagrelorSlide76
What are two drug classes you may want to avoid for patients on
clopidogrel
?Slide77
What are two drug classes you may want to avoid for patients on
clopidogrel
?
PPIs
MacrolidesSlide78
Which P2Y12 inhibitor should you avoid in a patient with a history of TIA or CVA
PrasugrelSlide79Slide80
How do you treat a patient on
clopidogrel
with major bleeding?Slide81
How do you treat a patient on
clopidogrel
with major bleeding?
Platelets – 2 units
DDAVP?fFVII?Slide82
GPIIbIIIa Inhibitor
Abciximab
(
ReoPro
)Triofiban (Aggrastat)Eptifibatide (Integrillin)Slide83Slide84
STEMI ProtocolSlide85
What antiplatelet is given to STEMI patients at
SJH and MMC
?
Slide86
What antiplatelet is given to STEMI patients at
SJH and MMC
?
Ticagrelor
(Brilinta)Slide87
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. Slide88
What has just replaced heparin in the STEMI (Star 80) at MMC?Slide89
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 medicinalisSlide90
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
BSlide91
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
B
I
IIa
IIb
III
B
HarmSlide92
Why I get confused
Aggrenox
Angiomax
AggrastatSlide93
Objectives
Learn strategies for treating patients with iatrogenic coagulopathy
Understand recent changes in STEMI care
Review the ICH treatment protocolSlide94
Dr. J. Wall on coagulopathy in trauma June 6
th
.Slide95
Recommended preparation
CAEP 2012 Annual Conference
June 3- June 6,
2012
What's New in the Management of the Massively Bleeding Trauma PatientDr. Sandro Rizoli