ANTICUAGULANT A.Rahimzadeh.B.sc,M.sc Shahid Beheshty university

What is Anticoagulation? Anticoagulation: blocking, suppression or delaying of clotting of the blood Clot formation occurs when blood contact “foreign” surface,such as: Blood enters the bloodlines & dialyzer

What cause blood to clot? Clotting is a part of complex body process: Hemostasis Hemostasis involves: Retraction and contraction of the injured vessel Platelets to stick to the injured area A complex interaction of coagulation factor Coagulation factor: present in normal blood identify by roman numerals

Clotting of the ExtraCorporeal Circuit : Favoring Factors High Ultra Filtration Rate High Hematocrit Problems With a Dialysis Access Blood and Blood Product Transfusion Intradialytic Lipid Infusion Use of Drip Chambers Low Blood Flow

Assessing Coagulation During Dialysis Visual Inspection ExtraCorporeal Circuit Pressures Dialyzer Appearance After Dialysis Clotting Time Tests

Visual Inspection: Signs of Clotting in the ExtraCorporeal Circuit Extremely Dark Blood Shadows or Black Streaks in the Dialyzer Foaming with Subsequent Clot Formation in Drip Chambers and Venous Trap Presence of Clots at the Arterial-Side Dialyzer

ExtraCorporeal Circuit Pressures Pre-pump Arterial Pressure Post-pump arterial Pressure Venous Pressure Increase Post-pump Arterial Pressure & Decrease Venous Pressure Increase Post-pump Arterial Pressure & Increase Venous Pressure

Dialyzer Appearance After Dialysis Determine of Dialyzer Clotting Grade * Grade 1: rate of Clotting < 10% * Grade 2: rate of Clotting < 50% * Grade 3: rate of Clotting > 50 % Report of High Grade Clotting

Clotting Time Tests Whole- Blood Partial Thromboplastin Time (WBPTT) Activated Clotting Time (ACT) Lee-White Clotting Time (LWCT)

Goal Clotting Time In Hemodialysis Normal Range :60-85 s During Dialysis:+80% (120-140 s) Normal Range:120-150 s (200-250 s) Normal Range: 4-8 m During Dialysis:20-30 m Whole- Blood Partial Thromboplastin Time Activated Clotting Time Lee-White Clotting Time

تجویز هپارین به مقدار کم Goal Clotting Time in Hemodialysis تجویز هپارین به مقدار کم تجویز روتین هپارین میزان مطلوب پایان دیالیز حین دیالیز میزان طبیعی نوع آزمایش +40% (85-105)" (85-105)'' %80+ (120-140)” 60”-85” WBPTT %40+ (170-190)” (200-250)” 120”-150” ACT 9-16' 20-30' 4'-8' LWCT

Which tests are best for HD? Lee- white clotting time: Long clotting time involved Poor standardization Poor reproducibility PTT: Must be performed in laboratory Is reliable only at lower levels of Heparin ACT: Easily used in dialysis

Anticoagulation Techniques Routine Heparin: a- Constant–infusion method b- Repeated–bolus method Tight Heparin Heparin-Free Dialysis Regional Anticoagulation with Protamin Reversal Regional Citrate Anticoagulation Regional Prostacyclin Anticoagulation Recombinant Hirudin Anticoagulation Low Molecular Weight Heparin

Routine Heparin 1- Constant–infusion method Bolus : 2000 & infusion: 1200 IU/hr Control Clotting Time: every hour Discontinue infusion: 1 hour before the termination of Dialysis 2- Repeated–bolus method Primary Bolus: 4000 IU Additional Bolus Dose: 1000-2000 IU

Tight Heparin Indications: gastritis, Peptic Ulcer, Diabetic Retinopathy, First Dialysis, … 1- Constant–infusion method Primary Bolus: 750 IU infusion Rate: 600 IU/hr 2- Repeated–Bolus method Primary Bolus: 1000 IU Bolus: 500 IU/hr

Heparin- Free Dialysis: Indications Pericarditis Recent Surgery: Vascular/Cardiac Surgery Eye Surgery Renal Transplant Brain Surgery Coagulopathy Thrombocytopenia Intracerebral Hemorrhage Active Bleeding

Heparin-Free Dialysis Heparin Prime (2000-5000 IU/1000 cc Nacl ) Prime without heparin BF: 250-500ml/min Nacl falsh every 25-30 min ( 25-30 cc)

Primary Bolus: 25-50 IU/kg (50 > Body weight >90 ) Heparin Dosage 1- Heparin dosage prescribe base on DW: Primary Bolus: 25-50 IU/kg (50 > Body weight >90 ) Bolus : 1000-2000 IU/hr 2- Dosage adjustment need if there is a change in: Patient dry weight Length of treatment Dialyzer membrane EPO Dosage Urea clearance

Blood Transfusion in Heparin-free dialysis BT can complicate Heparin-free dialysis Blood Transfusion: increases viscosity of the blood Infuse normal clotting factor Solution: Saline rinses Other parameters remain like Heparin-free Dilalysis

Vascular Catheter & Heparin Lock After Dialsis : Flush each lumen of the catheter with 10 ml normal saline Instill a prescribed volume of heparin in lumen Clamp the lumen immediately

Clotting Factors: Technical or Operator-Induced Dialyzer Priming Retained Air in Dialyzer Lack or Inadequate Priming of Heparin Infusion Line Heparin Administration Incorrect Heparin Pump Setting Incorrect Loading Dose Delayed Starting of Heparin Pump Failure to Release Heparin Line Clamp Improper Time Lapse after Loading Dose Vascular Access Inadequate Blood Flow (Needle/Catheter Positioning or Clotting) Frequent Interruption of BF(Machin alarm/Inadequate BF)

Heparin–Associated Complications Bleeding Hyperlipedemia Hyperkalemia Thrombocytopenia Pruritus

Drugs intraction with Heparin Enhance the effectiveness of heparin: Aspirin Nonstreroidal anti-inflammatory agents Dextran Decrease the effectiveness of heparin: Cardiac glycoside Nicotine Quinine Tetracycline

کلام آخر هر 100 میلی لیترخون حاوی14- 17 گرم پروتئین میباشد ! هربیمار دیالیزی درهرجلسه دیالیز 5- 10 گرم آمینواسید از دست می دهد شما چه سهمی در کاهش این رقم دارید؟ به نظر شماچه راهکاری در جهت کاهش احتمال تشکیل لخته موثرتراست؟