1. Chapter 9 Medications that Affect Coagulation Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.

2. Objective 1  Define terms related to blood coagulation and medications that affect coagulation.

3. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 1  Anticoagulants  Agents that inhibit blood clotting  Coagulation (clotting) factors  A series of twelve factors essential to normal blood clotting  Coagulants  Agents that promote, accelerate, or make possible blood coagulation  Hemostatics  Agents that enhance clot formation and reduce bleeding

4. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 1  Parenteral  Administration route other than the alimentary canal (e.g., intramuscular, intravenous, subcutaneous)  Platelet aggregation  Clumping together of platelets; part of a sequential mechanism leading to blood clot (thrombus) formation

5. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 1  Systemic  Pertaining to or affecting the body as a whole  Thrombolytics (fibrinolytics)  Agents that dissolve blood clots  Thrombosis  Abnormal formation or presence of a blood clot within a blood vessel

6. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2  Describe the physiology of blood clot formation.

7. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Physiology of Clotting  Blood naturally has  Coagulants  Anticoagulants  Blood must flow smoothly  But not from a damaged vessel

8. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Physiology of Clotting  Natural coagulants  For small vessels only Example: paper cut on finger Example: paper cut on finger  Prevents some blood loss

9. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Physiology of Clotting  Natural anticoagulants  Prevent undesired clotting in undamaged vessels  Interfere with clotting sequence

10. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Physiology of Clotting  Physiology of clotting is a  Cascade in 3 stages  Stage 1: thromboplastin  Stage 2: thrombin  Stage 3: fibrin

11. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Physiology of Clotting

12. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Physiology of Clotting  Stage 1: 2 mechanisms  Extrinsic — initiated by Factors outside blood Factors outside blood  Intrinsic — initiated by Factors contained in blood Factors contained in blood

13. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Physiology of Clotting  Stage 1: extrinsic  Damaged tissue releases  Factor III (t. thromboplastin)  Plus factor VIII and Ca + =  Activated factor X, plus factor V plus Ca + = thromboplastin

14. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Physiology of Clotting  Stage 1: intrinsic  Damaged vessel releases  Factor XII activates factor XI  Activates factor IX  Factor VIII and Ca + =  Activated factor X, plus factor V plus Ca + = thromboplastin

15. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Physiology of Clotting So, Stage 1 is the formation of:  Thromboplastin  (Prothrombin activator)  Two pathways to achieve it  Intrinsic  Extrinsic

16. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Physiology of Clotting Stage 2:  Thromboplastin converts  Prothrombin (factor II)  into thrombin

17. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Physiology of Clotting Stage 3:  Thrombin converts  Fibrinogen (factor I)  into fibrin  Fibrin is a mesh of protein threads; a net to form clot.

18. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Physiology of Clotting  A cascade requires many substances  In the correct amount  At the correct time  Remove 1 substance = no cascade = no clot

19. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Physiology of Clotting  Calcium (Ca + ) is required at all stages to enable critical steps.  Vitamin K is also required to synthesize several factors.

20. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Physiology of Clotting  Clotting in an intact vessel  Thrombosis  Arterial requires surgery  Venous usually treated medically

21. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3  List agents that affect coagulation by category.  Presented under the discussion of each category  Make drug cards for each

22. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 4  Identify the category of various agents that effect coagulation.  Each category will be presented with discussion.

23. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 5  State the purpose of each category of medications that effect coagulation.  Presented during discussion

24. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 6  Describe the action of medications that affect coagulation.  Presented during discussion of each agent.

25. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7  List uses, routes of administration, side effects, and contraindications for agents that affect coagulation. – Presented during discussion of each agent.

26. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Note: all categories/agents  These categories and agents do one of two things:  Assist natural clotting or  Prevent natural clotting

27. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Coagulants  Category: (objective 4)  Hemostatics  Purpose: (objective 5)  Promote, accelerate, or make possible blood clotting

28. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Coagulants: Hemostatics  Agents: (objective 3)  Absorbable gelatin  Action: (objective 6)  Primarily mechanical, with pressure to promote clot formation

29. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Absorbable Gelatin  Uses  General surgery, otologic, orthopedic, neurosurgery  Administration routes  Topical only

30. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Absorbable Gelatin  Side effects  N/A  Contraindications  Presence of infection

31. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Coagulants: Hemostatics  Agents: (objective 3)  Microfibrillar collagen Avitene; Instat MCH Avitene; Instat MCH

32. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Coagulants: Hemostatics  Microfibrillar collagen  Action: (objective 6)  Attracts platelets; triggers platelet aggregation

33. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Microfibrillar Collagen  Uses  General surgery, otologic, orthopedic, neurosurgery  Administration routes  Topical only

34. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Microfibrillar Collagen  Side effects  N/A  Contraindications  presence of infection

35. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Coagulants: Hemostatics  Agents: (objective 3)  Oxidized cellulose Surgicel, Oxycel Surgicel, Oxycel  Action: (objective 6)  Serves as a nucleus for clotting

36. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Oxidized Cellulose  Uses  Neurosurgery, otorhinolaryngology  Administration routes  Topical only

37. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Oxidized Cellulose  Side effects  N/A  Contraindications  Presence of infection

38. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Coagulants: Hemostatics  Agents: (Objective 3)  Absorbable collagen sponge Hemopad, Helistat, Collastat Hemopad, Helistat, Collastat  Action: (Objective 6)  Promotes platelet aggregation

39. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Absorbable Collagen Sponge  Uses  General surgery  Administration routes  Topical only

40. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Absorbable Collagen Sponge  Side effects  N/A  Contraindications  Not used on bone when using cement

41. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Absorbable Collagen Sponge  Agent: Superstat  Contains calcium  Action:  Activates body’s coagulation mechanism

42. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Absorbable Collagen Sponge  Uses  General surgery  Route  Topical  Side effects  N/A  Contraindications  Neurosurgery

43. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Coagulants: Hemostatics  Agents: (Objective 3)  Thrombin  Action: (Objective 6)  Catalyzing the conversion of fibrinogen to fibrin

44. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Thrombin  Uses  General surgery  Administration routes  Topical ONLY  Can cause systemic clotting if injected!

45. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Thrombin  Side effects  N/A  Contraindications – hypersensitivity

46. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Coagulants: Hemostatics  Agents: (objective 3)  Bone wax  Action: (objective 6)  Mechanical only, physical plug

47. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Bone Wax

48. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Bone Wax  Uses  Orthopedics, neurosurgery  Administration routes  Topical  Side effects  N/A  Contraindications  Hypersensitivity

49. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Coagulants: Hemostatics  Agents: (Objective 3)  Chemical Hemostatics Tannic acid Tannic acid Silver nitrate Silver nitrate  Action: (Objective 6)  Cauterization

50. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Chemical Hemostatics  Uses  Tannic acid (in combination) Tonsillectomy Tonsillectomy  Silver nitrate Remove warts Remove warts  Admin route  Topical

51. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Chemical Hemostatics  Side effects  N/A  Contraindications  Not for use near eyes

52. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Coagulants: Hemostatics  Agents: (Objective 3)  Chemical Hemostatics Monsel’s solution Monsel’s solution  Action: (Objective 6)  Cauterization

53. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Monsel’s Solution  Uses  Hemostasis for cervical cone biopsy  Admin route  Topical  Side effects  N/A  Contraindications  N/A

54. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Chemical Hemostatics  CAUTION: Do NOT confuse Monsel’s solution with Lugol’s solution, which is a staining agent  Both are iodine-based and brown in color  Both may be on back table for cervical conization

55. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Coagulants  Category: (Objective 4)  Systemic coagulants  Purpose: (Objective 5)  Replace deficiencies in natural clotting mechanism

56. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Coagulants: Systemic  Agents: (Objective 3)  Calcium salts  Action: (Objective 6)  Promotes clotting in all 3 stages of cascade

57. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Calcium salts  Uses  Replace deficiency  Preoperative or intraoperative  Administration routes  Surgery — IV  Medical — oral or IM

58. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Calcium salts  Side effects  N/A  Contraindications  MH susceptible patients

59. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Coagulants: Systemic  Agents: (Objective 3)  Vitamin K  Action: (Objective 6)   synthesis of prothrombin by liver

60. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Vitamin K  Uses: replace deficiency  Preoperative  Administration routes  Subcutaneous  RARE: IV  Side effects  N/A  Contraindications  N/A

61. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Coagulants: Systemic  Agents: (Objective 3)  Coagulation factors  VIII (AHF) & IX complex  Action: (Objective 6)  Vital links in cascade

62. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Coagulation factors  Uses: replace deficiency  Preoperative  Administration routes  IV  Side effects  N/A  Contraindications  N/A

63. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Anticoagulants  Category: (Objective 4)  Parenteral anticoagulants  Purpose: (Objective 5)  Prevent or interfere with clotting

64. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Anticoagulants: Parenteral  Agents: (Objective 3)  Heparin  Action: (Objective 6)  Inhibits factor X and thrombin  Inhibits platelet aggregation

65. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Heparin  Uses  All vascular and cardiac surgery  Administration routes  IV, subq  Topical (at surgical site)

66. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Heparin  Side effects   risk hemorrhage  Thrombocytopenia  Contraindications  Existing thrombocytopenia

67. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Heparin  Note: heparin strengths must be labeled

68. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Anticoagulants: Parenteral  Agents: (Objective 3)  Enoxaparin (Lovenox)  A LMW form of heparin  Action: (Objective 6)  Inhibits factor X and thrombin  Inhibits platelet aggregation

69. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Lovenox  Uses  Prevent DVT following hip or knee replacement  Medical, not surgical use  Administration routes  Subcutaneous

70. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Lovenox  Side effects  Local irritation, pain  Fever, nausea  Contraindications  Active major bleeding  Hypersensitivity

71. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Anticoagulants  Category: (Objective 4)  Oral anticoagulants  Purpose: (Objective 5)  Long-term management of thromboembolic disease PE, DVT, CVA PE, DVT, CVA

72. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Anticoagulants: Oral  Agents: (Objective 3)  Warfarin (Coumadin)  Action: (Objective 6)  Inhibits vitamin K activity in liver

73. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Warfarin  Uses  Long-term management of DVT, PE, CVA DVT, PE, CVA  Administration routes  Oral

74. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Warfarin  Side effects  Epistaxis, hematuria, bleeding gums  Contraindications  Do not use concurrently with aspirin

75. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Warfarin and Aspirin

76. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Anticoagulants: Oral  Agents: (Objective 3)  Aspirin  Action: (Objective 6)  Inhibits platelet aggregation

77. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. aspirin  Uses (pertaining to clotting)  Post-MI, post-TIA: prevent additional clot formation  Administration routes  Oral

78. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Aspirin  Side effects  Normal bleeding time may be doubled  Contraindications  Not for use concurrent with warfarin therapy

79. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Anticoagulants  Category: (Objective 4)  Thrombolytics  Purpose: (Objective 5)  Break down existing blood clots

80. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Anticoagulants: Thrombolytics  Agents: (Objective 3)  Streptokinase, urokinase, antistreplase  Action: (Objective 6)  Activate plasminogen

81. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Thrombolytics  Uses  Acute MI w/coronary artery thrombosis  Treatment of DVT, PE  Administration routes  IV

82. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Thrombolytics  Side effects  Hemorrhage, skin rash, itching, nausea, headache  Contraindications  Hypersensitivity

83. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Anticoagulants: Thrombolytics  Agents: (Objective 3)  Alteplase (Activase)  Action: (Objective 6)  Human enzyme; tissue-type plasminogen activator (tPA)

84. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Alteplase  Uses  Acute MI w/coronary artery thrombosis  Treatment of DVT, PE, CVA  Administration route  IV

85. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Alteplase  Side effects  Fewer due to human origin of enzyme  Contraindications  N/A

86. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 8  Describe the impact of preoperative oral anticoagulant therapy on the surgical patient.

87. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 8  Bleeding times will be prolonged.  Meticulous hemostasis is necessary  Have additional hemostatic aids available

88. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 9  List examples of surgical procedures in which agents that affect coagulation may be administered.

89. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 9  General surgery  Cholecystectomy (liver bed)  Liver resection/trauma  Spleen or kidney repair

90. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 9  Orthopedics  Total hip/knee arthroplasty  Spinal fusion  Neurosurgery  Craniotomy  Spinal surgery

91. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 9  Peripheral vascular  AAA  Carotid endarterectomy  Femoral embolectomy  Venous access procedures  Dialysis graft insertion

92. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 9  Cardiovascular  CABG  Valve replacement/repair

93. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 10  Compare and contrast administration route, onset of action, antagonist, and purpose of parenteral and oral anticoagulants.

94. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 10  Compare and contrast  Ask yourself:  How are these alike?  How are they different?

95. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 10:  Administration route  Different  Parenteral anticoagulants  IV, subq, topical  Oral anticoagulants  Oral only

96. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 10  Onset of action: Different  Parenteral anticoagulants  Heparin = 5 minutes  Oral anticoagulants  Warfarin = 12-72 hours

97. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 10  Antagonist  Different  Parenteral anticoagulants  Protamine sulfate  Oral anticoagulants  Vitamin K (for warfarin)

98. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 10  Purpose: Similar purpose but different indications  Both prevent clots  Parenteral anticoagulants  Short-term treatment/surgery  Oral anticoagulants  Long-term management