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Anticoagulants
What is the deal with clots…?

Anticoagulation therapy is used a in a number of different types of patients. The frequent use of anticoagulant therapy in surgical patients, particularly orthopedic and heart surgeries means that health care providers should have a relatively good and in-depth understanding of anticoagulants, why they are used and what they do.

Anticoagulation therapy is used primarily to prevent the formation of deep vein thrombosis (DVT) as a serious complication of DVT is of course pulmonary embolism (PE).
DVT
DVT is a serious and potentially life threatening situation. There are three factors that are known to cause DVT: vessel wall damage, venous stasis, and hypercoagulability. Damage to the vessel walls can cause DVT because the body will respond to damage with the standard clotting cascade which ultimately results a fibrin clot in the vascular system. Venous stasis caused by pooling of blood, which may occur in a situation where a limb is dependant or in individuals with poor venous return resulting in edematous extremities. Hypercoagulabilty can cause DVT if the body is over reactive to insult and frequent clots are formed. DVT complicates because there is a potential risk that the thrombosis dislodges and results in an embolism, causing PE.

Anticoagulation therapy can be used to either help to dissolve a clot that is present (thrombolytic agents, save this for later) or prevent further clots from forming.

Prophylactic anticoagulation
...Here's looking at some commonly used medications...
Heparin/Hepalean (CAN)
Heparin binds with antithrombin III, which will enhance the inactivation of thrombin, Xa, and XIa (clotting factors). Because thrombin is required in the body for the conversion of fibrinogen into fibrin, the absence of thrombin results in an absence of fibrin, and therefore clots are unable to form. Low doses of heparin will inhibit Xa therefore inhibiting the conversion of prothrombin into thrombin. High doses of heparin act directly on the thrombin by inactivating it, preventing fibrin formation.
Heparin may be administered with an initial bolus followed by a continuous infusion. It is incredibly important for the individual who is administering this to be aware of the partial thomboplastin time (PTT) or aPTT lab values. These are taken depending on hospital policy, but roughly every 6 hours following the initial bolus.
Heparin is given by the subcutaneous (SC) or intravenous (IV) route only. Heparin given intramuscularly (IM) can cause hematoma, irritation, and pain.
Overdosing heparin will make you at risk for hemorrhage and death. Therefore, it is also important to know that the antidote for heparin is Protamine Sulphate. Heparin’s onset is immediate (IV) so in the event of overdose stopping the infusion may be an effective intervention (follow up with PTT).

Warfarin/Coumadin
Warfarin works to anticoagulant in a different way that heparin. Warfarin and heparin can be given simultaneously because they do work in different ways. Where heparin works directly on the clotting cascade, warfarin actually works by inhibiting vitamin K, therefore having a more indirect effect on coagulation. By interfering with the liver’s ability to synthesize vitamin K-dependent clotting factors, the clotting cascade is interrupted.
Warfarin is an oral anticoagulant. There is conflicting data as to warfarin’s onset, but it is generally accepted that the time required to reach therapeutic levels is approximately 24-72 hours.
The lab value that you should be aware of when giving warfarin therapy is the INR. The INR is the “international normalized ratio.” It is a ratio of the recipient’s prothombin time (PT) compared to a normal PT.

Low molecular weight heparin
Enoxaparin/Lovenox
Enoxaparin works by inhibiting factor Xa, therefore inhibiting prothrombin into thrombin and therefore inhibiting fibrinogen into fibrin. This drug is used in orthopedic patients. The FDA approved this drug for prevention of clots in knee and hip surgeries.
Enoxaparin is a relatively new drug. It is given SC mainly to the abdomen. Injections given to the flank may limit the health care providers ability to assess the site for complications if the recipient is positioned supine. Rotate the sites as per hospital policy.
Normal dosage is 30mg given twice a day. Lovenox comes in a pre-filled glass syringe directly from the manufacturer.
Enoxaparin will not affect PT or PTT lab values because the chemical structure of this drug will not bind with many plasma proteins so there is a more predictable dose.

Anticoagulants are medications that prevent the coagulation, or clotting, of blood. Normally, coagulation is a good thing, since it keeps us from bleeding to death when we scrape our knees, but there are times when it is most emphatically a Bad Thing™.

Coagulation is the process of clot, or thrombus, formation. When it occurs in the normal process of hemostasis, stopping the bleeding from a wound, hemostasis is survival positive. Lack of coagulation is what causes hemophiliacs to bleed excessively from minor injuries.

However, thrombi can wreak havoc on the body in certain situations. When there is stasis of the blood, like in prolonged immobility, thrombi can form in the veins without any injury having occurred. These thrombi are attached to the wall of the blood vessel, but they can break loose. If this happens, the veins carry this clot (or cluster of clotlets) back to the heart, along with all the other returning blood. When the clot gets to the heart, it can get lodged in the lungs (pulmonary embolism) or in the coronary arteries (heart attack), although heart attacks usually occur when a clot forms in a narrowed section of a coronary artery (as opposed to a floating clot). In atrial fibrillation, clots may form in the heart, and may travel from the left ventricle to the brain (stroke). This is usually not considered good.

There are conditions that predispose people to thrombus formation, such as atrial fibrillation, and there are situations, such as open heart surgery or dialysis, when clotting would be VERY VERY BAD. Anticoagulants are used to prevent thrombus formation in these situations, and also when the patient has had thrombotic problems in the past.

When anticoagulants are used, the patient's bloodwork must be monitored closely, to ensure that the patient is not in danger of excessive bleeding. Patients must also be warned not to take salicylates or any other medications that have anticoagulant side effects unless prescribed.

Anticoagulants

Brand/Generic Drug Names

ardeparin, Lovenox/enoxaparin, heparin, lepirudin, Coumadin/warfarin
Common uses
deep vein thrombosis, pulmonary embolism, myocardial infarction, open-heart surgery, disseminated intravascular coagulation, atrial fibrillation with embolization, transfusion, dialysis
Pharmacology
interfere with blood clotting by preventing clot formation
Class contraindications
hemophilia, leukemia with bleeding, peptic ulcer disease, thrombocytopenic purpura, blood dyscrasias, acute nephritis, subacute bacterial endocarditis
Class precautions
alcoholism, elderly, pregnancy
Interactions
increased anticoagulation: salicylates, steroids, NSAIDs
Adverse Reactions
hemorrhage, agranulocytosis, leukopenia, eosinophilia, thrombocytopenia, diarrhea, rash, fever
Additional Information
Assess PT/PTT daily; hematocrit, platelets and occult blood every 3 mos
Assess vitals, watch for bleeding gums, petechiae, ecchymosis, melena, hematuria
Administer at same time each day to maintain blood levels
Do not massage injection site or aspirate
Evaluate therapeutic response: decrease in deep vein thrombosis
Date of most recent Update
August 05, 2002
Further information is available in the writeup for the specific name(s) of this medication class

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