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

2. 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

3. 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

4. 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

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

6. 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

7. 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

8. 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

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

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

11. 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+
( )”
60”-85”
WBPTT
%40+
( )”
( )”
120”-150”
ACT
9-16'
20-30'
4'-8'
LWCT

12. 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

13. 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

14. 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: IU

15. 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

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

17. Heparin-Free Dialysis
Heparin Prime ( IU/1000 cc Nacl )
Prime without heparin
BF: ml/min
Nacl falsh every min ( cc)

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

19. 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

20. 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

21. 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)

22. Heparin–Associated Complications
Bleeding
Hyperlipedemia
Hyperkalemia
Thrombocytopenia
Pruritus

27. 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

28. کلام آخر هر 100 میلی لیترخون حاوی14- 17 گرم پروتئین میباشد !
هربیمار دیالیزی درهرجلسه دیالیز 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؟