1. Thromboembolic Disorders and Related Medications Nsg 106 Pharmacotherapeutics

2. Thromboembolic Disorders Thrombosis is the formation of a fibrin blood clot (thrombus) in a blood vessel.Thrombosis is the formation of a fibrin blood clot (thrombus) in a blood vessel. An embolus is a fragment of a thrombus which has broken off and travels through the circulation until it becomes trapped in a vessel or capillary, causing ischemia or infarct to the area(s) distal to the embolusAn embolus is a fragment of a thrombus which has broken off and travels through the circulation until it becomes trapped in a vessel or capillary, causing ischemia or infarct to the area(s) distal to the embolus –E.g., cerebral or pulmonary embolus Causes:Causes: –Bed rest, immobility, increased blood viscosity, blood vessel injury, cardiac arrhythmias (afib)

3. Drug Therapy for Thromboembolic Disorders PurposePurpose –The following categories of pharmacologic agents will either prevent platelet aggregation or inhibit various steps of the clotting cascade. Prototype drugs:Prototype drugs: – anticoagulants – platelet inhibitors, and – fibrinolytic agents (“clot busters”)

4. Platelet Inhibitors ASA (aspirin)ASA (aspirin) –Inhibits platelet aggregation and prolongs bleeding time. UsesUses –Reduce risk of stroke (CVA), MI (myocardial infarction). –Expect to give ASA p.o. during acute MI intervention. Side EffectsSide Effects –GI upset, GI bleed Take with foodTake with food –Additive effect with anticoagulant agents Monitor labs closelyMonitor labs closely

5. Platelet Inhibitors Pt. TeachingPt. Teaching –Be alert for GI irritation, change in stool color and consistency –Take only daily prescribed dose; do not modify dose.

6. Platelet Inhibitors Clopidogrel Bisulfate (Plavix)Clopidogrel Bisulfate (Plavix) –Anti-aggretory effect on platelets and prolongs bleeding time. UsesUses –Reduces the risk of MI, CVA –Can be used concurrently with ASA Side Effects/Pt. TeachingSide Effects/Pt. Teaching –Neutropenia, agranulocytosis Report any S/S of infectionReport any S/S of infection –Bleeding Report changes in stool, increased bruising, nosebleeds, hematuriaReport changes in stool, increased bruising, nosebleeds, hematuria

7. Platelet Inhibitors Side Effects, cont.Side Effects, cont. –Can inhibit metabolism of Dilantin, tamoxifen, warfarin, NSAIDS Know the patient’s medications and monitor closelyKnow the patient’s medications and monitor closely Therapeutic OutcomeTherapeutic Outcome –Reduced frequency of TIA’s, CVA, MI, and complications from PVD

8. Anticoagulant Therapy HeparinHeparin –Prevents clotting by helping to block the formation of thrombin; also neutralizes certain factors in the clotting cascade. –Uses Can be SQ or IV - delivered in Units/mlCan be SQ or IV - delivered in Units/ml DVT, pulmonary and cerebral embolusDVT, pulmonary and cerebral embolus Prophylaxis forProphylaxis for – cardiac surgery, – post-op or immobilized patients, and –during hemodialysis to prevent clot formation

9. Anticoagulant Therapy Lab values to monitorLab values to monitor –The aPTT=activated partial thromboplastin time Should be 1.5-2.5 times the control aPTT value.Should be 1.5-2.5 times the control aPTT value. –Example: If control is 30 seconds, the aPTT should be 45-75 seconds to be therapeutic. Values outside the therapeutic range require an order to increase or decrease the dose or IV infusion rate. –Also monitor platelet counts and hematocrit level

10. Anticoagulant Therapy Side EffectsSide Effects –Bleeding, increased bruising, hematoma at injection site (SQ) Rotate SQ sites-inject in abdominal SQ tissue, do not inject within 2 inches of umbilicus, or into a hematoma; do not aspirate; do not massageRotate SQ sites-inject in abdominal SQ tissue, do not inject within 2 inches of umbilicus, or into a hematoma; do not aspirate; do not massage –Thrombocytopenia (low platelets) –Antidote – protamine sulfate

11. Anticoagulant Therapy Lovenox (enoxaparin sodium)Lovenox (enoxaparin sodium) –Interrupts specific steps along the coagulation pathway –Does NOT affect PT or aPTT. =Preferred over heparin = low molecular wt heparin=Preferred over heparin = low molecular wt heparin –Less potential for hemorrhage and longer duration of action UsesUses –Prevention of DVT following hip replacement, knee replacement, or abdominal surgery

12. Anticoagulant Therapy Uses, cont.Uses, cont. –Prevent complications from unstable angina Injection procedure same as heparinInjection procedure same as heparin Rotate SQ sites-inject in abdominal SQ tissue, do not inject within 2 inches of umbilicus, or into a hematoma; do not expel air bubble from syringe; do not aspirate; do not massageRotate SQ sites-inject in abdominal SQ tissue, do not inject within 2 inches of umbilicus, or into a hematoma; do not expel air bubble from syringe; do not aspirate; do not massage Pt. TeachingPt. Teaching –Bleeding S/S Monitor plateletsMonitor platelets

13. Fibrinolytic Agents = “Clot Busters” PurposePurpose –These agents activate the conversion of plasmin to plasminogen to make fibrinolysin, which digests fibrin, dissolving clots. –With this “clot busting” action, these agents can: Prevent further damage to heart muscle in acute MI by improving circulation in the affected vessel(s).Prevent further damage to heart muscle in acute MI by improving circulation in the affected vessel(s). Reperfuse the brain and resolve symptoms of stroke caused by an embolus (NOT for Hemorrhagic stroke).Reperfuse the brain and resolve symptoms of stroke caused by an embolus (NOT for Hemorrhagic stroke). Reopen a pulmonary vessel which has been blocked by an embolus.Reopen a pulmonary vessel which has been blocked by an embolus.

14. Fibrinolytic Agents = “Clot Busters” Prototype is tPA or ActivasePrototype is tPA or Activase –Commonly used for acute MI, PE, and CVA diagnoses preferably within one to two hours of onset of symptoms. –These agents are also used to reopen IV or central venous catheters which have clotted off, such as PICC lines.

15. Fibrinolytic Agents = “Clot Busters” Adverse EffectsAdverse Effects –Obviously, Bleeding is the most significant side effect – contraindications are: Active internal bleedingActive internal bleeding Intracranial or interspinal surgery or trauma within the past 2 monthsIntracranial or interspinal surgery or trauma within the past 2 months Bleeding disordersBleeding disorders Severe, uncontrolled HTNSevere, uncontrolled HTN PregnancyPregnancy Current use of anti-coagulantsCurrent use of anti-coagulants

16. Warfarin (Coumadin) Oral dosing = convenienceOral dosing = convenience Long onset & half life = danger/difficulty controlling therapeutic levelLong onset & half life = danger/difficulty controlling therapeutic level 2 person check:2 person check: – tablet dose, order, PT & INR Same time every daySame time every day Antidote: Vitamin K (aquamephyton)Antidote: Vitamin K (aquamephyton) Therapeutic effect: increased tissue perfusionTherapeutic effect: increased tissue perfusion Monitor for bleeding, bruisingMonitor for bleeding, bruising Preventative steps to avoid injuryPreventative steps to avoid injury

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