Coagulation Disorders

Hemostasis

• Prevention or stoppage of blood loss from injured vessel (maintains vascular compartment integrity)

• Mechanisms involved: vasoconstriction

  • Formation of platelet plug

  • Sequential activation of clotting factors

  • Reparation of the opening in damaged vessel

Primary Hemostasis

• Initiated by endothelial damage

• Vasoconstriction

• Platelet adhesion

• Platelet activation

• Platelet aggregation

• Leads to the formation of primary platelet plug

Secondary Hemostasis

• Strengthening of plug with fibrin to form thrombus

• Involves clotting factors

Clotting Disorders

• Thrombogenesis

  • Normal body defense

  • Becomes pathologic when causes vascular obstruction

    • Section that breaks off and travels is known as an embolus

• Atherosclerosis

Why Should a DVT BE TREATED?

• Deep vein thrombosis that form in the deep veins can break loose and move to other parts of the body, including lungs or brain (this is referred to as an embolus).

• The presence of a blood clot greatly increases the chance that another clot will form.

• There are long term problems that can happen if the blood clot is not treated

Common REASONS for Blood Clots

• Abnormal anatomy

• Birth control (hormones)

• Cancer and chemotherapy drugs

• Chronic diseases (sickle cell, nephrotic syndrome, Crohns, lupus)

• COVID-19 (Coronavirus)

• Dehydration

• Genetic or inherited disorder

• History of a previous blood clot

• Inflammation

• Lack of movement for a long time (ex. bedridden)

• Long term central line like a port or PICC

• Obesity

• Pregnancy

• Procedures and surgeries

• Some types of bacterial infections

• Smoking

Atherosclerosis

• Can affect any organ or tissue

• Often involves arteries supplying

  • Heart (Thrombus may precipitate MI.)

  • Brain (Thrombus may precipitate stroke.)

  • Legs (Thrombus may precipitate DVT.)

• Consequences and clinical implications depend on location and size of thrombi/emboli.

Anticoagulants use

• Used in thrombotic disorders

• Interferes with clotting cascade and thrombin formation

Antiplatelets use

• Used to prevent arterial thrombosis

• Alters formation of the platelet plug

Thrombolytics use

• used to dissolve thrombi and limit tissue damage in thromboembolic disorders

• Breaks down the thrombus that has been formed by stimulating the plasmin system

Anticoagulants

• Given to prevent new clot formation and extension of clots present

• does not: dissolve formed clots, improve blood flow in tissues around the clot, or prevent ischemic damage beyond the clot

• Indications for use: prevention or management of thromboembolic disorders

  • Thrombophlebitis, DVT, pulmonary embolism

• Main adverse effect: bleeding

Thrombolytic Agents

• Given to dissolve thrombi

• Stimulate conversion of plasminogen to plasmin (enzyme that breaks down fibrin)

• Management of acute, severe thromboembolic disease

  • iliofemoral thrombosis

• Goal: Reestablish blood flow as quickly as possible, prevent/limit tissue damage

• Main adverse effect: bleeding

Anticoagulant Management - Heparin

• regulated by activated partial thromboplastin time (aPTT)

• Lab drawn approximately equal to 1 hour before dosing

Anticoagulant Management - Warfarin

• regulated by international normalized ratio (INR), based on prothrombin time (PT)

• Lab drawn daily until therapeutic

• Once therapeutic, drawn every 2 to 4 weeks for duration of anticoagulant therapy, unless dose adjusted

Thrombolytic Therapy

• Performed only by experienced personnel in ICU or diagnostic/interventional setting with cardiac monitoring in place

• Baseline laboratories (INR, aPTT, platelet count, fibrinogen) needed preadministration

• Factors in bleeding decrease include careful selection of recipients, avoiding invasive procedures, omitting anticoagulants or antiplatelets during use

Antiplatelets

• Prevent one or more steps in prothrombotic activity of platelets

• Act by a variety of mechanisms

  • Inhibit platelet activation

  • Inhibit platelet adhesion

  • Inhibit platelet aggregation

  • Inhibit procoagulant activity

• Adverse effects depend on the medication used

Herbal & Alternative Therapies that Enhance Bleeding

• Can cause excessive bleeding or decrease effect of medication

• Avoid angelica, cat’s claw, chamomile, chrondroitin, feverfew, garlic, ginkgo, goldenseal, grape seed extract, green leaf tea, horse chestnut seed, psyllium and turmeric.

Antiplatelet meds

• Decrease the formation of the platelet plug

  • Abciximab (ReoPro)

  • Anagrelide (Agrylin) Aspirin (generic) Cilostazol (Pletal) Prototype

  • Clopidogrel (Plavix) Prototype

  • Dipyridamole (Persantine),

  • Eptifibatide (Integrilin)

  • Ticagrelor (Brilinta), ticlopidine (generic), tirofiban (Aggrastat), and vorapaxar (Zontivity)

Antiplatelets action

• Inhibit platelet adhesion and aggregation by blocking receptors sites on the platelet membrane

• Anagrelide – Blocks the production of platelets in the bone marrow, avoid if thrombocytopenia

Antiplatelets Indications

Reduce risk of recurrent TIAs or strokes; reduce death or nonfatal MI; MI prophylaxis; anti-inflammatory, analgesic, and antipyretic effects

Antiplatelets pharmacokinetics

• Well absorbed and bound to plasma proteins

• Metabolized in the liver and excreted in the urine

Antiplatelets contraindications

Allergy, pregnancy, and lactation

Antiplatelets caution

Bleeding disorder, recent surgery, closed-head injury

Antiplatelets adverse rxn

• Bleeding, bruising, bleeding gums – Bleeding precautions

• Headache, dizziness, and weakness

• GI distress, Nausea

Antiplatelet Nursing Considerations

• History and Physical Exam and known allergy

• Pregnancy and lactation

• Know bleeding disorders, recent surgery, or closed head injury

• Baseline status including body temperature; skin color, lesions, and temperature ; affect, orientation, and reflexes; pulse, blood pressure, and perfusion; respirations and adventitious sounds; CBC; and clotting studies

antiplatelet prototype

aspirin

Warfarin (Coumadin)

Maintains a state of anticoagulation when patient is susceptible to potentially dangerous clot formation by decreasing production of Vitamin K dependent clotting factors

Heparin (Generic)

Inhibits the conversion of prothrombin to thrombin

Antithrombin (Thrombate III)

Used for hereditary antithrombin III deficiencies; replacement therapy in congenital antithrombin III deficiency

Anticoagulants action

Interfere with the normal cascade of events involved in the clotting process

Anticoagulants contraindications

• Allergy and condition that could be compromised by increased bleeding tendencies (hemorrhagic disorders, trauma, spinal puncture, GI ulcers, TB, indwelling catheters, IUD placement)

• Pregnancy, renal, or hepatic disorders

Anticoagulants caution

• CHF, thyrotoxicosis, senility, or psychosis

• Diarrhea, fever

Anticoagulants Adverse Effects

• Bleeding – varying degrees

• GI upset

• Hepatic dysfunction

• Alopecia, dermatitis, bone marrow suppression, prolonged, and painful erection

Anticoagulants Drug-to-Drug Interactions

• Heparin and oral anticoagulants, salicylates, penicillins, or cephalosporins – increase bleeding

• Heparin and nitroglycerine – decrease anticoagulation

• Warfarin – Number of documented interactions

Anticoagulants – Nursing Considerations

• History and Physical Exam and known allergy

• Recent history of surgery, active internal bleeding, CVA within the last 2 months, aneurysm, obstetrical delivery, organ biopsy, recent serious GI bleeding, rupture of a non-compressible blood vessel, recent major trauma (including cardiopulmonary resuscitation)

• Blood-clotting defects, cerebrovascular disease, uncontrolled hypertension, liver disease, pregnancy and lactation, VS, clotting studies, renal and hepatic function tests, CBC, guaiac test for occult blood in stool, and ECG

Anticoagulant Prototype

Heparin

Thrombolytic Agents - “ase” endings

• Break down the thrombus that has been formed by stimulating the plasmin system

  • Alteplase (Activase)

  • Reteplase (Retavase)

  • Tenecteplase (TNKase)

  • Urokinase (Abbokinase)

Thrombolytic Agents action

Activating plasminogen to plasmin, which in turn breaks down fibrin threads in a clot to dissolve a formed clot

Thrombolytic Agents indications

Acute MI, pulmonary emboli, ischemic stroke

Thrombolytic Agents pharmacokinetics

• Drugs must be injected and are cleared from the body after liver metabolism

• Lactation (unknown effect)

Thrombolytic Agents contraindications

• Allergy

• Any condition that would be worsened by dissolution of clots – see notes

• Pregnancy

Thrombolytic Agents adverse rxn

• Bleeding

• Cardiac arrhythmias – reperfusion arrhythmias

• Hypotension

• Hypersensitivity – Rash, flushing, bronchospasm, and anaphylactic reaction

Thrombolytic Agents nursing intervention

• History and Physical Exam and known allergy

• recent surgery, active internal bleeding, CVA within the last 2 months, aneurysm, obstetrical delivery, organ biopsy, recent serious GI bleeding, rupture of a non-compressible blood vessel, recent major trauma (including cardiopulmonary resuscitation)

• Known blood-clotting defects, cerebrovascular disease, uncontrolled hypertension, liver disease

• Baseline status to include, VS, skin, orientation, appropriate lab values and ECG

Low Molecular Weight Heparin

• Inhibit thrombus and clot formation by blocking factors Xa and Iia

• do not greatly affect thrombin, clotting, or prothrombin times; therefore cause fewer systemic adverse effects

• Block angiogenesis, the process that allows cancer cells to develop new blood vessels

• Are indicated for specific uses in the prevention of clots and emboli formation after certain surgeries or bed rest

Bleeding Disorders Treated With Clotting Factors

• Hemophilia

  • Genetic lack of clotting factors that leaves the patient vulnerable to excessive bleeding with any injury.

• Liver Disease

  • Clotting factors and proteins needed for clotting are not produced.

• Bone Marrow Disorders

  • Platelets are not formed in sufficient quantity to be effective.

Antihemophilic

• Replacement factors for the specific clotting factors that are genetically missing in that particular type of hemophilia

  • (Bioclate, ReFacto, and others), coagulation factor VIIa (NovoSeven), and factor IX (BeneFix,Profilnine SD, and others), factor IX complex (Bebulin VH,Profilnine SD), anti-inhibitor coagulant complex (Feiba NA)

  • Factor XIII (Corifact) ,antihemophilic factor Fc fusion protein (Eloctate), and antihemophilic factor porcine sequence (Obizur)

Antihemophilic actions

Replace clotting factors that are either genetically missing or low in a particular type of hemophilia

Antihemophilic indications

Prevent blood loss from injury or surgery and to treat bleeding disorders

Antihemophilic Pharmacokinetics

Replace normal clotting factors and are processed as such by the body

Antihemophilic contraindications

• Allergy

• Factor IX in the presence of liver disease

• Lactation

Antihemophilic caution

pregnancy

Antihemophilic adverse effects

• Involve risks associated with the use of blood products

  • HIV

  • AIDS

  • Hepatitis

• Headache, flushing, fever, chills, lethargy

• Nausea and vomiting

• Stinging, itching, and burning at the site of injection

Antihemophilic nursing intervention

• History and Physical Exam and known allergy

• Liver disease

• Baseline status including, temperature; skin color, lesions, and temperature; affect, orientation, and reflexes; pulse, blood pressure, and perfusion; respirations and adventitious sounds; clotting studies; and hepatic function tests

Systemic Hemostatic Agents

• Prevent body wide or systemic clot breakdown, thus preventing blood loss in situations in which serious systemic bleeding could occur, or hyperfibrinolysis

• Aminocaproic acid (Amicar)

Systemic Hemostatic Agents actions

Stop the natural plasminogen clot-dissolving mechanism by blocking its activation or by directly inhibiting plasmin.

Systemic Hemostatic Agents indicactions

Prevent or treat excess bleeding in hyperfibrinolytic states

Systemic Hemostatic Agents contraindicactions

• Allergy

• Acute DIC (Disseminated Intravascular Coagulation (DIC): This is a serious medical condition where blood clotting occurs throughout the body's small blood vessels.)

Systemic Hemostatic Agents caution

Cardiac disease, renal or hepatic dysfunction, pregnancy and lactation

Systemic Hemostatic Agents adverse effects

• Excessive clotting

• CNS – Hallucinations, drowsiness, dizziness, headache, and psychotic states

• GI – Nausea, cramps, diarrhea

• Weakness, fatigue, malaise, and muscle pain

• Aprotinin – Cardiac arrhythmias, MI, CHF, and hypotension

Systemic Hemostatic Agents d-d interaction

• Heparin

• Oral contraceptives or estrogen

Systemic Hemostatic Agents nursing intervention

• History and Physical Exam and known allergy

• Acute disseminated intravascular coagulation

• Renal and hepatic dysfunction

• Baseline status to include, temperature; skin color, lesions, and temperature; affect, orientation, and reflexes; pulse, blood pressure, and perfusion; respirations and adventitious sounds; bowel sounds and normal output; urinalysis and clotting studies; and renal and hepatic function tests