week 4 counseling points

heparin sodium

• Contraindication(s): Uncontrolled active bleed, history of HI

• Warning(s): Fatal medication error; verify correct concentration is chosen, High Alert Medication

• Monitor: anti-Xa levels and aPTT

• Note(s): Heparin lock flush solution is intended only to maintain patency of IV devices and is NOT to be used for systemic anticoagulant therapy. UFH is often preferred in severe renal impairment because it does not require the same renal dose adjustment as LMWH and has a short half-life with rapid reversibility. Use total body weight for dosing

• Antidote: Protamine

enoxaparin sodium

• BBW: Risk of hematomas and subsequent paralysis in patients receiving neuraxial anesthesia (epidural, spinal)

• Contraindication(s): History of HIT (heparin-induced thrombocytopenia), active major bleed

• Note(s): Common Adult Dosing:

Prophylaxis of VTE- 40 mg SC daily

Treatment of VTE- 1 mg/kg SC Q12H

• Antidote: Protamine

argatroban

Note(s): Safe for use with active HIT or history of HIT; no antidote

bivalirudin

Note(s): Safe for use with active HIT or history of HIT; no antidote

fondaparinux

BBW: Risk of hematomas and subsequent paralysis in patients receiving neuraxial anesthesia (epidural, spinal)

Contraindication(s): Severe renal impairment (CrCl <30mL/min)

4-factor prothrombin complex concentrate

Indication(s): Bleeding
Note(s): Contains factors II, VII, IX and X and Protein C and Protein S. Administer with vitamin K.

phytonadione (vitamin K1)

Indication(s): Warfarin reversal, vitamin K deficiency
BBW: Fatal hypersensitivity reactions, including anaphylaxis
Note(s): Protect from light

protamine

Indication(s): UFH/LMWH reversal

Heparin neutralization: 1 mg of protamine will reverse 100 units of heparin

Low-molecular-weight heparin neutralization: 1 mg protamine per 1 mg of enoxaparin

idarucizumab

Indication(s): Dabigatran reversal

desmopressin

BBW: Life threatening hyponatremia

octreotide

Indication(s): Acute esophageal variceal bleeding;
Side effect(s): bradycardia, hyperglycemia or hypoglycemia, cholelithiasis, biliary sludge