Mechanical Clot Detection Stago\'s Viscosity-based Clot Detection SystemSlide 2
Viscosity based Detection SystemSlide 3
Viscosity based Detection SystemSlide 4
Viscosity based Detection SystemSlide 5
Viscosity based Detection SystemSlide 6
Viscosity based Detection SystemSlide 7
NEW ANTICOAGULANTS Katy Whelchel MT(ASCP)SH Diagnostica Stago, Inc. Specialized Support Specialist February 23, 2006Slide 8
Maintain hemostatic adjust the body must keep up a liquid balance need to keep up harmony between draining & thickening vessels "Coagulation" Proteins Platelets Fibrinolysis/InhibitorsSlide 9
ANTICOAGULANT THERAPY Decrease the danger of post-operation thrombosis Decrease the danger of thrombosis in patients with hazard variables Decrease the danger of unconstrained premature births in patients with Anti-Phospholipid Syndrome (APS) - lupus anticoagulantsSlide 10
STANDARD ANTICOAGULANTS HEPARIN (UFH) COUMADIN (warfarin)Slide 11
UFH – a couple of things to recall Will influence PTT-what amount depends dosing and your reagent framework Easily observed (precisely!) with the Anti-Xa strategy Can be utilized as a part of patients with renal disappointment HAS a cure (protamine sulfate)Slide 12
Coumadin –a couple of things to recollect Can be checked by the PT/INR Can be given long haul for high hazard patients Can be utilized as a part of patients with renal disappointment HAS an antitoxin (Vitamin K)Slide 13
St. Lucia Island blossomsSlide 14
2 classes of NEW ANTICOAGULANTS Antithrombin Dependant LMWH – Lovenox, Fragmin, Innohep (tinzaparin – has been utilized on CAP reviews) DANAPROID (not accessible in US) FONDAPARINUX (Arixstra) Direct Thrombin Inhibitors HIRUDEN – LEPIRUDEN (Refludan) ARGATROBAN (Novastan) Bivalirudin Ximelagatran-the "new" coumadinSlide 15
Why do we think about these new anticoagulants?? They are promoted as "no checking required"!Slide 16
Why do we think about these new anticoagulants?? They can and DO meddle with our present coagulation tests Can you say what amount of this new medication is in the patient\'s framework? What do you accomplish for these patients? Patient is draining Patient is coagulating – regardless of treatment Pre-operation appraisal? PT and PTT might possibly be "ordinary"Slide 17
Why do we think about these new anticoagulants?? Extraordinary patient populaces require exceptional thought: Pregnancy Renal brokenness Liver brokenness Anorexic or gargantuan patientsSlide 18
Heparins UFH take a shot at the initiated components LMWHs work where the outward and inherent variables meet up with Factor Xa Both utilize the patient\'s ATIII to workSlide 19
Coag CascadeSlide 20
LMWH ActionSlide 21
LMWH HEPARINS LMWH – preferable bioavalibility over UFH Created from UFH Since it\'s a littler atom it can be directed as a subcutaneous infusion – given in settled measurements for MOST patients Therapeutic Ranges: 0.5 – 1.1 (2 infusions/day) 1.0 – 2.0 (1 infusion/day) Timing of examples - crest at around 4 hours after sub Q infusionSlide 22
Heparin Family pictureSlide 23
LMWH HEPARIN Doesn\'t change the APTT (much) – an expanded APTT may connote an overdose of LMWH or some other impact on the APTT (platelet antibodies) Difficult to turn around with protamine sulfate (antitoxin for UFH) Cleared through the kidneysSlide 24
LMWH HEPARIN LMWH accessible in the US: Enoxaparin (Lovenox): avoid DVT/PE around surgery, treat DVT/PE, insecure angina Dalteparin (Fragmin): anticipate and treat DVT/PE, treat shaky angina Tinzaparin(Innohep): treat DVT/PESlide 25
Who ought to be observed for LMWH? Patients with kidney issues (need to check creatinine leeway) Patients that are hefty or have a low body weight Children, smolder patientsSlide 26
How ought to LMWH be observed? Screen with a hostile to Xa technique, utilizing LMWH calibrators and controls. Tests ought to be drawn 4 hours in the wake of dosing.Slide 27
Marigot Bay, St. LuciaSlide 28
Danaproid, FonduparinuxSlide 29
DANAPROID (not accessible in the US) Mixture of heparinoids Usually given to HIT patients Works through antithrombin to repress figure Xa (little impact on different elements) Administered twice per day – IV or Sub Q Therapeutic extents – IV=0.5 – 0.8 Sub Q= 0.13-0.35 Monitored by hostile to Xa (like LMWH) – utilizing danaproid as the calibrator.Slide 30
Danaproid (cont\'d) It might draw out the PTT,as well as influence the PT, TT and ACT. Utilized effectively as a part of HIT – be that as it may, platelet tally ought to be observed. No operator that will switch the impacts of the medication.Slide 31
FONDAPARINUX (Arixtra) Synthetic pentasaccharide – quickens the authoritative of AT to Xa – "a definitive LMWH" Pure hostile to Xa impact Commonly used to anticipate VTE in orthopedic surgery Administered Sub Q Half-existence of 13 – 15 hours, so just 1 measurement for each day. Discharged through kidney (check creatinine leeway… ..)Slide 32
Fondaparinux (cont\'d) PT and PTT are moderately inhumane to this medication, yet might be somewhat drawn out. Low draining occurrence. Has not been appeared to bring about HIT No immediate inhibitor for Arixtra which can turn around it\'s anticoagulant impact. May be checked by an Anti-Xa technique utilizing the medication as a calibrator.Slide 33
Fondaparinux (cont\'d) Remember – there is no antitoxin. So if the patient has a lot "on board", the PT and PTT might be ordinary, yet they may in any case be dying… … .can utilize Factor VIIa think (novoseven) or actuated prothrombin concentrates to turn around impact.Slide 34
Ship: The Brig UnicornSlide 35
DIRECT THROMBIN INHIBITORS Hirudin – Lepirudin (Refludan) Hirudin: Medicinal Leech Refludan: recombinant polypeptide with same activity Agatroban Bivalirudin (Angiomax) Do not bring about thrombocytopenia; utilized effectively with HIT Directly pieces Thrombin Administered by IV or Sub Q REQUIRES MONITORINGSlide 36
Direct Thrombin InhibitorsSlide 37
DIRECT THROMBIN INHIBITORS These medications have a short half life. Agatroban cleared by the liver Lepirudin is cleared by the kidneys. Bivalirudin is cleared by the kidneys Have to know about these variables with the patient!Slide 38
ARGATROBAN Derivative of amino corrosive arginine Directly ties to Thrombin Metabolized by the liver, and discharged through the kidney – so can be an other for patients with renal sickness. Must be checked by APTT (can likewise be observed by the ACT). Remedial range is 1.5-3.0 x Baseline APTT.Slide 39
REFLUDAN - Lepirudin APTT – IV=1.5 – 3.0 x quiet pattern Sub Q= 2.2 – 2.7 X standard APTT (specimen drawn 3 hours after organization) HOWEVER , APTT reagents differ in their affectability to Refludin ECARIN CLOTTING TIME (utilized as a part of a few offices) CHROMOGENIC ASSAY BASED ON THROMBIN INHIBITION (produced for research just now) – most exact measureSlide 40
DIRECT THROMBIN INHIBITORS These medications will influence the PT/INR – since they work at the base of the course Lepirudin: prescribe halting medication once INR>2.0 Agatroban: suggest ceasing drug once INR>4.0 Levels are PT reagent subordinate!! Writing says that reagents with a lower ISI have less inconstancy in reactivity. Higher ISI reagents have more prominent variablity accordingly. Will influence comes about if patient is additionally on Coumadin!Slide 41
DIRECT THROMBIN INHIBITORS Since these medications influence the PT/INR framework – and since they have a short half-life – the uplifting news is that in the event that they are suspended for a few hours, the PT ought to come back to ordinary. The awful news is that the kidneys and liver must work for this to happen.Slide 42
Bivalirudin Approved for use in the cardiovascular cath lab Bivalent thrombin inhibitor Short half-life (20 - 30 min) Exclude patients with creatinine >3.0Slide 43
Live Volcano, St. LuciaSlide 44
DIRECT THROMBIN INHIBITORS Ximelagatran – the "new Coumadin" Oral tablet Direct thrombin inhibitor Converts to melagatran in the stomach Cleared by kidneys Irreversible – figure VII think prescribed for serious drainSlide 45
DIRECT THROMBIN INHIBITORS Ximelagatran – the "new Coumadin" (cont\'d) it should work superior to our current LMWHs in averting DVTs in individuals who have had hip surgery Theoretically: NO MONITORING! It doesn\'t make a difference how old you are, the amount you weigh, and so forth it should be protected… ..be that as it may it causes liver harm in 6-10% of patients who take it long haul. Also, recollect – it is cleared by the kidneys.Slide 46
DIRECT THROMBIN INHIBITORS Ximelagatran – the "new Coumadin" (cont\'d) Not endorsed by FDA – yet. In the event that you would screen Ximelagatran, recall that it is a thrombin inhibitor – so you\'d need to screen the APTT – NOT a PT despite the fact that it is the "new Coumadin"!! APTT\'s reaction again will be variable relying upon reagent framework.Slide 47
DIRECT THROMBIN INHIBITORS Ximelagatran – the "new Coumadin" (cont\'d) So – until further notice, despite everything we\'ll be doing PT/INR for coumadin treatment.Slide 48
Summary Many of these anticoagulants are presently being used. They may influence routine and claim to fame coagulation tests – recollect where they influence the course! On the off chance that strange outcomes are acquired, and not expected – ask what tranquilizes the patient is on. Keep in mind many will act diversely if the patient has renal or hepatic disability. The "proven" may even now be the most effortless to utilize if checked accurately.Slide 49
St. Lucia SunsetSlide 50
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