Anticoagulants

(Parenteral)

N203
ATI (Unit 7)
Hematologic System -
Expected Action: Proto: Heparin — Others: enoxaparin, tinzaparin (Innohep)
 Intrinsic factors and thrombin conversion are inhibited by heparin
Therapeutic Uses:  Evolving stroke, PE, MI, DVT  During pregnancy
 Adjunct during ♥ surgery, dialysis, abdominal surgery, or joint replacement
 Disseminated intravascular coagulation
Adverse Effects:  Hypersensitivity reaction (chills, fever, urticaria)
 Hemorrhage 2º heparin OD (treat ĉ protamine sulfate)
 Heparin-induced thrombocytopenia (stop if PLT < 100,000/cc)
Contraindications/Precautions:  CI:  PLT or uncontrollable bleeding
 CI: Surgery of eye, brain, spinal cord; regional anesthesia; lumbar puncture
Interactions:  Anti-platelet agent  additive risk of bleeding

Education:  Monitor aPTT levels Q4-6h and then QD (60-80 sec)

Treatment of Heparin OD

N203
ATI (Unit 7)
Hematologic System -
Expected Action: Proto: Protamine sulfate
 Binds with heparin and forms a non-coagulating complex
Therapeutic Uses:  Antidote to severe heparin overdose
 Reversal of heparin administered during procedures
Adverse Effects: 

Contraindications/Precautions: 

Interactions: 

Education:  Administer slowly (20 mg/min or 50 mg in 10 min)
 aPTT levels of 60-80 sec
Anticoagulant
(Oral)

N203
ATI (Unit 7)
Hematologic System -
Expected Action: Proto: warfarin (Coumadin)
 Antagonizes vitamin K / prevents synthesis of 4 intrinsic factors & prothrombin
Therapeutic Uses:  Prevention of venous thrombosis
 Prevention of thrombi in A-fib and with prosthetic heart valves
Adverse Effects:  Hemorrhage (Tx with vitamin K)

Contraindications/Precautions:  Pregnancy (X)
 CI: Surgery of eye, brain, spinal cord; regional anesthesia; lumbar puncture
 CI:  PLT counts, uncontrolled bleeding, vit. K δ, liver problems, alcoholism
Interactions:  Heparin, aspirin, glucocorticoids   bleeding
 Acetaminophen, sulfonamides, parenteral cephalosporins, ASA   [warfarin]
 Phenobarbital, carbamazepine, phenytoin, OC, vitamin K   warfarin effects
Education:  PT therapeutic level = 18-24 sec (normal = 11-12.5 sec)
 Onset takes 8-12 hrs, full effect takes 3-5 days
Treatment of Warfarin OD

N203
ATI (Unit 7)
Hematologic System -
Expected Action: Proto: Vitamin K (Phytonadione)
 Promote synthesis of intrinsic factors and prothrombin
Therapeutic Uses:  Vitamin K deficiency
 Reversal of hypoprothrombinemia and bleeding d/t warfarin OD
Adverse Effects:  Anaphylactoid reaction (infuse slowly in diluted solution)

Contraindications/Precautions: 

Interactions: 

 Administer small doses (2.5 mg PO / 0.5-1 mg IV) of vitamin K to
Education:
prevent development of resistance to warfarin.

Antiplatelets

N203
ATI (Unit 7)
Hematologic System -
 Expected Proto: Aspirin — Others: ticlopidine (Ticlid), clopidogrel (Plavix),
Action: dipyridamole (Persantine), abciximab (Reo Pro)
 Prevent platelet clumping by inhibiting arterial clotting enzymes and factors
Therapeutic Uses:  Primary prevention of acute MI  Prevention of stroke
 Prevention of reinfarction
 Acute coronary syndromes (abciximab and tirofiban {Aggrastat})
Adverse  GI effects (concurrent PPI / enteric-coated / take ĉ food)
Effects:  Hemorrhagic stroke
Contraindications/Precautions:  Pregnancy (D)
Interactions: 
 Medications that enhance bleeding  additive risk for bleeding
Education: 
 ASA (81 mg) for prevention / ASA (325 mg) during initial acute MI episode
Thrombolytic Medications

N203
ATI (Unit 7)
Hematologic System -
 Proto: streptokinase
Expected Action: Others: alteplase (tPA), tenecteplase, reteplase
 Clot dissolution by plasminogenplasmin which destroys fibrinogen
Therapeutic Uses: 
 Acute MI / DVT / Massive PE / Ischemic stroke (alteplase)
Adverse Effects: 
 Serious risk of bleeding from different sites
Streptokinase  Hypotension (infuse slowly)
 Allergic reaction or anaphylaxis
Contraindications/Precautions:  Hx of intracranial hemorrhage
 Brain tumors / pericarditis / Recent head or facial trauma / internal bleeding
Interactions: 
 Meds that enhance bleeding have additive risk for bleeding
Education:  Admin within 4-6 hours of onset
 IV aminocaproic acid for excessive fibrinolysis
 Administer H2 antagonists such as ranitidine (Zantec) or PPI such as
omeprazole (Prilosec) to prevent GI bleeding.
Iron Preparations

N203
ATI (Unit 7)
Hematologic System -
Expected Action: Proto: Ferrous sulfate — Others: Iron Dextran

 Increase iron level for RBC development and oxygen transport capacity
Therapeutic Uses:  Treat and prevent iron-deficiency anemia
Adverse Effects:  Teeth staining (liquid) {Dilute / Drink ĉ straw / Rinse}
 GI distress: {take ĉ food if necessary but  absorption}
 Anaphylaxis (parenteral): IV is safer / Deep IM ĉ Z-track / Infuse slowly
Contraindications/Precautions: 

Interactions:  Vitamin C   absorption but  side effects
 Antacids or tetracyclines   absorption
Education:  Take on empty stomach to  absorption
 Anticipate dark green or black stool
 Vitamin B12
(Cyanocobalamin)

N203
ATI (Unit 7)
Hematologic System -
Expected Action: Proto: Vitamin B12 (cyanocobalamin)
 Necessary to convert folate (required for DNA production) from inactive form
Therapeutic Uses:  Treatment of B12 deficiency
 Megaloblastic (macrocytic) anemia related to B 12 deficiency
Adverse Effects: 
 Hypokalemia 2º  RBC production
Contraindications/Precautions: 

Interactions:  Folic acid supplements mask signs of B12 deficiency

Education:  Intranasal spray / oral / IM / SC
 Injections are painful; reserved for reduced ability to absorb.
Folic Acid

N203
ATI (Unit 7)
Hematologic System -
Expected Action: Proto: Folic Acid
 Folic acid is essential in DNA production & erythropoiesis (RBC, WBC, PLT)
Therapeutic Uses:  Tx of macrocytic anemia
 Prevention of neural tube defects in pregnancy
Adverse Effects:  None

Contraindications/Precautions: 

Interactions: 
 Sulfonamides, sulfasalazine, methotrexate   folate levels ĉ concurrent use
Education: 

Hematopoietic Growth Factors

N203
ATI (Unit 7)
Hematologic System -
Expected Action: Proto: Epoetin alfa (Epogen, Procrit) — Others: darbepoetin alfa
 Act on bone marrow to  RBC production
Therapeutic Uses:  Anemia of chronic renal failure or chemotherapy
 HIV patients taking zidovudine  Anemia in patients schedule for
(Retrovir) elective surgery
Adverse Effects:  Hypertension 2º  Hct
  risk for CV event (MI, stroke, arrest) ĉ  Hgb > 12 g/dL or > 1 g in 2 weeks
Contraindications/Precautions:  CI: uncontrolled hypertension

Interactions: 

Education:  RBC production requires iron, folate, and vitamin B12
 Monitor Hgb and Hct 2x per week until target range is reached
Granulocyte Colony
Stimulating Factor

N203
ATI (Unit 7)
Hematologic System -
Expected Action: Proto: filgrastim (Neupogen) — Others: pegfilgrastim (Neulasta)
 Medications stimulate bone marrow to  production of neutrophils.
Therapeutic Uses:   infection risk with neutropenia (e.g. cancer)
Adverse Effects:  Bone pain
 Leukocytosis:  dose / interrupt treatment if WBC > 50,000/cc, ANC >
20,000/cc, or platelets > 500,000/cc.
Contraindications/Precautions:  CI: Sensitive to E. coli proteins

Interactions: 

Education:  Filgrastim should not be agitated nor mixed
 Monitor CBC 2x per week
Granulocyte Macrophage
Colony Stimulating Factor

N203
ATI (Unit 7)
Hematologic System -
Expected Action: Proto: Sargramostim (Leukine)

  production of WBCs in bone marrow

Therapeutic Uses: 
 Facilitates recovery of bone marrow after marrow transplant.
Adverse Effects:  Diarrhea, weakness, rash, malaise, and bone pain (call)
 Leukocytosis, thrombocytosis: Δ if WBC>50,000, ANC>20,000, PLT>500,000
Contraindications/Precautions:  CI: Allergic to yeast products
 Caution ĉ ♥ disease, hypoxia, peripheral edema, pleural/pericardial effusion.
Interactions: 

Education:  Sargramostim should not be agitated nor mixed with other meds.

Thrombopoietic Growth
Factors

N203
ATI (Unit 7)
Hematologic System -
Expected Action: Proto: oprelvekin (Interleukin 11, Neumega)

 Increases production of platelets.

Therapeutic Uses:   thrombocytopenia ĉ myelosuppressive chemotherapy
Adverse Effects:  Fluid retention (peripheral edema, dyspnea on exertion)
 Dysrhythmias  Conjunctival injection, transient blurring, and papilledema
Contraindications/Precautions: 

Interactions: 

Education:  Treat for 21 days or until PLT  > 50,000

Whole Blood

N203
ATI (Unit 7)
Hematologic System -
Expected Action:  Increases circulating blood volume
Therapeutic Uses:  Acute blood loss, extensive burns, dehydration, shock
Adverse Effects:  Sepsis (culture, antibiotics, IV fluids, vasopressors, steroids)
 Acute hemolytic rxn (fever, tachycardia, hypotension): VS Q5m for 15m
 Febrile nonhemolytic rxn (most common) (fever, headache): VS Q5m for 15m
 Anaphylaxis: VS Q5m for 15m – IM or IV epinephrine
 Mild allergy: If respiration uncompromised, antihistamines and restart
 Circulatory overload: Place upright / O2 and diuretics / slower rate
Education:  Requires countersign  Assess before, during, & after
 Assess site & patency  Use ≥19 ga, filter, Y-tubing  No Mix
 Complete in 2-4 hours   Hgb 1-2 g/dL per unit
Packed RBCs

N203
ATI (Unit 7)
Hematologic System -
Expected Action:   # of RBCs
Therapeutic Uses:  Erythroblastosis fetalis  Hemoglobinopathies
 Severe symptomatic anemia (Hgb<6 g/dL)  Med-induced hemolytic anemia
Adverse Effects:  Sepsis (culture, antibiotics, IV fluids, vasopressors, steroids)
 Acute hemolytic rxn (fever, tachycardia, hypotension): VS Q5m for 15m
 Febrile nonhemolytic rxn (most common) (fever, headache): VS Q5m for 15m
 Anaphylaxis: VS Q5m for 15m – IM or IV epinephrine
 Mild allergy: If respiration uncompromised, antihistamines and restart
Education:  Requires countersign  Assess before, during, & after
 Assess site & patency  Use ≥19 ga, filter, Y-tubing  No Mix
 Complete in 2-4 hours   Hgb 1-2 g/dL per unit
Platelet Concentrate

N203
ATI (Unit 7)
Hematologic System -
Expected Action:   platelet count

Therapeutic Uses:  Thrombocytopenia (< 20,000/cc)

 Active bleeding (platelets < 80,000/cc)
Adverse Effects:  Sepsis (culture, antibiotics, IV fluids, vasopressors, steroids)
 Febrile nonhemolytic rxn (most common) (fever, headache): VS Q5m for 15m
 Mild allergy: If respiration uncompromised, antihistamines and restart
Education:  Requires countersign  Assess before, during, & after
 Assess site & patency  Use special platelet kit (smaller filter, shorter tube
Fresh Frozen Plasma

N203
ATI (Unit 7)
Hematologic System -
Expected Action:  Replaces coagulation factors
Therapeutic Uses:  Massive hemorrhage  Extensive burns  Shock
 Disseminated intravascular coagulation  Antithrombin III deficiency
 Thrombotic thrombocytopenic purpura  Reverse warfarin effects
 Replacement therapy for factors II, V, VII, IX, X, & XI
Adverse Effects:  Sepsis (culture, antibiotics, IV fluids, vasopressors, steroids)
 Acute hemolytic rxn (fever, tachycardia, hypotension): VS Q5m for 15m
 Febrile nonhemolytic rxn (most common) (fever, headache): VS Q5m for 15m
 Anaphylaxis: VS Q5m for 15m – IM or IV epinephrine
 Mild allergy: If respiration uncompromised, antihistamines and restart
 Circulatory overload: Place upright / O2 and diuretics / slower rate
Education:  Requires countersign  Assess before, during, & after
 Assess site & patency   No Mix
Pheresed Granulocytes

N203
ATI (Unit 7)
Hematologic System -
Expected Action:  Replace neutrophils / granulocytes
Therapeutic Uses:  Neonatal sepsis  Severe neutropenia (ANC < 500)
 Neutrophil dysfunction  Nonresponsive life-threatening infection
Adverse Effects:  Sepsis (culture, antibiotics, IV fluids, vasopressors, steroids)
 Acute hemolytic rxn (fever, tachycardia, hypotension): VS Q5m for 15m
 Febrile nonhemolytic rxn (most common) (fever, headache): VS Q5m for 15m
 Anaphylaxis: VS Q5m for 15m – IM or IV epinephrine
 Mild allergy: If respiration uncompromised, antihistamines and restart
 Circulatory overload: Place upright / O2 and diuretics / slower rate
Education:  Requires countersign  Assess before, during, & after
 Assess site & patency   No Mix
Albumin

N203
ATI (Unit 7)
Hematologic System -
Expected Action:  Expands circulating blood volume by oncotic pressure
Therapeutic Uses:  Hypovolemia  Burns  Adult respiratory distress
 Hypoalbuminemia  Cardiopulmonary bypass surgery
 Hemolytic disease of the newborn

Adverse Effects: 
 Risk for fluid volume excess such as pulmonary edema

Contraindications: CHF or renal insufficiency

Education:  Must administer IV: Slowly using an infusion pump
 Can be administered ĉ whole blood, plasma, saline, or glucose.