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Anticoagulsants
‡The Hashemite University ‡Abdulqadir Nashwan ‡Faculty of Nursing ‡Pharma Project

wikipedia.org .org ‡ http://www. et al. USA. Lippincott¶s.. Aschenbrenner. ‡ http://www.teratology. 2002.. Drug Therapy in Nursing.References: ‡ Diane S.

Outlines: ‡Heparin ‡Protamine Sulfate ‡Warfarin .

‡The blood cells known basophiles produce a small amount as well. is produced by mast cells located in connective tissue throughout the body. ‡The areas that produce the largest amount of Heparin are the lunges and to a lesser degree the liver. a naturally occurring anticoagulant. .Anticoagulant Drugs ‡Heparin. ‡This is a natural protective mechanism of the body are these two areas receive the most small emboli.

‡ALL Anticoagulants interfere with the clotting cascade and prolong blood clotting time . ‡They vary by their route and their method of action . . those that can be administered parenterally and those that can only be administered orally . ‡The parenteral anticoagulants work by preventing the conversion of fibrinogen to fibrin. ‡There are two types of anticoagulants.

(1972) ‡Two different lab.‡The oral anticoagulants work by preventing the synthesis of factors dependent on vitamin K for synthesis. VII. IX. and X . . factors II (prothrombin). tests are therefore used to measure the therapeutic effects of these anticoagulants.

Heparin ‡Pharmaceutical grade Heparin is commonly derived from the tissue of slaughter house animals e.g. pigs intestine or beef lung . ‡Is a widely used as an injectable anticoagulant. ‡It is also used to form an inner anticoagulant surface on various experimental and medical devices such as test tubes and renal dialysis machines. .

hence its name (hepar is Greek for "liver"). ‡It was originally isolated from liver cells. .History ‡Heparin is one of the oldest drugs currently still in widespread clinical use.

prevention of left ventricular thrombi and CVA post-MI.Indications ‡Prevention and treatment of venous thrombosis and pulmonary embolism . ‡Diagnosis and treatment of DIC . ‡Treatment of atrial fibrillation with embolization . prevention of cerebral thrombosis in the evolving stroke . . ‡Prevention of clotting in blood samples and Heparin lock sets and during dialysis procedures . ‡Unlabeled uses: adjunct in therapy of coronary occlusion with acute MI.

the drug is widely distributed in the body . ‡Although it does NOT cross the placenta. ‡Metabolism occurs in the liver where it is inactivated . Half-life: 30 to 180 min ‡When administered SC.Pharmacokinetics: ‡When administered IV. . ‡It is eliminated from the body in the urine. ‡After administration. nor is it found in breast milk. Heparin has an immediate onset of action. Heparin¶s onset of action is 20 to 60 min.

Contraindications: ‡Hypersensitivity to beef or pork because some Heparin products are derived from the intestinal mucosa of pigs and other from beef lungs.g. ‡Heparin is also contraindicated in patients with thrombocytopenia. ‡Bleeding disorders.. E. Cautions: ‡Patients with the potential for hemorrhage.. in patients immediately after surgery or in those with peptic ulcer disease and liver disease. . And active bleeding other than DIC.

it is potentially life-threatening.Adverse effects: ‡ ‡ ‡ The most common adverse effect of Heparin is bleeding. . Prolonged use may lead to osteoporosis. Although Heparin-induced thrombocytopenia (HIT) occurs rarely.

‡An IV controller or pump should be used for continuous IV drip Heparin to promote a steady rate of delivery and prevent rapid over dosage. . Ht.Minimizing adverse effects: ‡Before initiating therapy. ‡If the APTT during treatment exceeds the desired range. baseline information. and platelet count. However these tests are NOT usually performed for prophylactic Heparin use. the dosage should be decreased. the nurse should review such laboratory values as APTT.

An additional peripheral IV line or multilumen CV line should be used instead. nose.‡Administration of IV Heparin should NOT be interrupted to give another drug. . ‡The patient should be monitored for bleeding from the gums. ‡Urine and stools should be examined to detect blood as well. or wounds. vagina. ‡Other drugs should NOT be administered through the same tubing as heparin because heparin is incompatible with many other drugs and fluids. Doing so increases the risk of thrombus formation because therapeutic levels may NOT be maintained.

restless. ‡IM injection should be avoided to prevent bleeding into the muscle. particularly if the patient is confused. DO NOT aspirate or massage the area after administration. side rails should be raised or padded. disoriented. . ‡To protect the patient from injury or falls. Pressure should be placed on IV sites when removing the line until the bleeding stops. cleansing the skin before injection with alcohol (a vasodilator) increases the chance of hematoma formation.‡The skin should be inspected for echymoses or hematomas that indicate bleeding into the tissues. ‡For SC administration of heparin.

avoid activities that might lead to injury. .‡The nurse should educate the patient to use a soft toothbrush and an electric razor during therapy. ‡The nurse should explain the frequent blood samples will need to be analyzed to measure the patient¶s clotting time and determine whether the patient is receiving a safe amount of heparin. ‡avoid contact sports.

‡Doses of SC heparin should NOT be missed. usually 6 to 8 hrs after the infusion starts . .Maximizing therapeutic effects: ‡Heparin levels should be allowed to reach steady state before measuring APTT. the new IV line should be inserted as soon as possible to minimize the disruption of the infusion. ‡If occlusion or infiltration necessitates changing the IV site. they should be administered at the regularly prescribed times to maintain blood levels. ‡Mix well when adding heparin to IV infusion. ‡IV heparin therapy should NOT be interrupted.

tetracycline. erythromycin. hydrocortisone. pentazocine. diazepam. netilimicin. phenytoin. ergotamine. Monitor patient closely. codeine. methadone. triflupromazine. kanamycin. vancomycin . direct incompatibilities in solution and at Y-site seen with amikacin. cytarabine. streptomycin. tobramycin. gentamicin. D5W. polymyxin B. Ringer's. methicillin. dobutamine. methotrimeprazine.‡Continuous infusion: Can be mixed in normal saline. infusion pump is recommended. chlorpromazine. doxorubicin. promethazine. invert bottle numerous times to ensure adequate mixing. droperidol. morphine. hyaluronidase. meperidine. haloperidol. ‡Incompatibilities: Heparin should not be mixed in solution with any other drug unless specifically ordered. levorphanol. mix well.

protamin itself has some anticoagulant effect. ‡Infusion should be slow to minimise these side effects.Protamine Sulfate ‡Protamine is a drug that reverses the anticoagulant effects of heparin by binding to it. for every 100 IU of active heparin.v. ‡Dosage for heparin reversal is 1mg Protamine sulfate i. ‡It causes significant histamine release resulting in hypotension and bronchoconstriction. ‡Protamine is isolated from the sperm of various fish. and also causes pulmonary hypertension. ‡In large doses. .

Enoxaparin . c.APTT ‡Lower limit of normal: 20-25 sec ‡Upper limit of normal: 32-39 sec ‡Low molecular weight fragments of heparin may be safer. ‡ Low molecular weight Heparin includes: a. Dalteparin . b. Ardeparin . but are more expensive at present.

Warfarin (Coumadin ®) .

and X. it prevents the activation of factors II (prothrombin). It has no effect on factors that have already been activated.Action: ‡Warfarin works by competitively blocking vitamin K at its sites of action. Thus. . IX. VII.

which is the time required for the drug to reach a steady state in the blood. .Pharmacokinetics: ‡After absorption. the anticoagulant effects do not begin for 24 hours. warfarin is bound to albumin in the plasma. maximum effect occurs 3 to 4 days after dosing starts. ‡The time factor is related to previously activated factors that are still circulating in the blood. ‡The drug action peaks in 1 to 9 hours. however.

‡Patients receiving heparin therapy will begin taking warfarin before they discontinue heparine. The practice is safe because the two drugs affect different clotting factors. this allows the warfarin to reach a therapeutic level before heparin is discontinued. ‡The drug crosses the placenta but is NOT present in breast milk. ‡The effects of of warfarin will persist for 4 to 5 days after discontinuation.‡Each time the dose changes. . ‡It metabolized in the liver and excreted in the bile. another 3 to 4 days are needed for the drug to reach its full effects.

.Indications : ‡Warfarin is an oral anticoagulant . when the mitral valve has been replaced or when hypercoagulability is a chronic concern related to venous stasis . ‡It is administered after heparin therapy to complete treating a thrombus or embolism . for example. ‡It is also used prophylactically in patients with atrial fibrillation . ‡Warfarin is also used prophylactically for patients with a long-term risk of thrombus formation.

‡The patient¶s PT is measured against a control PT.‡Dosage is based on achieving a therapeutic level as measured by changes in the prothrombin time (PT). so a standardized unit. ‡PT control times vary with laboratory test methods and equipment. known as the International Normalized Ratio (INR). has been measure therapeutic levels of warfarin. . ‡The INR is determined by a mathematic equation and reflects the patient¶s PT compared with the standardized PT value .

the patient¶s PT should be 1.5 to 3.5 . ‡For prophylaxis in patients with mechanical heart valves.7 times the control or the INR should be 2. the PT should be 1. the INR should be equal to 2 to 3.4 to 1.6 times the control time. .5 to 1.‡For treatment or prophylaxis of a thrombus or embolus.

‡It is not recommended for use in patients with subacute endocarditis. open wounds or ulcerations of the GI tract. cranial.Contraindications: ‡Warfarin is contraindicated for patients with active bleeding. such as hemophilia or thrombocytopenia. the drug is discontinued 7 days before elective surgery. . eye. or pericardial effusions. pericarditis. Usually. or bleeding disorders. ‡Warfarin is also contraindicated for patients who are undergoing surgery in which hemorrhage is possible (spinal. and arterial bypass grafting).

. Adverse effects: -the most frequent adverse effects of warfarin are bleeding and hemorrhage.Cautions: ‡In patients with renal and hepatic impairment. Nausea. vomiting. -A fetal warfarin syndrome has been identified when warfarin is given to pregnant women. ‡Warfarin use is primarily determined by comparing the risks of the drug versus the benefits to the patient. and abdominal cramps can occur as well. diarrhea. Tissue necrosis is a rare adverse effect.

mental retardation. The embryopathy described above results from maternal use during early pregnancy while central nervous system disorders are due to dosage at a later stage in pregnancy.teratology. ‡http://www.org .‡primary teratogenic effect of warfarin is in the axial and appendicular skeleton. ‡The effect of warfarin is directly dependant upon the time of dosage. eye abnormalities. Effected children also have a hypoplastic nose. brachydactyly and scoliosis.

‡Doses are usually given in the evening at 6 PM. This timing allows for early morning blood draws for PT or INR by hospital laboratory personnel. This is then followed by a maintenance dose.Maximizing therapeutic Effects: ‡Warfarin dosage should be individualized until PT or the INR is in therapeutic range. ‡An initial loading dose is given to attain a rapid therapeutic level. .

the antidote. or the INR. . ‡The prescriber needs to be notified if the patient¶s clotting time is greater than the therapeutic level. ‡In case of warfarin overdose. drug dosage will be decreased if this occurs. is administered. ‡Skipping one dose may be all that is required to lower the PT to the therapeutic level. vitamin K (phytonadione).Minimizing Adverse Effects: ‡The patient¶s response to warfarin therapy is measured by using either the ratio of the patient¶s PT compared with the control PT. Usually.

.‡Falls may cause internal bleeding. which may help prevent falls. The patient¶s home should be assessed for factors that may lead to falls. Encourage the use of proper lighting and handrails on stairways.

‡The nurse should educate the patient that skipping a dose of warfarin could alter therapeutic levels. The patient should be advised to return for follow-up blood work. they should NOT double up on the next dose to prevent bleeding. . Dosing so may increase absorption and improve adherence to drug therapy. After the drug level is stabilized and daily PT is not needed.Providing Patient and Family Education: ‡The nurse should teach the patient information regarding signs of bleeding (which are the same as for Heparin). ‡The nurse should instruct the patient to take the drug at the same time each day because this helps prevent a drop in warfarin blood levels. they should take it as soon as they remember. If patients forget a dose. the patient may switch to morning dosing. However.

‡The nurse should emphasize to patients the importance of informing other health care providers (dentist. ‡The nurse should warm women to avoid becoming pregnant while on this drug.‡The nurse should instruct the patient that taking Aspirin. . primarily green vegetables. and so on) that they are on warfarin. or other over-the-counter drugs with these ingredients can affect Warfarin¶s action. ‡The nurse¶s dietary teaching should focus on the need to avoid increased intake of foods rich in vitamin K. large doses of Acetaminophen. ‡Patients should also be instructed to wear or carry medical identification stating that they are receiving warfarin. podiatrist.

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