ATI Pharmacology Medications Affecting the Blood

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Anticoagulants

Proto: Heparin — Others: enoxaparin, tinzaparin (Innohep)
Expected Action: 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: decreased 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 Overdose

Proto: Protamine sulfate
Expectedion Action: Binds with heparin and forms a non-coagulating complex
Therapeutic Uses: Antidote to severe heparin overdose + Reversal of heparin administered during procedures
Education
• Administer slowly (20 mg/min or 50 mg in 10 min)
• aPTT levels of 60-80 sec

Warfarin (Coumadin) (Oral Anticoagulant)

Expected Action: 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) + Surgery of eye, brain, spinal cord; regional anesthesia; lumbar puncture + decreased platelet counts, uncontrolled bleeding, vit. K δ, liver problems, alcoholism
Interactions: • Heparin, aspirin, glucocorticoids --> increased bleeding
• Acetaminophen, sulfonamides, parenteral cephalosporins, ASA --> increased [warfarin]
• Phenobarbital, carbamazepine, phenytoin, OC, vitamin K ---> decreased 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 Overdose

Proto: Vitamin K (Phytonadione)
Expected Action: 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)
Pt Edu: Administer small doses (2.5 mg PO / 0.5-1 mg IV) of vitamin K to prevent development of resistance to warfarin

Antiplatelets

Proto: Aspirin — Others: ticlopidine (Ticlid), clopidogrel (Plavix), dipyridamole (Persantine), abciximab (Reo Pro)
Expected Action: 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 Effects: GI effects (concurrent PPI / enteric-coated / take ĉ food) + 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

Proto: streptokinase, Others: alteplase (tPA), tenecteplase, reteplase
Expected Action: 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

Proto: Ferrous sulfate — Others: Iron Dextran
Expected Action: 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 extremely decreases absorption}
• Anaphylaxis (parenteral): IV is safer / Deep IM ĉ Z-track / Infuse slowly
Interactions: • Vitamin C --> increased absorption but increased side effects
• Antacids or tetracyclines --> decreased absorption
Education: • Take on empty stomach to increase absorption
• Anticipate dark green or black stool

Vitamin B12 (Cyanocobalamin)

Expected Action: Necessary to convert folate (required for DNA production) from inactive form
Therapeutic Uses: • Treatment of B12 deficiency
• Megaloblastic (macrocytic) anemia related to B12 deficiency
Adverse Effects: Hypokalemia 2º increased RBC production
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

Expected Action: essential in DNA production & erythropoiesis (RBC, WBC, PLT)
Therapeutic Uses: • Tx of macrocytic anemia
• Prevention of neural tube defects in pregnancy
Pt Edu: Sulfonamides, sulfasalazine, methotrexate --> decreased folate levels ĉ concurrent use

Hemapoetic Growth Factors

Proto: Epoetin alfa (Epogen, Procrit) — Others: darbepoetin alfa
Expected action: Act on bone marrow to increase RBC production
Therapeutic Uses: • Anemia of chronic renal failure or chemotherapy
• HIV patients taking zidovudine (Retrovir) • Anemia in patients schedule for elective surgery
Adverse Effects: • Hypertension 2º increase Hct
• increased risk for CV event (MI, stroke, arrest) ĉ increase Hgb > 12 g/dL or > 1 g in 2 weeks
Contraindications: uncontrolled hypertension
Education: • RBC production requires iron, folate, and vitamin B12
• Monitor Hgb and Hct 2x per week until target range is reached

Granulocyte Stimulating Colony Factor

Proto: filgrastim (Neupogen) — Others: pegfilgrastim (Neulasta)
Expected Action: Medications stimulate bone marrow to increase production of neutrophils.
Therapeutic Uses: • decreased infection risk with neutropenia (e.g. cancer)
Adverse Effects: • Bone pain
• Leukocytosis: decreased dose / interrupt treatment if WBC > 50,000/cc, ANC > 20,000/cc, or platelets > 500,000/cc.
Contraindications: Sensitive to E. coli proteins
Education: • Filgrastim should not be agitated nor mixed
• Monitor CBC 2x per week

Sargramostim (Leukine) (Granulocyte Macrophage Colony Stimulating Factor)

Expected Action: increase 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.
Education: Sargramostim should not be agitated nor mixed with other meds.

Oprelvekin (Interleukin 11, Neumega) (Thrombopoietic Growth Factors)

Expected Action: Increases production of platelets.
Therapeutic Uses: • increased thrombocytopenia ĉ myelosuppressive chemotherapy
Adverse Effects: • Fluid retention (peripheral edema, dyspnea on exertion)
• Dysrhythmias • Conjunctival injection, transient blurring, and papilledema
Education: Treat for 21 days or until PLT increase to > 50,000

Whole Blood

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 • increased Hgb 1-2 g/dL per unit

Packed RBCs

Expected Action: increase # 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 • increased Hgb 1-2 g/dL per unit

Platelet Increase

Expected Action: increased 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

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

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

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.

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