Unique Anticoagulation Issues at University Hospitals Case 独特的抗凝问题在大学医院的案例.pptVIP

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Unique Anticoagulation Issues at University Hospitals Case 独特的抗凝问题在大学医院的案例.ppt

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Unique Anticoagulation Issues at University Hospitals Case 独特的抗凝问题在大学医院的案例

Unique Anticoagulation Issues at University Hospitals Case Medical Center Teresa L. Carman, MD Director, Vascular Medicine Case Medical Center Pager 33515 Discussion Use of the heparin protocol Anti-Xa assay vs. aPTT Safe discharge of patients Anticoagulation monitoring service referrals Heparin Order Set IV Heparin Protocol Diagnosis / Weight Based Dosing Low intensity dosing ACS, Stroke High intensity dosing VTE, CVT, Afib Nurse Driven Titration Titration table based on 4 hr anti-xa lab value obtained after initial dosing or titration changes With the change in monitoring the titration table will change to reflect a 6 hr interval for required titrations IV Heparin Protocol Full Protocol Includes: Initial Loading Bolus Titrated Drip Additional (Repeat) Bolus IV Heparin Protocol Ordering IV Heparin Protocol Ordering IV Heparin Protocol Ordering IV Heparin Protocol Why order the full protocol? Clinical Results: Full protocol NOT ordered 39 hr average time to therapeutic Full protocol ordered 11 hr average time to therapeutic All patients were either therapeutic or supratherapeutic within 6 hrs IV Heparin Protocol Why the 4 hour dosing change to the protocol? With a 6 hour protocol it usually takes 8 hours between dose adjustments The 4 hour protocol should decrease this interval to approximately 6 hours This should allow patients to a reach consistent therapeutic range sooner thus impact the risk for recurrent events aPTT VS. Heparin Assay Monitoring Overview of aPTT The aPTT is used in most clinical laboratories to monitor coagulation and specifically monitor anticoagulants ie. intravenous unfractionated heparin and direct thrombin inhibitors Clinicians have familiarity with assay Readily automated Current targets were established based on data from a post-hoc analysis of a 1972 study which suggested 1.5-2.5 times aPTT control reduced risk the of recurrent thromboembolism Disadvantages of Using aPTT to Monitor Heparin aPTT has variable a