NUR 4257 - final exam (renal, blood components, snake
bites, and trauma) Questions With Complete Solutions
!! pt has Hx PE, on Coumadin, INR in goal range 2-3...comes in
with GI bleed. Will we reverse their INR?
yes - have to reverse and lower INR (use FFP)
even though they have clotting condition and may have further
clotting, internal bleeding way more likely to kill them
INR is > 1.5
!! INR and INR reversal
goal: 2-3 (for pts on Coumadin)
tells you how long it takes for your blood to clot
high INR: higher risk of bleeding
INR reversal - quick (FFP) slow (vit K) for pts on warfarin who
are bleeding or have low levels of clotting factors
(pts on warfarin have higher INRs - clot slower - to reduce
formation of clots)
-if pt is bleeding and on warfarin, want to reverse INR and
make it lower (increase time it takes to clot)
protamine sulfate
medication for hemostasis
heparin overdose, reverse effects of heparin during heart sx
!! rarely used in pts on heparin who are bleeding - just shut off
,heparin (only really use in sx or with OD)
-binds to heparin to neutralize it form inactive salt aggregate
-risks: anaphylaxis
risk of using protamine sulfate
anaphylaxis
prothrombin complex concentrate (PCC) [Kcentra]
medication for hemostasis
indicated for the urgent reversal of coagulation factor deficiency
induced by vitamin K antagonist (warfarin)
RAPID reversal of INR
!! hemorrhaging patients, within few minutes
rapidly increases plasma concentration of vit K dependent coag
factors (II, VII, IX, and X, antithrombotic proteins C/S
slow, quick, and rapid reversal of INR
slow (vit K)
quick (FFP - plasma) few hours
rapid (prothrombin complex concentrate) [Kcentra] few minutes
DDAVP
desmopressin - synthetic vasopressin (ADH)
stop bleeding in pts with von willebrand's or mild hemophilia A
!! used when pts PLT are not very functional (PLT lvl may be
,normal)
-also used for antidiuretic action in pts with DI
-stimulates von willebrand antigen - hemostasis
FEIBA
RAPID hemostasis
tx bleeding in pts with hemophilia A or B, off label use for INR
reversal for pts on warfarin
!! slow, quick, and rapid hemostasis medications/transfusions
rapid:
PRBCs (1 hr), platelets (1 hr)
protamine sulfate (5 mins)
PCC [KCentra] (30 mins)
DDAVP [Desmopressin] (15-30 mins)
FEIBA (15-30 mins)
quick:
FFP
slow:
vitamin K
A patient is admitted to your unit and needs an emergent dialysis
catheter placement. The patient takes Coumadin at home, and
when his INR is checked, it is 2.7. Would it be better to give this
patient FFP or Vitamin K, and why?
, FFP bc need QUICK reversal of INR (want to stop bleeding,
clot faster) cx hemostasis
-newer drugs out now that can also be used: prothrombin
complex concentrate [KCentra], FEIBA (off label)
why restrictive strategy for blood transfusion?
-risk of rxn
-volume overload
-shortage of blood products
-minimal clinical benefits with aggressive thresholds
-studies show using lower threshold for transfusions (Hgb < 7
compared to Hgb < 10 not associated with adverse effects
blood product transfusion threshold for pts not actively bleeding
-PRBCs: HD stable pts (including critically ill pts): threshold 7
g/dL (give PRBCs if Hgb under 7)
for pts undergoing cardiac/ortho sx or pre-existing CV disease:
threshold 8 g/dL
-PLT < 50,000 (if oncology pt, PLT < 20,000 - hard to keep plt
up d/t bone marrow suppression - chemo)
-FFP if INR > 1.5 ???
-cryo if fibrinogen < 100
!! blood products and meds like Vit K may be given non-
emergently in advance of an invasive procedure
-thresholds do not apply to pts with ACS (MI), severe
thrombocytopenia, chronic transfusion-dependent anemia
bites, and trauma) Questions With Complete Solutions
!! pt has Hx PE, on Coumadin, INR in goal range 2-3...comes in
with GI bleed. Will we reverse their INR?
yes - have to reverse and lower INR (use FFP)
even though they have clotting condition and may have further
clotting, internal bleeding way more likely to kill them
INR is > 1.5
!! INR and INR reversal
goal: 2-3 (for pts on Coumadin)
tells you how long it takes for your blood to clot
high INR: higher risk of bleeding
INR reversal - quick (FFP) slow (vit K) for pts on warfarin who
are bleeding or have low levels of clotting factors
(pts on warfarin have higher INRs - clot slower - to reduce
formation of clots)
-if pt is bleeding and on warfarin, want to reverse INR and
make it lower (increase time it takes to clot)
protamine sulfate
medication for hemostasis
heparin overdose, reverse effects of heparin during heart sx
!! rarely used in pts on heparin who are bleeding - just shut off
,heparin (only really use in sx or with OD)
-binds to heparin to neutralize it form inactive salt aggregate
-risks: anaphylaxis
risk of using protamine sulfate
anaphylaxis
prothrombin complex concentrate (PCC) [Kcentra]
medication for hemostasis
indicated for the urgent reversal of coagulation factor deficiency
induced by vitamin K antagonist (warfarin)
RAPID reversal of INR
!! hemorrhaging patients, within few minutes
rapidly increases plasma concentration of vit K dependent coag
factors (II, VII, IX, and X, antithrombotic proteins C/S
slow, quick, and rapid reversal of INR
slow (vit K)
quick (FFP - plasma) few hours
rapid (prothrombin complex concentrate) [Kcentra] few minutes
DDAVP
desmopressin - synthetic vasopressin (ADH)
stop bleeding in pts with von willebrand's or mild hemophilia A
!! used when pts PLT are not very functional (PLT lvl may be
,normal)
-also used for antidiuretic action in pts with DI
-stimulates von willebrand antigen - hemostasis
FEIBA
RAPID hemostasis
tx bleeding in pts with hemophilia A or B, off label use for INR
reversal for pts on warfarin
!! slow, quick, and rapid hemostasis medications/transfusions
rapid:
PRBCs (1 hr), platelets (1 hr)
protamine sulfate (5 mins)
PCC [KCentra] (30 mins)
DDAVP [Desmopressin] (15-30 mins)
FEIBA (15-30 mins)
quick:
FFP
slow:
vitamin K
A patient is admitted to your unit and needs an emergent dialysis
catheter placement. The patient takes Coumadin at home, and
when his INR is checked, it is 2.7. Would it be better to give this
patient FFP or Vitamin K, and why?
, FFP bc need QUICK reversal of INR (want to stop bleeding,
clot faster) cx hemostasis
-newer drugs out now that can also be used: prothrombin
complex concentrate [KCentra], FEIBA (off label)
why restrictive strategy for blood transfusion?
-risk of rxn
-volume overload
-shortage of blood products
-minimal clinical benefits with aggressive thresholds
-studies show using lower threshold for transfusions (Hgb < 7
compared to Hgb < 10 not associated with adverse effects
blood product transfusion threshold for pts not actively bleeding
-PRBCs: HD stable pts (including critically ill pts): threshold 7
g/dL (give PRBCs if Hgb under 7)
for pts undergoing cardiac/ortho sx or pre-existing CV disease:
threshold 8 g/dL
-PLT < 50,000 (if oncology pt, PLT < 20,000 - hard to keep plt
up d/t bone marrow suppression - chemo)
-FFP if INR > 1.5 ???
-cryo if fibrinogen < 100
!! blood products and meds like Vit K may be given non-
emergently in advance of an invasive procedure
-thresholds do not apply to pts with ACS (MI), severe
thrombocytopenia, chronic transfusion-dependent anemia
