Anticoagulant Wk4 Fhm

7/23/2019 Anticoagulant Wk4 Fhm

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Georgina Follows Hdx foundation module

Anticoagulation and its use inAnticoagulation and its use inhaemodialysishaemodialysis

Basic clinical dialysis,

Lestariningsih

Subbag Nefrologi / Hipertensi

Bag Penyakit Dalam ! "ND#P/$S Dr !ariadi



Georgina Follows Hdx foundation module

Highlight

% contact &ith plastic tubing, the dialysis membran and air

in the HD circuit stimulates the clothing cascades% e'cessi(e clotting in the dialysis circuit and filter need to be

discarded, in adult, this can mean the loss of )*+*-+ ml of blood

% clotting &ithin an HD circuit can be minimised through aprpropiate

use of anticoagulant therapy% periodic anticoagulation is normally gi(en during the dialysis

treatment




.eorgina ollo&s Hd

Aims and objectives% o gain understanding of the mechanisms in(ol(ed in the

clotting process and coagulation assessment0

% o gain understanding of heparin, its administration,

ad(antages and disad(antages0

% o gain understanding of any contraindications to heparin

uses0

% o gain understanding of any alternati(es to heparin usage0




.eorgina ollo&s Hd

Introduction

Blood comes into contact &ith e'trinsic factors during

haemodialysis0

Heparin is the most commonly used anticoagulant during

dialysis0

Administration of heparin

% Bolus dose at the beginning of dialysis

%1ontinuous infusion during dialysis0

%Both of these methods are prescribed and can be altered to

tailor each patients needs0




.eorgina ollo&s Hd

he 1oagulation 1ascadehe 1oagulation 1ascade

2ascular 1onstriction

Platelet plug formation

ormation of blood clots




.eorgina ollo&s Hd

Normal clotting mechanisms

here are t&o methods by &hich the coagulation cascade is

acti(ated3

Intrinsic pathway.

#nitiated &hen blood comes into contact &ith foreign

surface0

Platelets become damaged and release phospholipids0

Phospholipids 4oin &ith actor 2### and actor #5 to formactor 50 actor 5 combines &ith calcium to form

prothrombin and acti(ates the coagulation cascade0




.eorgina ollo&s Hd

Extrinsic pathway

% Damaged tissue 6 thromboplastin released 6 initiates

formation of prothrombinase in presence of actor 5 and

calcium ions0

%he coagulation cascade then occurs by using thrombin 6

an en7yme that con(erts fibrinogen into fibrin0 his forms

a mesh trapping the formed elements of blood 6 thus

forming a 1L80




.eorgina ollo&s Hd

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<hich path&ay<hich path&ayis initiated duringis initiated during

haemodialysis;haemodialysis;




.eorgina ollo&s Hd

Heparin

% Disco(ered in )=)> by ?cLean

% Anticoagulant found in the li(er

% Porcine and bo(ine preparations

% ?olecular &eight @ +++ to ++++ Daltons

% Binds to thrombin inhibitor AN#H$8?B#N ###

inacti(ates acti(e actor 5 and inhibits con(ersion of

prothrombin to thrombin




.eorgina ollo&s Hd

Advantages of Heparin

% #020 6 direct access

% 1heap

% ?etabolised naturally by the li(er

% Acts Cuickly and effecti(ely on the intrinsic path&ay

% $e(ersed Cuickly and easily by Protamine

% Long, established history of use




.eorgina ollo&s Hd

Disadvantages of Heparin

% Bleeding

% Hyperlipidaemia

% hrombocytopenia

% Allergic reactions

% Pruritis

% Alopecia

% 8steoporosis




.eorgina ollo&s Hd

Assessment of coagulation

% 1lotting times 6 AP Actual Partial thromboplastinimeE or A1 Acti(ated 1lotting imeE 6 )*+ secs

% 8bser(e for signs of clotting

Darkened blood Streaks in dialyser

1lots / fibrin rings in chambers

Blood entering (enous isolator

$ising / falling (enous pressure




.eorgina ollo&s Hd

actors affecting coagulation

% Blood flo&

% High haematocrit le(els

% :P8

% Blood transfusion

% #ntradialytic lipid infusion

% High " rate

% ype of circuit

% ?edication




.eorgina ollo&s Hd

actors affecting coagulation cont.

% #ndi(idual clotting abnormalities

% ype of dialyser

% ?embrane

Natural membranes e0g0 cuprophane 6 relati(elyhigh platelet acti(ation

Synthetic membranes (ary0 Polysulphone more

compatible &ith blood than 1uprophane and

1ellulose




.eorgina ollo&s Hd

!ontraindications for heparin use

% Pericarditis

% Pre and post surgery, F G hour

% ollo&ing temporary line insertion

% 1oagulation abnormalities, therapy antiplatelet

% hrombocytopenia, F )-+ 5 l+ =/L

% #ntracranial haemorrhage

% Any acti(e bleeding

% "raemic patients

% Heparin free dialysis 3 flushing the dialy7er &ith )++ml Nacl +,=I

:(ery +>+ minute




.eorgina ollo&s Hd

!ontraindications for heparin use cont.

% Peptic ulcer

% Aortic aneurysm

% 1erebral aneurysm

% Se(ere li(er disease

% Hypersensiti(ity / allergic reactions




.eorgina ollo&s Hd

"tandard Heparin #$H% Dose

% bolus dose *-++ " -+"/kgBBE, maintenance )+++/4am

% atau initial HD3 loading dose of *-+-++ " follo&ed by infusion

rate *-+-++, ma' *+++"

Heparin ree Dialysis

% 8btain baseline clotting time

% -+++u heparin rinse

% High blood flo& rate

% )++*++ mls saline flush e(ery + mins




.eorgina ollo&s Hd

% L0?0<0H0 6 inhibits actor 5, little thrombin inhibition,

AP / A1 minimally prolonged0

Advantages

% Safe, effecti(e J decreased bleeding risk

% Simple 6 single dose reCuired

% $educed cholesterol and triglyceride le(els

% $educed alopecia

Disadvantages% :'pensi(e, long half life, not use A1Ks




.eorgina ollo&s Hd

utureuture

1oating of elements of1oating of elements ofcircuit &ith acti(ecircuit &ith acti(eheparin0heparin0

Nonthrombogenic Nonthrombogenicmembranes0membranes0

Heparinised coatedHeparinised coatedcartridges capable ofcartridges capable of

remo(ing heparinremo(ing heparininfused into the e'trainfused into the e'tracorporeal circuit0corporeal circuit0




.eorgina ollo&s Hd

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.eorgina ollo&s Hd

.$8"P <8$! .$8"P <8$!

A patient complains of loss of hair o(er the past

couple of months0 She has minimal heparin on

dialysis, but still no change, &hat &ould you do;;

A patient has 4ust completed dialysis and you

notice that the kidney is (ery dark0 he patient isalready on high doses of heparin0 <hat &ould you

do;;


Anticoagulant Wk4 Fhm

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