Pharmacology Case Presentation Margaret Baldwin, PharmD, BCPS Pharmacist, Intermountain Medical Center, Intermountain Healthcare; Salt Lake City, Utah Objectives: • Review new antithrombotics on the market • List new antithrombotics in the pipline • Discuss how these new medications will impact patient care
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Pharmacology Case Presentation
Margaret Baldwin, PharmD, BCPS
Pharmacist, Intermountain Medical Center, Intermountain Healthcare; Salt Lake City, Utah
Objectives: • Review new antithrombotics on the market • List new antithrombotics in the pipline • Discuss how these new medications will impact patient care
Clinical Application of Thromboelastography
Margaret Baldwin, PharmD, BCPSCritical Care Clinical PharmacistShock Trauma ICUIntermountain Medical Center
Objectives
Review how to interpret thromboelastography (TEG)
Discuss how anticoagulant and antiplateletmedications affect TEG results
Evaluate TEG and it’s implication to pharmacologic therapy
Adapted from Haemonetics Corporation educational material 8/5/2013 Dan Mason
Interpreting TEG
Value Definition Normal rangeSP Initial thrombin burstR End of thrombin burst 5-10 minutesDelta R-SP = thrombin burst 0.7-1.1K Fibrinogen function /crosslinking 1-3 minutesAngle Speed of clot strength 53-72 degreesMA Clot strength 50-70 mmG Mathematical conversion of MA 4.5-11 Kdynes/cm2
EPL Clot breakdown 0-15%LY30 Lysis 30 minutes after MA is reached 0-8%
SP = split point, time to first fibrin strands
R = reaction time to end of thrombin burst
R-SP = Delta = thrombin burst
K = fibrin cross-linkage, fibrinogen function
Angle = fibrinogen function
MA = platelet function in mm
G = MA converted to Kdynes/cm2
EPL = estimated percent lysis, clot breakdown
LY30 = lysis 30 minutes after MA reached
EPL, LY30
G = clot strength
= platelet function
R
K
Adapted from Haemonetics Corporation educational material 8/5/2013 Dan Mason
Platelet Mapping
Uses the patient’s baseline platelet activity as a reference
Effect of antiplatelet drug therapy Pathologic platelet dysfunction Help determine the cause of decreased MA
Platelet Mapping
Evaluate both platelet adhesion and aggregation Arachidonic acid (AA)
Evaluates adhesion Not applied to anything, just look at percent
Adenosine diphosphate (ADP) Evaluates aggregation Apply percent inhibition to the TEG G to calculate the
actual platelet function G integrity of the platelet
Reported in percent of platelet inhibition
Thrombelastograph ParametersMA Thrombin - Maximum clot strength induced by thrombin
MA Fibrin - Maximum contribution of fibrin only to MA
MA ADP or A.A - Measures ADP or arachidonic acid stimulated clot strength
0 MinutesAdapted from Haemonetics Corporation educational material 8/5/2013 Dan Mason
Applying TEG
Hyperfibrinolysis
Confidential Report for Improvement of Hospital, Facility and Patient Care--Not Part of Medical Record and Not to be Used in Litigation--Prepared Pursuant to Utah Code Ann. ? 26-25-1 et seq., or Idaho Code Ann. ? 39-1392 et seq.
28.2 79.1
Tranexamic Acid (TXA)
Inhibits lysine dependent plasminogen conversion to plasmin
Dosing 1000 mg IV over 10 minutes, then 1000 mg IV infusion over 8 hours
Effects of tranexamic acid on death, vascular occlusiveevents, and blood transfusion in trauma patients withsignificant haemorrhage (CRASH-2): a randomised,
TXA reduced all-cause mortality and death due to bleeding with no risk of increased thromboembolic events
Hyperfibrinolysis
Confidential Report for Improvement of Hospital, Facility and Patient Care--Not Part of Medical Record and Not to be Used in Litigation--Prepared Pursuant to Utah Code Ann. ? 26-25-1 et seq., or Idaho Code Ann. ? 39-1392 et seq.
Hypercoagulable
Confidential Report for Improvement of Hospital, Facility and Patient Care--Not Part of Medical Record and Not to be Used in Litigation--Prepared Pursuant to Utah Code Ann. ? 26-25-1 et seq., or Idaho Code Ann. ? 39-1392 et seq.
Platelet Mapping
Confidential Report for Improvement of Hospital, Facility and Patient Care--Not Part of Medical Record and Not to be Used in Litigation--Prepared Pursuant to Utah Code Ann. ? 26-25-1 et seq., or Idaho Code Ann. ? 39-1392 et seq.
Desmopressin (DDAVP)
Synthetic vasopressin analog Used in patients with hemophilia A and von
Willebrand disease Prevents surgical bleeding in uremic patients Improves adhesion and enzymatic function
by increasing vWF and factor VIII Dosing
0.3 mcg/kg IV over 30 minutes Max 20 mcg
Platelet Mapping after DDAVP
Confidential Report for Improvement of Hospital, Facility and Patient Care--Not Part of Medical Record and Not to be Used in Litigation--Prepared Pursuant to Utah Code Ann. ? 26-25-1 et seq., or Idaho Code Ann. ? 39-1392 et seq.
Adapted from Haemonetics Corporation educational material 8/5/2013 Dan Mason
Patient Case
Trauma 1 Activation on 12/17
MM is a 21 year old female who rear-ended a UTA bus at full speed. She was unrestrained and required prolonged extrication from under the dashboard of her vehicle.
PMH was not significant NKDA MM drinks alcohol regularly, smokes 1 pack
of cigarettes per day and admits to occasional marijuana use
Hemodynamically stable Multiple abrasions and lacerations Severe distress secondary to pain and