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

Discussion,Use of the heparin protocolAnti-Xa assay vs.aPTTSafe discharge of patientsAnticoagulation monitoring service referrals,Heparin Order Set,IV Heparin Protocol,Diagnosis/Weight Based DosingLow intensity dosingACS,StrokeHigh intensity dosingVTE,CVT,AfibNurse Driven TitrationTitration table based on 4 hr anti-xa lab value obtained after initial dosing or titration changesWith 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 BolusTitrated DripAdditional(Repeat)Bolus,IV Heparin Protocol Ordering,Choose the“Loading Dose”to order the initial bolus,IV Heparin Protocol Ordering,Choose“Continuous Infusion”to order the drip Includes standard nurse driven titration protocol,IV Heparin Protocol Ordering,Choose the“Repeat Bolus”for nursing to give a bolus based on Q 4 hr aPTT(anti-Xa)lab value,X,IV Heparin Protocol,Why order the full protocol?Clinical Results:Full protocol NOT ordered39 hr average time to therapeuticFull protocol ordered11 hr average time to therapeuticAll 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 inhibitorsClinicians have familiarity with assayReadily 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,Eikelboom JW.Thromb Haemost 2006;96:547-52.Francis JL.Pharmacotherapy 2004;24:108S-19S.,Disadvantages of Using aPTT to Monitor Heparin,aPTT has variable a response to heparin determined by the different coagulometers and the reagentsThere is no aPTT“standard”When the tissue thromboplastin lot changes,a new therapeutic range needs to be established for the new lot of reagentTest may be affected by numerous factors other than heparin concentrationBaseline elevated aPTT makes titration difficult and inaccurate,Eikelboom JW.Thromb Haemost 2006;96:547-52.Francis JL.Pharmacotherapy 2004;24:108S-19S.,Conditions that May Prolong the Baseline aPTT,Lupus anticoagulantsOther antiphospholipid antibodiesPrekallikrein,High Molecular Weight Kininogen LevelLow levels(40%)of:FibrinogenProthrombinFactors V,VIII,IX,X,XI,and XII,Eikelboom JW.Thromb Haemost 2006;96:547-52.Francis JL.Pharmacotherapy 2004;24:108S-19S.,Current Recommendations from CHEST Guidelines,Each coagulation laboratory determines the therapeutic range for their aPTT reagent that correlates with a heparin assay level of 0.3 to 0.7 international units(IU)/mL(by anti-Factor Xa assay)Each laboratory must determine its own therapeutic range for heparin for the aPTT whenever the aPTT reagent changes or with a change in instrumentationTherefore,the range changes almost annually,Hirsh J.Chest 2008;133:141-59,Monitoring,Update on Monitoring,As of summer 2011 the use of the“aPTT,heparin”is not available for monitoring IV unfractionated heparin therapy at University Hospitals Case Medical Center.(no correlations have been done)The“aPTT,heparin”has been replaced by anti-Xa monitoring using the“heparin assay,UFH”The use of the“heparin assay,UFH”will standardize IV unfractionated heparin monitoring and make the use of the aPTT inaccurate,Heparin Assay,Specifically determines anticoagulant activity of IV unfractionated heparin by measuring ability of heparin-bound antithrombin to inhibit a single enzymeMore specific than aPTT since it measures inhibition of a single enzymeMajor advantage is lack of biologic factors that affect its result,Eikelboom JW.Thromb Haemost 2006;96:547-52.Francis JL.Pharmacotherapy 2004;24:108S-19S.,Limitations of Heparin Assay,Clinical data examining outcomes is limited,Eikelboom JW.Thromb Haemost 2006;96:547-52.Francis JL.Pharmacotherapy 2004;24:108S-19S.,Comparison of Monitoring with aPTT vs.Anti-Factor Xa Assay,Prospective,single-center study268 patients on IV heparin for variety of indicationsUtilizing anti-Factor Xa assay led to fewer tests and dose adjustments Cost increase of$1.09/day more using anti-Factor Xa assay,P0.0001,P0.0001,Rosborough TK.Pharmacotherapy 1999;19:760-66.,“High-Intensity Therapeutic Heparin”Anticoagulation Orders for Adult Patients,Current“High-Intensity Therapeutic Heparin”Anticoagulation Orders Using Heparin Assay for Adult Patients(VTE etc),Current“Low-Intensity Therapeutic Heparin”Anticoagulation Orders Using Heparin Assay for Adult Patients(ACS,stroke),No Changes for the Monitoring of Other Anticoagulants,Prothrombin time/INR is still be used to monitor warfarinTherapeutic monitoring of direct thrombin inhibitors(bivaliruding and argatroban)still use the aPTTSpecial monitoring for enoxaparin(Lovenox)is done by Heparin assay,Lovenox,Summary Order Set Changes,Heparin assay,UFH will be done after initiation and dose changes as well as each morning.Timing will be changed to a 4 hour response time for all dose adjustments.,Summary,UH uses the heparin assay,UFH for monitoring all intravenous unfractionated heparin therapy.The order set will change to reflect the therapeutic ranges for“High-dose”and“Low-dose”indications“high-dose”anti-Xa=0.3-0.7 IU/ml“low-dose”anti-Xa=0.3-0.6 IU/mlThe time between adjustments and monitoring will decrease to 4 hours in an effort to shorten the time to therapeutic,Summary,No changes will occur related to warfarin monitoring Prothrombin time/INR is the standardNo changes will occur related to direct thrombin inhibitor monitoring,aPTTEnoxaparin(Lovenox)is monitored by the Heparin assay,Lovenox.,Overview of the Trends In VTE Management,Prevention*-to decrease the incidence of VTEALL PATIENTS REQUIRE PROPHYLAXIS*Improved sensitivity/specificity and ease of diagnosisImprove treatment increased efficacy and reliability of pharmaceuticalsImprove outcomes-decrease risk of recurrenceDecrease longterm morbidity from VTEPost-thrombotic syndrome(PTS)Chronic thromboembolic disease(CTED),Anticoagulation Committee,Meaningful Use VTE quality measure VTE prophylaxis within 24 hours of arrival ICU VTE Anticoagulation overlap therapy Platelet monitoring for unfractionated heparin Comprehensive discharge instructions Incidence of potentially preventable VTE Approach Fit compliance into current clinician workflow No additional resources No retrospective chart abstraction,Essentials,All patients require DVT prophylaxis screen on admission The proper prophylaxis is ordered or an appropriate reason of ommission is documentedHospital acquired VTE is considered a“never event”VTE treatment transition must meet current guidelines and this is documented and supported by the discharge orders,VTE Quality Measure,To meet certain care standards to prevent and treat DVT/PEMust complete the DVT Risk Assessment Screening on admissionIncludes orders based on risk score for both pharmacologic and mechanicalBe sure to enter omission reason if choosing not to order prophylaxis,Deep Vein Thrombosis Risk Screening,Deep Vein Thrombosis Risk Screening,Deep Vein Thrombosis Risk Screening,Deep Vein Thrombosis Risk Screening,Deep Vein Thrombosis Risk Screening,Deep Vein Thrombosis Risk Screening,Safe Discharge on Anticoagulation,Anticoagulation Medication Reconciliation,New drop down box specific to anticoagulant drugsShow screen shot of the drop downMay enter up to 2 anticoagulants that the patient is being discharged onWill include a question about whether the patient had a DVT or PE confirmed during this hospital admission.If yes,then you must enter in the date of the diagnostic test that gave the confirmation.,Warfarin,Anticoagulant effect(VII,IX)vs.Antithrombotic effect(X,II)Anticoagulant effect can be seen within 2 daysAntithrombotic effect takes minimum of 4-5 days due to the t of prothrombin(24-48 hours),Warfarin,Current ACCP guidelines recommend 5-10 mg initial dosing In the elderly,patients who are debilitated,malnourished,have CHF,liver disease or recent surgery or who are taking medications which increase sensitivity to warfarin-initial dose should be 5 mgHospitals patients should RARELY receive more than 5 mg initial coumadin dosingHigher initial doses may be suitable for stable,healthy outpatientsMonitoring should begin after 2-3 doses 5 mg vs.10 mg initial dose debateEarly INR changes are due to FVII depletionMinimum of 4-5 days are required to deplete FX and FII,Chest 2008;133(3Suppl):454-545.,Warfarin Follow Up Appointment,All patients discharged on Warfarin:Discharge instructions must include an appointment for Warfarin follow up monitoring.Discharging provider enters this information in the follow up section on patient profile(CMC)which has a new option specific to Warfarin follow up.Includes:The clinic or physician that will cover the follow up monitoring(UH“Coumadin Clinics”are now called“Anticoagulation Monitoring Services”Phone numberDate next PT/INR is due,Anticoagulation Monitoring ServiceAKA Coumadin Clinic,Anticoagulation Monitoring Service Referral,AMS Referral,Anticoagulation Monitoring Service Referral,Anticoagulation Monitoring Service,Therefore engage the PCP early and often,Anticoagulation Management,Must document and“manage”all aspects of anticoagulationMinimum of 5 days overlap requiredINR max 3 days after starting therapy Min every 2 days during the transitionNeed 2 checks the week following,Anticoagulation Monitoring Service,Monitor anticoagulation for a MANAGING PHYSICIANNurse driven protocol following the orders of the physicianWe ARE NOT responsible for the patient until the first visit usually 3-5 days after dcIf the visit is delayed someone else needs to be monitoringIf the visit is missed someone else is responsibleWe do NOT dose adjust without ordersExpectations are that the orders are followed any desirable adjustments may be made and will be followedIe shorter or longer intervals for managementIf warfarin or lovenox etc are required the managing physician must be engagedWe will facilitate referrals for the physician with the pharmacy,Warfarin Follow Up Appointment,All patients discharged on Warfarin:Discharge instructions must include an appointment for Warfarin follow up monitoring.Discharging provider enters this information in the follow up section on patient profile(CMC)which has a new option specific to Warfarin follow up.Includes:The clinic or physician that will cover the follow up monitoring(UH“Coumadin Clinics”are now called“Anticoagulation Monitoring Services”Phone numberDate next PT/INR is due,Conclusions,On admission ALL patients require DVT risk assessment and prophylaxis ordersHeparin when required-use the order setsHigh dose vs.Low doseAnti-Xa monitoring is the UHCMC standard for adult patientsDischarge on anticoagulation requires effortPCP contact for follow upAMS referralInterim plan for delays in presentation to the AMS*LMWH or other anticoagulants may require pre-authorization so request SW/pharmacy approvals early,