Hematology: Hemostasis and Steroids

COX-1 seen in all cells; protective=good
COX-2 seen with inflammation=bad

pain
swelling
redness
warmth
loss of function

**A process by which your body's white blood cells and the things they make protect you from infection from outside invaders, such as bacteria and viruses**

Indications: pain, fever, inflammation, Kawasaki disease, pretention of TIAs/MIs

MOA: inhibits prostaglandin synthesis, decreases platelet aggregation

Side effects: tinnitus, rash, GI bleedingpset

ASPIRIN: Abdominal pain, Salicylism, PUD, Intestinal blood loss, Reye's syndrome, Itchy rash, Noise (tinnitus)
**do NOT give to children w/ fever, no use with PUD or bleeding disorders. Monitor for salicylism (tinnitus, vomiting, diarrhea, resp. alkalosis)

Indications: mild to moderate pain, fever

MOA: inhibits prostaglandin synthesis in CNS; central acting COX-2 inhibitor, NO anti-inflammatory action

Side effects: hepatoxicity in high doses, nausea, skin rash

Antidote: Mucomyst (acetylcysteine)

**NOT for pts w/ liver disease & ETOH abuse, MAX DOSE: 3g/day**

**Ibuprofen (Advil, Motrin, Excedrin); naproxen (Aleve); Ketorolac IV (Toradol); indomethacin (Indocin)

Indications: mild to moderate pain, fever, inflammation
*indomethacin is used to close PDA in premature babies**

MOA: inhibits prostaglandin synthesis, inhibits both COX-1/COX-2

Side effects: GI upset, rash, HA, GI bleeding, renal toxicity

**do NOT use in patients with PUD or bleeding disorders, avoid in pregnancy and ETOH use**

"with CELEcoxib, you can CELEbrate without arthritis pain"

Indications: osteoarthritis, rheumatoid arthritis

MOA: inhibits COX-2 enzyme, decreasing prostaglandin synthesis

Side effects: thrombosis (MI, stroke), GI bleeding, rash

**caution in patients with cardiac history, do NOT administer to patients with allergy to ASA, NSAIDs, or sulfonamides**

**schedule II controlled substance**
Indications: moderate to severe pain, promotion to sedation

MOA: binds to opioid receptors in the CNS to reduce perception and response to pain

Side effects: respiratory depressions, sedation, constipation, hypotension, urinary retention, N/V, hypothermia, euphoria

**can cause tolerance/dependence**

Antidote: naloxone

**R.U.S.H to give narcan:
Resp. depression
Urinary retention
Sedation
Hypotension **

Indication: OD, reverse opioid effects, reverse neonatal resp. depression

MOA: binds to opioid receptors to block the effects of opioids

Side effects: withdrawal symptoms

Indication: moderate to moderately severe pain

MOA: binds to selected opioid receptors and blocks reuptake of norepinephrine and serotonin in the CNS

Side effects: lightheadedness, dizziness, nausea, vomiting, constipation, headache

**drug interactions with MAOIs, SSRIs, Tegretol, CNS depressants

Assessment: Hx, pain levels, VS, safety
Plan: pain goals, plan for safety, frequent checks, meds before activity
Implement: monitor for side effects, teaching- what to expect
Evaluate: pain score, effectiveness, vitals, tolerance, psychosocial changes

**most end in -SONE**
**monitor for S/S infection and PUD, periods of stress may require additional doses, do NOT stop suddenly, avoid NSAIDs, take calcium and vitamin D. **
Indications: wide variety of illnesses: asthma, autoimmune disorders, inflammatory disorders

MOA: decreases inflammation and suppresses the immune response

Side effects: Bone loss, weight gain/fluid retention, hyperglycemia, hypokalemia, infection, PUD, adrenal gland suppression, skin fragility, GI upset, bleeding tendencies, blurred vision, loss of color acuity

Contraindications:
-Systemic fungal infections (increases infections)
Precautions:
-Heart failure
-PUD
-DM
-HTN
-Renal dysfunction
-Myasthenia gravis
-Osteoporosis

Cushing's Syndrome

migraine:
-nausea
-sensitivity to light or sound
-pounding or throbbing pain
-moderate to severe pain
-pain on one side of head
-aura before onset
Both:
-steady ache
-mild to moderate pain
Tension HA:
- dull tightness
-distracting pain, not debilitating

STOP migraine in progress
PREVENT migraines from occurring

Triptans:
-serotonin agonists
- constrict certain intracranial vessels
Ergot Alkaloids:
-interact with adrenergic, dopaminergic, and serotonin receptors
-act as a vasoconstrictors
-terminate ongoing migraines
Ergot Alkaloids: Ergotamine (Ergomar)

Indications: vascular headaches (migraine HA, cluster HA)

MOA: vasoconstriction of intracranial blood vessels ( risk of stroke and HTN)

Side effects:
Ergotamine: GI upset, HTN
Sumatriptan: dizziness/vertigo, warm/tingling sensation

**advice pt to lay down in a dark and quiet place to help w symptoms. Avoid tyramine-rich foods (deli meats, wine, beer) and ETOH which can trigger migraines**

1. Beta-Adrenergic Blockers: Propranolol (lowers BP)
2. Calcium Channel Blockers: Nifedipine(Procardia) (lowers BP)
3. Tricyclic antidepressants: Amitriptyline
4. Anticonvulsants: Divalproex, topiramate (topamax)
5. Estrogens

1. combination OTC analgesics: acetaminophen, aspirin, caffeine
2. isometheptene(relieves HA through vasocontraction of arterioles)/
dichloralphenazone (sedative properties)/ acetaminophen (mild analgesic)
3. miscellaneous drugs: methysergide (sansert), onabotulinumtoxin A (Botox), riboflavin (vitamin B2)

involves 3 basic steps: vascular spasm, formation of a platelet plug and coagulation, in which clotting factors promote the formation of a fibrin clot.

Vascular injury causes vasoconstriction, platelet aggregation, and formation of a platelet plug (which triggers secondary hemostasis)

Clotting factors (I-XIII) activate each other in a clotting cascade. Three pathways: Intrinsic, Extrinsic, Common

Intrinsic Pathway: activation of clotting factors inside the blood (aPTT)

Extrinsic Pathway: activation of clotting factors outside the blood (PT)

Common Pathway: Intrinsic and Extrinsic Pathways merge: Prothrombin becomes thrombin/ fibrinogen becomes fibrin (clot)

1. prevent blood clots (thrombi)
2. prevent clumping of platelets (aggregation)
3. dissolve clots
4. replace blood components to maintain homeostasis
5. prevent anemia
**the reason these drugs are given is ALWAYS one of the above**

aPTT: clotting time- intrinsic system and common pathways in coagulation cascade

expected range: 30-40 seconds
therapeutic range on heparin therapy: 1.5-2.0 times baseline (60-80 seconds)
increased time: causes include heparin therapy, DIC, hepatic disease

protamine sulfate

expected range: 11-13 seconds
therapeutic range on warfarin therapy: 1.5-2.0 times baseline (17-26 seconds)
increased time: causes include DIC, liver disease, vitamin K deficiency, clotting factor deficiency

vitamin k

INR: ratio of the patients prothrombin time (PT) to a control PT; used to determine the effectiveness of warfarin therapy

expected range: 0.8-1.1
therapeutic range: 2-3
elevated levels: causes include warfarin therapy, bleeding disorders, liver disease, sudden decrease in vitamin K intake

D-Dimer: protein fragment from the breakdown of a blood clot.
**I like to DIM the lights really low, almost to zero**

expected range: less than 0.4mcg/mL (neg or normal result)-used to rule out a blood clot

pos result (greater than 0.4mcg/mL) indicates there may be a blood clot in the body (DVT, PE, DIC)

MOA: inhibit specific clotting factors

Type of modification: prevent clot formation

MOA: Inhibit platelet action

Type of modification: Prevent clot formation

MOA: Dissolve existing clot

Type of modification: Remove existing clot

MOA: Inhibit fibrin destruction

Type of modification: Promote clot formation/stability

**the "H" in Heparin looks like two "T"s put together, to remind you that you monitor aPTT with Heparin**

Indications: stroke, DVT, PE and other thromboembolic disorders requiring fast anticoagulation.

MOA: activates antithrombin, inhibiting thrombus formation. Prevents new clots does NOT break up existing clots

Side effects: bleeding, heparin induced thrombocytopenia (low platelets) hypersensitivity

**closely monitor aPTT, bleeding**

antidote: protamine sulfate

*warfarin is going to war on vitamin K*

Indications: Prevention and treatment of thromboembolic disorders (ex: DVT, PE, AFIB with thrombus). Prevention of complications following an MI

MOA: Antagonizes vitamin K, which prevents formation of several clotting factors.

Side effects: Bleeding, GI upset, hepatitis

**closely monitor PT/INR levels, maintain consistent intake of vitamin K, bleeding**

antidote: vitamin K

**rivaroxaban helps your blood flow like a river by inhibiting factor Xa**

Indications: prevention of DVT, PE, stroke in pt with AFIB

MOA: selectively inhibits factor Xa, which blocks the coagulation cascade

Side effects: bleeding, elevated liver enzymes

**monitor liver function. hemoglobin, and hematocrit during therapy**

**horse clops on platelets to prevent them from aggregating**

Indications: prevention of MI, stroke in pts with acute coronary syndrome

MOA: inhibits platelet aggregation

Side effects:
Abciximab: bleeding, hypotension, dysrhythmias
Clopidogrel: bleeding, GI upset, rash

**assess for bleeding, monitor EKG, and VS for abciximab**

**There is no time to argue... you can't just dab at the blood. You need to hold pressure to stop the bleeding from Argatroban and Dabigatran**

Indications: DVT, PE, decrease stroke risk, HIT ( heparin-induced thrombocytopenia).

MOA: Blocks thrombin receptors, which prevents the activation of clotting factors and decreases thrombus (clot) formation

Side effects:
Argatroban: bleeding, hypotension
Dabigatran: bleeding, GI upset, angioedema

**Alteplase goes to the place where there is a blood clot and breaks it up**

Indications: MI, stroke, PE, and occluded central IVs

MOA: converts plasminogen to plasmin, which breaks up fibrinogen

Side effects: bleeding! Contraindicated in patients who have had a hemorrhagic stroke, internal bleeding, recent trauma/surgery, severe hypertension.

**For an ischemic stroke, administer within 3-4.5 hours of symptoms. Closely monitor labs and vital signs. Limit venipunctures and IM injections**

Indications: Hemorrhage

MOA: Inhibits the activation of plasminogen, which inhibits fibrinolysis and enables clot formation

Side Effects: GI upset, hypotension
Regularly assess patient for bleeding or thromboembolism (hypercoagulation is a risk with this med).

WBCs: Part of the body's immune system, WBCs fight infection and disease.

Expected Range: 5,000-10,000

Leukopenia (WBC < 4,000): Causes include autoimmune disease, bone marrow suppression, drug toxicity

Leukocytosis (WBC > 10,000): Causes include infection and inflammation.

Hemoglobin: Iron-rich protein in RBCs that carry oxygen

Expected range:
Females: 12-16 g/dL
Males: 14-18 g/dL

Lower levels: Causes include anemia, hemorrhage, kidney disease

Higher levels: Causes include COPD, severe dehydration

Hematocrit: Percentage of the blood made up of RBCs. Hematocrit is approximately 3 times Hemoglobin

Expected range:
Females: 37-47%
Males: 42- 52%

Lower levels: Causes include anemia, hemorrhage, kidney disease

Higher levels: Causes include COPD, severe dehydration

Platelets: Blood cell fragments used to form clots in the body (to stop bleeding). I'm throwing a big party, and I need 150-400 plates to feed everyone!

Expected range: 150,000- 400,000

Lower levels: Causes include hemorrhage, leukemia, splenomegaly

Higher levels: Causes include polysythemia, inflammatory diseases (ex: RA, IBD), infection, cancer, splenectomy

Low Platelets: high risk of bleeding!!!

**Taking epoetin alfa will fix your anemia so you can grow up to be a strong alpha male**
Indications: Anemia r/t chronic kidney disease, HIV, chemotherapy

MOA: Stimulates bone marrow to increase productions of red blood cells.

Side Effects: Hypertension (due to increase in Hct); Increased risk for stroke, DVT, MI, and seizures

**Do NOT agitate vial. Monitor BP and Hgb/Hct during therapy. Ensure sufficient iron levels.**

**You fill up on neutrophils with Filgrastim**

Indications: Neutropenia, decreases risk of infection in neutropenic patients (r/t chemotherapy).

MOA: Causes bone marrow to increase production of neutrophils.

Side Effects: Bone pain, leukocytosis (high WBC levels), splenomegaly

**Do not agitate vial. Monitor CBC twice a week.

Purpose: Stimulate WBC production.

Prototype: Sargramostim (Leukin)

USES: Facilitates recovery of bone marrow after transplant. Used also in treatment of failed bone marrow transplant.

Administration: do not give within 24 hours before/after chemo as effectiveness decreased.

Monitor: baseline CBC needed with differential and platelet count used to compare to post treatment labs to determine effectiveness.

PAY ATTENTION: the patients that are getting this are at risk for infection!

**Watch Out! Same as previous but add: cautious use with heart disease, hypoxia, peripheral edema, pleural/pericardial effusion. Contraindicated if patient allergic to yeast.

Adverse Reactions: Diarrhea, rash, bone pain infection.

If WBC >50,000 , ANC >20,000 or platelets >500,000...D/C or reduce treatment!

blood has reduced ability to carry oxygen

anemia is a sign, not a distinct disease

-yellowing eyes
-pale, cold, yellow skin
-SOB
-muscle weakness
-change in stool color
*fatigue*
-dizziness
-fainting
- low BP
-palpitations
-increased HR
*chest pain*
*angina*
*heart attack*
-enlarged spleen

*=in severe anemia

anti-anemic agents, vitamins, and minerals

most common:
-B12/
cyanocobalamin
-folic acid
-iron/ ferrous sulfate

can often be successfully treated with iron. supplements
Product:
1. Whole blood
2. PRBCs (packed red blood cells)
3. Platelet concentrate
4. FFP (fresh frozen plasma)
5. Pheresed granulocytes

Use:
1. massive blood loss when there is a need to replace RBCs and plasma (increases circulating volume)
2. increase RBCs (resulting in increased O2 carrying capacity)
3. increase platelet count
4. replace coagulation factors
5. replace neutrophilsranulocytes
6. expansion of. circulating volume by exerting oncotic pressure

purpose: to replace BOTH plasma. volume and RBCs to improve O2 carrying capacity
prototype: whole blood

purpose: use to treat bleeding due to decreased circulating platelet counts or functionally abnormal platelets

Use prophylactically to prevent bleeding at pre-specified low platelet counts

prototype: platelet concentrate
-Do not use in patients with autoimmune thrombocytopenia or thrombotic thrombocytopenic
purpura except for life-threatening hemorrhage.

Purpose: RBCs are. indicated for patients with a symptomatic deficiency of oxygen-carrying capacity or tissue hypoxia due to. an inadequate circulating red cell mass

prototype: packed red cells (PRBCs)

Purpose: indicated for use in patients with:
1. Active bleeding due to deficiency of multiple coagulation factors, or risk of bleeding due to deficiency of multiple coagulation factors.
2. Severe bleeding due to warfarin therapy, or urgent reversal of warfarin effect
3. Massive transfusion with coagulopathic bleeding.
4. Bleeding or prophylaxis of bleeding for a known single coagulation factor deficiency for which no concentrate is available.
5. Thrombotic thrombocytopenic purpura

prototype: FFP (fresh frozen plasma)

purpose:
Replace neutrophilsranulocytes (neutrophils, basophils, eosinophils).

Severe neutropenia (ANC <500)

Life-threatening bacterial/fungal infections

Neonatal sepsis

prototype: pheresed. granulocytes
ABO

ABO- blood type
Rh- rhesus factor
product:
1. Whole blood
2. PRBCs (packed red blood cells)
3. Platelet concentrate
4. FFP (fresh frozen plasma)
5. Pheresed granulocytes

administration notes:
1. ABO must be identical & Rh compatible
Infuse: as fast as possible
2. ABO & Rh must both be compatible
Infuse: < 4 hours per unit
3. ABO compatible preferred but not absolute; Rh compatible.
Infuse: as fast as possible but < 4 hours per unit
4. ABO compatible; Rh compatible preferred but not strictly required.
Infuse: <4 hours per unit & within 24 hours of thaw
5. ABO & Rh must both be compatible
Infuse: over 2 - 4 hours (usually faster...)
6. No compatibility testing required (No ABO present).
Infused: ATI says "slow" -Comes in 5% and 25% solutions; 5% given faster, 25% given slow.

Chills, fever, low back pain, tachycardia, tachypnea, hypotension
-•This is the most dangerous type of all of the reactions because the donor blood is incompatible with that of the recipient.
•Symptoms consist of chills, low back pain, headache, nausea, or chest tightness followed by fever and hypotension and vascular collapse. Severe reactions usually start within 10 minutes after the infusion is begun. Hemoglobinuria (blood in urine) appears at the next voiding.
-•Discontinue the transfusion
•Keep IV line open with normal saline.
•Notify physician and blood bank.
•You will likely be directed to initiate measures to combat hypotension and prevent
renal damage.

Chills, fever, headache
-If contaminated blood is infused, the patient develops fever, and shaking chills within 30 minutes, and shock soon follows.
-Discontinue the transfusion
Keep the IV line is kept open with normal saline.
Notify the physician and blood bank
Monitor the patient's temperature is monitored for 30 minutes after the chill and as indicated thereafter.

Anxiety, urticaria, wheezing, shock, cardiovascular collapse

Flushing, itching, urticaria (common and is why Benadryl may be given prophylactically)

-Cough, dyspnea, crackles at lung bases, hypertension, tachycardia, JVD
-Transfuse blood slowly to prevent.
Signs include dyspnea, orthopnea, cyanosis, or sudden anxiety. If the transfusion is continued, severe dyspnea and coughing of pink, frothy sputum can occur. Neck vein distention, crackles at the base of the lungs, and rise in central venous pressure will occur.
-Position the patient with the feet in a dependent position
-Discontinue the blood transfusion
Notify the physician.
-Keep the IV line patent with very slow infusion of normal saline to retain
access to the vein in case IV medications are necessary.
-Phlebotomy or diuretics, oxygen, morphine, and aminophylline may be necessary if improvement does not occur rapidly.-

Rapid onset of chills and fever; vomiting, diarrhea, hypotension, shock - generally not "immediate"
•Severe reaction that results from transfusion of blood or components contaminated with bacteria.
•Preventative measures include administering blood within a 4-hour period before warm room temperatures promote bacterial growth, inspecting blood or components for gas bubbles, clotting, or abnormal color before administration.

•STOP the transfusion! THIS IS THE PRIORITY!
•Keep line open with saline!
•Manage symptoms - pay special attention to the "ABCs" and assure a patent airway first and foremost!
•Send the blood bag and tubing back to lab for checking (this is a universal requirement by all blood banks).

Remember - this is blood - you must package the bag & tubing in a biohazard container

•Inadequate blood flow to meet body's needs
•Considered medical emergency
•Can lead to irreversible organ damage and death
•Collection of nonspecific signs and symptoms
•Affects the nervous, renal, cardiovascular systems

•ABCs of life support
•Circulation
•Airway
•Breathing
•Identify underlying cause, then start more specific treatment
•Connect to a cardiac monitor, and apply a pulse oximeter

Purpose: Stimulate production of platelets

Prototype: Oprelvekin (Interleukin II, Neumega)

USES: This medication is used to prevent very low platelet counts (thrombocytopenia) and to reduce the need for platelet transfusions after certain chemotherapy treatments.

Administration: Like the others -don't shake!
-Started 4 to 6 hours after chemo & given once/day

Watch Out! Caution if patient has: heart failure, pleural effusion, history of cardiac arrhythmia, bone marrow cancer.
Be aware - if platelets increase too much, you will be in trouble with hypercoag problems.

Adverse Reactions: Fluid retention. Conjunctival irritation, blurred vision, papilledema. Arrhythmias possible.

Anti-anemic agents, Vitamins and minerals
Most common
B12 / Cyanocobalamin
Folic acid
Iron / Ferrous sulfate
Can often be successfully treated with iron supplements

Severe allergic reaction
RR high or low
HR high
Low BP
flushed swollen itcy skin
No temp change
low urine
brochioconstriction ,decreased LOC,

Failing in pumping of the heart
RR High
HR High
Bp Low
Pale,cool,clammy
Chest discomfort, syncope,JVD, Pulm edema,

Reduced circulation blood volume
HIGH HR,RR,
LOW BP
pale cool clammy
anixety thrist, weakpulse confusion

Physical obstruction of the blood vessles
HIGH RR,HR
LOW BP
Extreme pale cool
low temp
Muffeled heart sounds, JVD, poor purfusion

severe central nervous system damage
HIGH RR
LOW BP,HR
warm flushed dry
Can be high or low Temp
paalysis, distal to injury site priaprism
NO BLADDER CONTROL

Extreme immune response to infection
HIGH RR,HR
LOW BP
flushed then pale and cool
HIGH GU RATE
Bounding pulse, altered LOC

•Plasma protein fraction (P P F h) (Plasmanate, Plasma-Plex, Plasmatein, Protenate)
•Dextran 40 (Gentran 40, Hyskon, Rheomacrodex) or dextran 70 (Hyskon, Macrodex)
•Hetastarch (Hespan)
•Normal serum albumin, human (Albuminar, Plasbumin, others)

•Normal saline (0.9% sodium chloride)
•Lactated Ringer's
•PlasmaLyte
•Hypertonic saline (3% sodium chloride)
•5% dextrose in normal saline (D5W)

Digoxin -ADR halos visual disterbances
dobutaime-ADR palpatations tilgining coldness of exremidies
dopamine,epinephrine,norepepherine- ADR dysrhymias severe HYPERTENTION,