Jessica Bryan, Natalia Evans, Karlyn Henderson, & Whitney Parks

Jessica Bryan, Natalia Evans, Karlyn Henderson, & Whitney Parks

1. What is the most common cause of death in hospitalized patients? 1. Hospital-acquired infection 2. Pulmonary embolism 3. Myocardial infarction 4. Medication error

2. What s/s would indicate a pulmonary embolism? 1. Chest pain 2. Hemoptsis 3. Bradypnea 4. Tachypnea 5. 1,2,3 6. 1,2,4

3. Which drug requires aptt monitoring? 1. Heparin 2. Lovenox 3. Arixtra 4. 1 and 3

4. Arixtra, like Heparin and Lovenox is primarily excreted via the liver. 1. True 2. False

5. What of the following is true of Arixtra? 1. It can be used on an outpatient basis for the treatment of DVT and PE. 2. It is effective in the treatment of DVT and PE as a bolus plus infusion of unfractioned Heparin. 3. It is more effective than Lovenox at preventing VTE s. 4. It can be given either intramuscular or subcutaneously.

Objectives Discuss and identify clinical manifestations venous thromboembolism (VTE) Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) in relation to the Critical Care setting Understand current prevention and treatment options Heparin and Lovenox Discuss Arixtra s action and side effects

Importance to Critical Care A predictive cohort study was completed using a sample of 300 patients that were discharged from the ICU for a predictive analysis of the development of an adverse event after discharge. The three most common adverse events were that of hospital acquired infection, hospital incurred accidents, and other complications such as deep vein thrombosis, pulmonary embolism, or myocardial infarction. Of these 300 patients, 147 developed an event, 44.9% of these events being related to either deep vein thrombosis or pulmonary embolism. Therefore, the nurse should take, record, and report vital signs on schedule as well as perform a detailed assessment prior to discharge to rule out risk factors related to the development of adverse events (Chaboyer, Thalib, Foster, Ball, & Richards, 2008).

VENOUS THROMBOEMBOLISM Venous thromboembolism (VTE) = deep vein thrombosis (DVT) and /or pulmonary embolism (PE). Hospitalized pt has more than 100-fold increased incidence of acute VTE than someone in the community. 900,000 episodes of VTE leading to hospitalization; - 300,000 related deaths in US

VENOUS THROMBOEMBOLISM PE is the most common cause of death in hospitalized pts. 650,000 patients have PE each year and of these, - 200,000 die. Misdiagnosis of PE is a common occurrence: - missed about 70% of the time. 10% of pts who develop PE die within the first hour. An additional 30% die from recurring PE (Hussey, 2009) It is estimated that 25% of deaths from PE can be prevented with appropriate diagnosis and treatment (Hussey, 2009)

Deep Vein Thrombosis DVT - a clot (thrombus) that forms in a large vein in the leg, pelvis, and arm. originate in venous valve pockets; sites of presumed venous stasis S/s -may be assymptomatic May be accompanied by inflammation, pain, tenderness, and redness at the site of the thrombus/ unilateral edema. Pain - aching, throbbing sensation, worsens with ambulation. Homans sign thrombus may migrate to the pulmonary vascular bed, causing a pulmonary embolism, development of pulmonary hypertension, or death.

Pulmonary Embolism PE thrombus travel through the right side of the heart to reach the lungs, thrombus lodges in the pulmonary blood vessels (too large to pass through the capillaries of the lungs) -section of the lung remains ventilated, but not perfused = > dead space -Thrombus usually originates in the deep veins of the legs (particularly the iliac, femoral, and popliteal veins) Other sources - right ventricle, the upper extremities, and the pelvic veins.

PE Signs and Symptoms S/S of PE - vary depending on the size of the emboli. Small emboli are not recognized in many cases may lodge in the pulmonary vasculature, causing pulmonary hypertension. causes dyspnea with exercise, syncope, and hypertrophy of the RV. Medium-sized emboli cause dyspnea, slight fever, a productive cough with blood-streaked sputum, tachycardia, and a pleural friction rub. Large PE occlude 75% of the pulmonary vasculature, cause sudden circulatory collapse and shock, accompanied by hypotension, weakness, paleness, diaphoresis, confusion, and decreased urinary output. Other common s/s decreased PO 2 with normal PCO 2, T-wave inversion on the ECG.

Virchow's Triad = 2 of these 3 conditions must be present for thrombosis to occur. Damage to venous wall Inflammation, or sepsis Trauma or injury (use of a tourniquet, IVs) Overdistention of vessel wall causing endothelial microtears Changes in volume or pattern of blood flow Venous stasis secondary to immobility Dehydration or shock states Increased age Obesity, Stroke, CHF Changes in ability of blood to coagulate or in constituency of blood Polycythemia Pharmacologic considerations, both expected and side effects Cancer Immediate postoperative periodpregnancy Three major predisposing factors: 1. stasis of blood, 2. endothelial injury, 3.hypercoagulability

NURSING MANAGEMENT Focus of nursing management is always to prevent the development of DVT. For the pt with DVT, the interventions include - rest the affected extremity, prevention of complications that may result from VTE, monitoring anticoagulant therapy. *** report immediately any chest pain, dyspnea, hemoptysis, or tachypnea = PE.

Current Treatment: Heparin Interferes with blood coagulation by blocking conversion of prothrombin to thrombin and fibrinogen to fibrin. Prevents further extension of existing thrombi or new clot formation. No effect on existing clots. Used for prophylaxis and treatment of thromboembolic disorders, cardiac surgery Prevention of clotting in patients with MI Prevents cerebral thrombosis in progressive strokes Effectiveness of treatment may be monitored by aptt or ACT Response is variable because of binding with plasma proteins Effects may be reversed with protamine sulfate Risk of developing HIT.

Current Treatment: Heparin Risk for Heparin Induced Thrombocytopenia (HIT) Immune response to form antibodies against Heparin Antibodies contribute to the formation of platelet clumps

Current Treatment: Lovenox Lovenox (Enoxaprin) Low molecular weight heparin Mechanism- enhances activity of antithrombin III Indications- prophylaxis and treatment of thromboembolic complications after surgery Prevention of clots in patients with unstable angina and MI

Current Treatment: Lovenox Special considerations more predictable response than heparin because the drug is not largely bound to protein aptt not particularly useful in monitoring treatments Adjusting the dose of LOVENOX may be necessary for patients who have certain forms of kidney disease patients with moderate (creatinine clearance 30-50 ml/min) and mild (creatinine clearance 50-80 ml/min) renal impairment, all such patients should be observed carefully for signs and symptoms of bleeding Common side effects include mild local reactions or irritation at the site of injection, pain, bruising, and redness of skin

Current Treatment: Lovenox Dosages- for inpatient (hospital) treatment, Lovenox is 1 mg/kg every 12 hours administered SC or 1.5 mg/kg once a day administered SC at the same time every day. In both outpatient and inpatient (hospital) treatments, warfarin sodium therapy should be initiated when appropriate (usually within 72 hours of Lovenox). Lovenox should be continued for a minimum of 5 days and until a therapeutic oral anticoagulant effect has been achieved (International Normalization Ratio 2.0 to 3.0).

ARIXTRA (fondaparinux sodium) Synthetic, nonheparin coagulant specifically inhibits coagulation factor Xa It s a once-daily dose Administered subcutaneously Renal excretion (vs. hepatic in heparin)

Indications Drug was approved for use by the FDA in 2005 with a strong recommendation for the treatment of DVT s and PE s when administered with warfarin sodium

Indications Other FDA-approved indications are prophylaxis for: Hip fracture surgery Knee replacement surgery Hip replacement surgery Abdominal surgery for pts at risk for thromboembolic complications

Advantages of Arixtra Administered ONCE daily Subcutaneous injection with specific weight-based parameters For TREATMENT of DVT/PE: ~If patient weighs under 50 kg then administer 5 mg in 0.4 ml ~If between 50-100 kg, then 7.5 mg in 0.6 ml ~If above 100 kg, then 10 mg in 0.8 ml

Prophylaxis Do not give prophylactically to patients under 50 kg! Above 50 kg, we ll give 2.5 mg daily The initial prophylactic dose should not be given until 6-8 hours after surgery as the patient needs to establish hemostasis

Other instructions The patient should begin treatment with warfain sodium as soon as possible and within 72 hours of initial Arixtra administration Usual duration of administration is 5-9 days for Arixtra; however, some patients, especially hip fracture patients may take it as long as 32 days Before discontinuation of Arixtra, the patient needs to have established a therapeutic INR of 2.0-3.0

Contraindications Patients with severe renal impairment (indicated by a creatinine clearance of less than 30 ml/min) Prophylaxis for patients under 50 kg Patients with active major bleeding Bacterial endocarditis Thrombocytopenia associated with a positive platelet antibody test in the presence of Arixtra Patients with a known hypersensitivity to Arixtra

Comparisons with UFH and LOVENOX Found to be as effective as a bolus dose with continuous infusion of unfractioned heparin in the TREATMENT of PE with a low incidence of major bleeding More effective than enoxaparin (LOVENOX) in the treatment of DVT After major orthopedic surgery, ARIXTRA had reduced the rate of VTE s by 55% compared with enoxaparin (LOVENOX)

Major advantage: Outpatient This drug can be administered on an outpatient basis. We encountered this drug in the ED when patients came in with suspected PE s. We initiate education and treatment in the hospital and then the patient is sent home. Patient Education is crucial!

Patient Education Teach patients about DVTs/PEs Teach how to administer a subcutaneous injection Educate on contraindications to the drug Emphasize the importance that they schedule followup appointments with PCP for the monitoring of warfarin levels RESEARCH!

Review Discuss and identify clinical manifestations venous thromboembolism (VTE) Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) in relation to the Critical Care setting Understand current prevention and treatment options Heparin and Lovenox Discuss Arixtra s action and side effects

1. What is the most common cause of death in hospitalized patients? 1. Hospital-acquired infection 2. Pulmonary embolism 3. Myocardial infarction 4. Medication error

Answer #1 B. Pulmonary embolism

What s/s would indicate a pulmonary embolism? 1. Chest pain 2. Hemoptsis 3. Bradypnea 4. Tachypnea 5. 1,2,3 6. 1,2,4

Answer #2 6. 1,2,4 Chest pain, hemoptysis, tachycardia

3. Which drug requires aptt monitoring? 1. Heparin 2. Lovenox 3. Arixtra 4. 1 and 3

Answer #3 1. Heparin

4. Arixtra, like Heparin and Lovenox is primarily excreted via the liver. 1. True 2. False

Answer #4 False- Arixtra is primarily excreted via kidneys

5. What of the folowing is true of Arixtra? 1. It can be used on an outpatient basis for the treatment of DVT and PE. 2. It is effective in the treatment of DVT and PE as a bolus plus infusion of unfractioned Heparin. 3. It is more effective than Lovenox at preventing VTE s. 4. It can be given either intramuscular or subcutaneously.

Answer #5 1. It can be used on an outpatient basis for the treatment of DVT and PE. 2. It is effective in the treatment of DVT and PE as a bolus plus infusion of unfractioned Heparin. 3. It is more effective than Lovenox at preventing VTE s. 4. {INCORRECT} It can be given either intramuscular or subcutaneously. {CORRECT} It can only be administered SUBCUTANEOUSLY and never intramuscularly.

References Hussey, L. (2009). Clinical Updates: Reducing Mortality in Pulmonary Embolism through Prevention and Careful Management. Retrieved March 2, 2010, from Mosby's Nursing Consultant: www.nursingconsult.com Once-Daily Arixtra (Fondaparinux Sodium) for Injection, (2009). Efficacy with ease [Brochure]. GlaxoSmithKline. Le Sage, S., McGee, M., & Emed, J. (2008). Knowledge of venous thromboembolism (VTE) prevention among hospitalized patients. Journal of Vascular Nursing, 26(4), 109-117. Retrieved from CINAHL database. Urden, L., Stacy, K., & Lough, M. (2009). Critical care nursing: Diagnosis and management (6 ed.). St. Louis: Mosby, Elsevier.