Heparin is an ________, ___________ glycosoaminoglycan found in the secretory granules of __________.
- Anionic (charged)
- Sulfated
- Mast Cells
How does heparin work?
- accelerate rate which ATIII neutralizes thrombin (IIa) and factor Xa
- Prevents fibrinogen from converting to fibrin
When is heparin used?
- Phophylaxis treatment of Embolisms
- DIC
- Anticoag during cardiac surgery
- Management of angina, MI, PCI
- Pregnancy complications
Heparin can only work on what type of factors?
-Unbound (not attached to platelet)
Heparin is cleared by what?
-Reticuloendothelial system
Does heparin cross the placenta? Warfarin?
- Heparin does not cross placenta
- Warfarin does cross the placenta
What can cause heparin resistance?
- Increased factor VIII
- Accelerated clearance w/ massive PE
- Inherited ATIII deficiency
- Acquired ATIII deficiency
What causes acquired ATIII deficiency? and how to treat?
- Cirrhosis, Nephrotic syndrome, DIC
- FFP or ATIII concentrate
What are some problems associated with heparin toxicity?
- Bleeding
- Thrombocytopenia (HIT)
- Abnormal LFTs
- Osteoperosis / vertebral fractures
What is protamine?
- Low molecular weight, cationic, strongly basic protein
- from Salmon sperm
- Heparin antagonist
Protamine has what effect on LMWHs?
-Not as effective, only 65% neutralization
What are the doses of protamine?
- 1-1.5mg per 100 units of heparin
- 0.5-0.75 after 30-60 minutes
- 0.25-0.375 after 2 hours
What are the adverse effects of protamine?
- Histamine hypotension
- Brady
- Pulmonary HTN
- Flushing
- Dyspnea
What are the hypersenitivity reactions of protamine?
- Uticaria
- Angioedema
- Pulmonary HTN
- Anaphylactoid/Anaphylaxis
What groups of people are at risk for hypersensitivity to proatmine?
- Fish allergy
- Previous protamine reversal
- Protamine containing insulin (NPH)
- Previous vasectomy
How do you pretreat for protamine hypersensitivity?
- Corticosteroids
- Antihistamine
What is heparin rebound?
- Re-anitcoagulate after protamine reversal
- Usually 8-9 hours (reported 30min to 18hrs post CPB)
What can happen with protamine OD?
- Bleeding
- Has anticoags and antiplatelets when given alone or in excess of heparin
Name 3 LMWH
- Dalteparin
- Enoxaparin
- Tinzaparin
How do LMWH work?
-Inhibition of factor Xa by antithrombin
What are the advantages of LMWH?
- Fixed dose sub Q
- Not dose monitoring or adjustments
What are LMWH uses
- Post op DVT/Embolisms
- Angina, MI, AFib
Can dosages of LMWH and Heparin be used interchangeably?
No
What are the adverese effects of LMWH?
- Thrombocytopenia
- Do not use with HIT
- Decrease dose in renal patients
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