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7/23/2019 Anticoagulant Wk4 Fhm
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Georgina Follows Hdx foundation module
Anticoagulation and its use inAnticoagulation and its use inhaemodialysishaemodialysis
Basic clinical dialysis,
Lestariningsih
Subbag Nefrologi / Hipertensi
Bag Penyakit Dalam ! "ND#P/$S Dr !ariadi
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Georgina Follows Hdx foundation module
Highlight
% contact &ith plastic tubing, the dialysis membran and air
in the HD circuit stimulates the clothing cascades% e'cessi(e clotting in the dialysis circuit and filter need to be
discarded, in adult, this can mean the loss of )*+*-+ ml of blood
% clotting &ithin an HD circuit can be minimised through aprpropiate
use of anticoagulant therapy% periodic anticoagulation is normally gi(en during the dialysis
treatment
Basic clinical dialysis,
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.eorgina ollo&s Hd
Aims and objectives% o gain understanding of the mechanisms in(ol(ed in the
clotting process and coagulation assessment0
% o gain understanding of heparin, its administration,
ad(antages and disad(antages0
% o gain understanding of any contraindications to heparin
uses0
% o gain understanding of any alternati(es to heparin usage0
Basic clinical dialysis,
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.eorgina ollo&s Hd
Introduction
Blood comes into contact &ith e'trinsic factors during
haemodialysis0
Heparin is the most commonly used anticoagulant during
dialysis0
Administration of heparin
% Bolus dose at the beginning of dialysis
%1ontinuous infusion during dialysis0
%Both of these methods are prescribed and can be altered to
tailor each patients needs0
Basic clinical dialysis,
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.eorgina ollo&s Hd
he 1oagulation 1ascadehe 1oagulation 1ascade
2ascular 1onstriction
Platelet plug formation
ormation of blood clots
Basic clinical dialysis,
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.eorgina ollo&s Hd
Normal clotting mechanisms
here are t&o methods by &hich the coagulation cascade is
acti(ated3
Intrinsic pathway.
#nitiated &hen blood comes into contact &ith foreign
surface0
Platelets become damaged and release phospholipids0
Phospholipids 4oin &ith actor 2### and actor #5 to formactor 50 actor 5 combines &ith calcium to form
prothrombin and acti(ates the coagulation cascade0
Basic clinical dialysis,
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.eorgina ollo&s Hd
Extrinsic pathway
% Damaged tissue 6 thromboplastin released 6 initiates
formation of prothrombinase in presence of actor 5 and
calcium ions0
%he coagulation cascade then occurs by using thrombin 6
an en7yme that con(erts fibrinogen into fibrin0 his forms
a mesh trapping the formed elements of blood 6 thus
forming a 1L80
Basic clinical dialysis,
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.eorgina ollo&s Hd
9":S#8N;;;9":S#8N;;;
<hich path&ay<hich path&ayis initiated duringis initiated during
haemodialysis;haemodialysis;
Basic clinical dialysis,
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.eorgina ollo&s Hd
Heparin
% Disco(ered in )=)> by ?cLean
% Anticoagulant found in the li(er
% Porcine and bo(ine preparations
% ?olecular &eight @ +++ to ++++ Daltons
% Binds to thrombin inhibitor AN#H$8?B#N ###
inacti(ates acti(e actor 5 and inhibits con(ersion of
prothrombin to thrombin
Basic clinical dialysis,
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.eorgina ollo&s Hd
Advantages of Heparin
% #020 6 direct access
% 1heap
% ?etabolised naturally by the li(er
% Acts Cuickly and effecti(ely on the intrinsic path&ay
% $e(ersed Cuickly and easily by Protamine
% Long, established history of use
Basic clinical dialysis,
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Disadvantages of Heparin
% Bleeding
% Hyperlipidaemia
% hrombocytopenia
% Allergic reactions
% Pruritis
% Alopecia
% 8steoporosis
Basic clinical dialysis,
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.eorgina ollo&s Hd
Assessment of coagulation
% 1lotting times 6 AP Actual Partial thromboplastinimeE or A1 Acti(ated 1lotting imeE 6 )*+ secs
% 8bser(e for signs of clotting
Darkened blood Streaks in dialyser
1lots / fibrin rings in chambers
Blood entering (enous isolator
$ising / falling (enous pressure
Basic clinical dialysis,
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.eorgina ollo&s Hd
actors affecting coagulation
% Blood flo&
% High haematocrit le(els
% :P8
% Blood transfusion
% #ntradialytic lipid infusion
% High " rate
% ype of circuit
% ?edication
Basic clinical dialysis,
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.eorgina ollo&s Hd
actors affecting coagulation cont.
% #ndi(idual clotting abnormalities
% ype of dialyser
% ?embrane
Natural membranes e0g0 cuprophane 6 relati(elyhigh platelet acti(ation
Synthetic membranes (ary0 Polysulphone more
compatible &ith blood than 1uprophane and
1ellulose
Basic clinical dialysis,
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.eorgina ollo&s Hd
!ontraindications for heparin use
% Pericarditis
% Pre and post surgery, F G hour
% ollo&ing temporary line insertion
% 1oagulation abnormalities, therapy antiplatelet
% hrombocytopenia, F )-+ 5 l+ =/L
% #ntracranial haemorrhage
% Any acti(e bleeding
% "raemic patients
% Heparin free dialysis 3 flushing the dialy7er &ith )++ml Nacl +,=I
:(ery +>+ minute
Basic clinical dialysis,
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.eorgina ollo&s Hd
!ontraindications for heparin use cont.
% Peptic ulcer
% Aortic aneurysm
% 1erebral aneurysm
% Se(ere li(er disease
% Hypersensiti(ity / allergic reactions
Basic clinical dialysis,
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.eorgina ollo&s Hd
"tandard Heparin #$H% Dose
% bolus dose *-++ " -+"/kgBBE, maintenance )+++/4am
% atau initial HD3 loading dose of *-+-++ " follo&ed by infusion
rate *-+-++, ma' *+++"
Heparin ree Dialysis
% 8btain baseline clotting time
% -+++u heparin rinse
% High blood flo& rate
% )++*++ mls saline flush e(ery + mins
Basic clinical dialysis,
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.eorgina ollo&s Hd
% L0?0<0H0 6 inhibits actor 5, little thrombin inhibition,
AP / A1 minimally prolonged0
Advantages
% Safe, effecti(e J decreased bleeding risk
% Simple 6 single dose reCuired
% $educed cholesterol and triglyceride le(els
% $educed alopecia
Disadvantages% :'pensi(e, long half life, not use A1Ks
Basic clinical dialysis,
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.eorgina ollo&s Hd
utureuture
1oating of elements of1oating of elements ofcircuit &ith acti(ecircuit &ith acti(eheparin0heparin0
Nonthrombogenic Nonthrombogenicmembranes0membranes0
Heparinised coatedHeparinised coatedcartridges capable ofcartridges capable of
remo(ing heparinremo(ing heparininfused into the e'trainfused into the e'tracorporeal circuit0corporeal circuit0
Basic clinical dialysis,
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.eorgina ollo&s Hd
9":S#8NS9":S#8NS
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.eorgina ollo&s Hd
.$8"P <8$! .$8"P <8$!
A patient complains of loss of hair o(er the past
couple of months0 She has minimal heparin on
dialysis, but still no change, &hat &ould you do;;
A patient has 4ust completed dialysis and you
notice that the kidney is (ery dark0 he patient isalready on high doses of heparin0 <hat &ould you
do;;
Basic clinical dialysis,