Coagulation cascade

Pradaxa

Dabigatran (Pradaxa in Australia, Europe and USA, Pradax in Canada, Prazaxa in Japan) is an anticoagulant from the class of the direct thrombin inhibitors. It is being studied for various clinical indications and in some cases it offers an alternative to warfarin as the preferred orally administered anticoagulant ("blood thinner") since it does not require frequent blood tests for international normalized ratio (INR) monitoring while offering similar results in terms of efficacy

fondaparinaux

One potential advantage of fondaparinux over LMWH or unfractionated heparin is that the risk for heparin-induced thrombocytopenia (HIT) is substantially lower. Furthermore, there have been case reports of fondaparinux being used to anticoagulate patients with established HIT as it has no affinity to PF-4. However, its renal excretion precludes its use in patients with renal dysfunction.

Unlike direct factor Xa inhibitors, it mediates its effects indirectly through antithrombin III, but unlike heparin, it is selective for factor Xa.^[1]

Heparin

An IV heparin protocol

When intravenous UFH is initiated for DVT anticoagulation, the goal is to achieve and maintain an elevated activated partial thromboplastin time (aPTT) of at least 1.5 times control. Heparin pharmacokinetics are complex, and the half-life is 60-90 minutes. A protocol for IV heparin use is as follows:

• Give an initial bolus of 80 U/kg.
• Initiate a constant maintenance infusion of 18 U/kg.
• Check the aPTT or heparin activity level 6 hours after the bolus, and adjust the infusion rate accordingly.
• Continue to check the aPTT or heparin activity level every 6 hours, until 2 successive values are therapeutic.
• Monitor the aPTT or heparin activity level, hematocrit, and platelet count every 24 hours.

hypercoagulation

case: young female patient with k/c/o prothrombin gene mutation( probably heterogenous) presented with rt arm swelling and tenderness around PICC line( peripherally inserted central cath for total parentral nutrition as she had small bowel ischemia few yrs back 2ndry to prothrobin gene mutation).

denied chest pain, cough, fever, ...
we did doppler for rt brachial vessels which came negative so she dint have any DVT in arm...

Dx: probably superficial vein thrombophlebitis..
Rx: intially we gave her heparin but when doppler came negative we stopped and discharged her on ice pack locally, acetaminophen and coumadin for her hypercoagulable state....