8/15/17 - cdn.ymaws.com...does not know why her elbow is hurting. Upon evaluating the patient she is crying, holding her right arm and is restless. She describes the pain as constant,

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MY PATIENT IS BLEEDING: WHAT DO I DO?TNP 2017 ANNUAL CONFERENCE

JOHN D. GONZALEZ DNP, RN, ACNP-BC, ANP-C

OBJECTIVES AND DISCLOSURES

¡ Discuss the evaluation of select disorders of hemostasis.

¡ Examine the effect of commonly used anticoagulant medications on hemostasis.

¡ Discuss the pharmacotherapeutic management of common bleeding scenarios encountered in the hospital setting.

¡ I have no disclosures

CASE ONE- CONGENITAL AFIBRINOGENEMIA

You are called to the ED to admit a 26-year-old Hispanic female for a complaint of right elbow pain x1 day. The Physician assistant who treated her in the ED reports that she has history of congenital afibrinogenemia. An US of the right arm has been completed that is negative for a DVT and the PA does not know why her elbow is hurting. Upon evaluating the patient she is crying, holding her right arm and is restless. She describes the pain as constant, pressure like, and states it is a 10 out of 10 in severity. She is unable to extend her right elbow. She denies any trauma to the right arm or elbow, fevers, chills, diarrhea, black stools, hematemesis, hematuria, bruising or hematomas.

• ROS is positive for only right elbow pain• PMH: Congenital afibrinogenemia, Congenital deafness, renal tubular acidosis • Past Surgical history: None• Current medications: ferrous sulfate, vitamin C, potassium • Social hx: negative

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Physical Exam• Vitals: 98.7-80-16-135/70• Right elbow is swollen, tight and fixed in a 90 degree angle. She is

unable to extend the elbow. No erythema is noted. Exam is otherwise negative.

• Labs: WBC 10.0, H&H 13/36, platelets 340,000• Na 140, potassium 3.5, CO2 16, anion gap 15, BUN 9, creatinine 0.85

CASE ONE-CONGENITAL AFIBRINOGENEMIA

¡ What is the general approach to the evaluation of a patient who has a bleed?

¡ The initial bedside goals include

¡ Resuscitation of the unstable patient

¡ Control of bleeding

¡ Prevention of further bleeding

¡ Bedside evaluation

¡ Vitals

¡ Assess for signs of adequate perfusion

¡ Mentation

¡ Urine output

¡ Medications


¡ What is the general approach to the evaluation of a patient who has a bleed?


¡ Medications

¡ beta blockers and calcium channel blockers

¡ NSAIDS

¡ Antiplatelet and anticoagulants

¡ Any medication which may cause thrombocytopenia

¡ Antiplatelet medications, beta lactam antibiotics, levofloxacin, sulfonamides, vancomycin, linezolid, quinine, heparin, valporic acid, Depakote, phenytoin, carbamazepine, rifampin


¡ What is the general approach to the evaluation of a patient who has a bleed or suspected bleed?


¡ Assess for the presence of life threatening bleeds. These include intracranial bleeds, GI bleeds, massive hemoptysis, post-partum hemorrhage, and retroperitoneal bleeds.

¡ Require specialty consultation

¡ These bleeds require specialty consultation

¡ Spontaneous Intracranial bleeds

¡ Traumatic intracranial bleed

¡ GI bleeds

¡ Retroperitoneal Hemorrhage

¡ Massive Hemoptysis

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¡ What is the general approach to the evaluation of a patient who has a bleed or suspected bleed?


¡ Signs of hemorrhage shock should be emergently treated with fluid and blood resuscitation.

¡ Assess for a history of bleeding since early childhood. This suggests the presence of an inherited disorder.

¡ Assess for vitamin K deficiency risk factors

¡ Poor nutrition (elderly, mentally ill, alcoholics)

¡ Cirrhotics

¡ Antibiotic use

¡ Assess for signs of vitamin c deficiency. This deficiency can cause bruising, hemorrhage, petechiae and gingivitis.


How can clinical manifestations from a bleed

help you to differentiate between a platelet dysfunction and a

coagulopathy?


Coagulopathy

¡ Manifests as joint bleeding or tissue hematomas

¡ Large, spontaneous, centrally located ecchymosis

¡ Bleeding post trauma, surgery, injury tends to be delayed

Platelet Dysfunction or Deficiency

¡ Epistaxis, oral bleeding, GI or GU bleeding (in the absence of malignancy), hemoptysis, protracted menstrual bleeding

¡ Bleeding occurs immediately after a trauma or injury


a.What initial lab work should be ordered to evaluate a bleed?

• CBC, BMP, Liver Function• PT/INR, PTT, Fibrinogen level • Type and cross match• H&H should be trended

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a.What initial lab work should be ordered to evaluate a bleed?

• PT/INR• Vitamin K deficiency, Liver Disease, warfarin use,

• PTT• May be elevated in any coagulation factor deficiency

except factor VII• Fibrinogen level

• Decreased in DIC, Liver disease, Fibrinolytic therapy, Congenital deficiencies

• Acute Phase reactant


a.How should a diagnosis of hemarthrosis be confirmed?

• Joint Aspiration is best


a.Case One Review

• This patient is stable, she is in a lot of pain. • The PA was unsure of diagnosis• Labs: PTT > 160.0, PT >60, INR > 12.8, Fibrinogen level was 2.0


a.How should this patient’s bleed be treated and what are our options? What level of fibrinogen is needed to maintain or

achieve hemostasis?

• Cryoprecipitate versus Fibrin Concentrates (RiaSTAP)• Fibrin goal

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CASE TWO- GI BLEED AND ANTIPLATELET THERAPY


¡ You are the medical consultant for a 75-year-old female patient who has been admitted to the hospital for repair of a left hip fracture. Orthopedics is the primary team on the case and you have been seeing the patient in consultation for 3 days. Today she is 2 days post op. Prior to seeing the patient you review the chart for overnight events and notice that the night nurse documented that she suddenly became confused and started having black stools. The nurse also documented that she notified the on-call physician who did not evaluate the patient nor give any orders.

¡ Past Medical History: NSTEMI post DES 3 months ago, Diabetes Mellitus Type 2, Osteoporosis

¡ Past Surgical History: Hysterectomy 30 years ago secondary to fibroid, and ORIF of the left hip 2 days ago.

¡ Current Medications: ASA, Plavix, morphine, hydrocodone, Lantus daily, SS insulin, docusate, Senna, metoprolol XL, lisinopril


¡ On exam she is confused, which is a definite change from baseline. She is drowsy and not in any obvious distress. She does complain of some mild chest pain. HR regular, Lungs clear, mildly dyspneic. Abdomen soft, nontender. Rectal exam with black stool, no rectal masses noted. There are no petechiae or hematoma noted. Left hip incision is without any bleeding, oozing, or hematoma.

¡ Vitals: 98-90-20-110/60. Baseline BP has been 150/70, with a pulse around 65.

¡ AM labs: WBC 10, H&H 6.7/21 (yesterday was 8.5/25.5), platelets 100,000

¡ Liver function tests are normal

¡ Creatinine 1.6 mg/dL and BUN 18 mg/dL

CASE TWO – GI BLEED AND ANTIPLATELET THERAPY

a. What is the risk of bleeding from antiplatelet therapy?

• Prasugrel & Ticagrelor > Clopidogrel (DAPT) • 2 Fold increase in risk

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a. What does the evidence say about treating a GI bleed in the setting of DAPT post PCI/MI?

• Continue or stop?• Interprofessional approach• What evidence is available


a. What are the current recommendations for the duration of DAPT?

• 2016 ACC/AHA Guideline Focused Updated on Duration of Dual Antiplatelet Therapy in patients With Coronary Artery Disease



• New Generation Drug eluting Stents for non-ACS• A duration of 3-6 months did not show any difference

in outcomes • A shorter duration resulted in less bleeding



• DAPT extended to 18-36 months in elective DES implantation • Decreased the risk of late stent thrombosis by 2%• Increased the risk of bleeding by 1% • In those with previous MI were higher 3% and 1%

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• ACS treated with PCI, CABG, Medical therapy • Duration 6-12 months

• Stable Ischemic Heart Disease: S/P PCI• BMS • DES• S/P CABG

• Longer versus shorter durations• Aspirin therapy

CASE TWO-GI BLEED AND ANTIPLATELET THERAPY

Increased Ischemic Risk Increased Risk of Stent Thrombosis

Increased Bleeding Risk

• Advanced Age• ACS Presentation• Multiple prior MIs• Extensive CAD• Diabetes Mellitus • Chronic Kidney Disease

• ACS Presentation • Diabetes Mellitus • Left Ventricular EF < 40%• First generation drug eluting stent• Stent under sizing• Stent under deployment• Small stent diameter• Greater stent length• Bifurcation stents• In-stent stenosis

• History of prior bleed• Oral anticoagulant therapy• Female sex• Advanced Age• Low body weight• Chronic Kidney Disease • Diabetes Mellitus • Anemia• Chronic steroid or NSAID

therapy

What are the risk factors for increased ischemic events/risk of stent thrombosis and increased risk of bleeding secondary to DAPT?


a. What do we know about the risk of clotting when an individual with coronary stents is off DAPT therapy?

• The highest risk for a thromboembolic event in persons with coronary artery stents is:• First 90 days following ACS, the risk is increased by 2 fold for cardiac death

or MI with the discontinuation of clopidogrel. This is true for persons treated with a PCI or medically. • First 30-45 days after PCI and bare metal stent insertion• First 3-6 months following PCI and DES insertion


¡ What do the guidelines recommend regarding DAPT continuation or discontinuation perioperatively?

¡ According to the 2016 ACC/AHA Guideline Focused Updated on Duration of Dual Antiplatelet Therapy in Patients with Coronary Artery Disease

¡ Elective noncardiac surgery should be delayed for 30 days after BMS implantation and optimally 6 months after DES implantation.

¡ In patients treated with DAPT after coronary stent implantation who must undergo surgical procedures that mandate the discontinuation of P2Y12 inhibitor therapy, it is recommended that aspirin be continued if possible and the P2Y12 platelet receptor inhibitor be restarted as soon as possible after the surgery.

¡ Obtain a consensus among treating providers regarding the discontinuation of DAPT in noncardiac surgery.

¡ Elective noncardiac surgery after DES implantation in patients for whom P2Y12 therapy will need to be discontinued may be considered after 3 months if the risk of further delay of surgery is greater than the expected risks of stent stenosis.

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¡ What does the evidence say regarding the safety of short term discontinuation of DAPT in persons with DES?

¡ In an article published in Circulation in 2009 a group of interventional cardiologists completed a medline search to answer this question.

¡ They searched for cases of late stent thrombosis and very late stent thrombosis.

¡ Late stent thrombosis was defined as a thrombosis which occurred 30 days to 1 year after DES implantation.

¡ Very late thrombosis was defined as a thrombosis which occurred > 1 year after the DES was implanted.

¡ This study only looked at the older DES and all persons included had confirmed evidence of stent thrombosis.


¡ What does the evidence say regarding the safety of short term discontinuation of DAPT in persons with DES?

¡ 161 Case Were found

¡ Mean age was 58.4% and 88% male

¡ 19 cases of thrombosis were noted in persons taking DAPT

¡ In patients who stopped DAPT simultaneously the median time to event was 7 days.

¡ If the patient stopped the thienopyridine without any adverse events and then stopped aspirin the median time to the event was 7 days post discontinuation of the ASA.

¡ If the thienopyridine was discontinued and ASA was continued the median time to an event was 122 days.

¡ Among the 48 persons who stopped both agents, 36 (75%) cases occurred within 10 days

¡ Among the 94 patients who discontinued the thienopyridine but continued ASA, only 6 (6%) cases of stent thrombosis occurred within 10 days.

¡ Conclusion of this study


a. What other evidence is available to assist with the management of a GI bleed in this

situation?

• Premature and complete discontinuation of antithrombotic therapy in anticipation of an endoscopic procedure can result in stent occlusion, MI, and mortality in 50% of patients. • Elective diagnostic endoscopy can safely be

performed without cessation of DAPT.


a. Should the antiplatelet therapy be stopped? How is this being handled in practice?

• Treat through the bleed• Stop clopidogrel and continue ASA• Antiplatelet effects of medications• ASA• Clopidogrel & Prasugrel • Ticagrelor

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a. Can she be treated with a PPI? Should she be discharged on a PPI?

• Drug interaction (Clopidogrel & PPIs)• Omeprazole vs. Pantoprazole • COGENT Trial • Prior GI Bleeds • PPIs help to stop bleeding acutely • Current AHA/ACC recommendations


a. What does the evidence say about reversing the effects of antiplatelet medications?

• No Guidelines • Platelet Transfusions • Small amount of evidence which says they can reverse the antiplatelet effects• Intracranial bleeds- evidence is conflicting and may be harmful

• Desmopressin • Some evidence which shows a reversal of antiplatelet activity. • Does reverse the effects of ASA, and partially clopidogrel. Has no effect on ticagrelor.

• Neurocritical Care Society and Society for Critical Care Medicine recommendations• American College of Gastroenterology


What is the role of PRBC transfusion in the setting of an active bleed?

When are platelet transfusions indicated in the treatment of an acute hemorrhage?

When should antithrombotic therapy be restarted post GI bleed?

• Restrictive protocol is best• Transfuse Hgb < 7g/dL• In persons with unstable CAD

transfuse with a Hgb < 9g/dL

• General guideline• Platelet count < 50,000 and

actively bleeding

• Once hemostasis is achieved

CASE THREE: CIRRHOTIC WITH A GI BLEED ON ANTICOAGULATIONNTICOAGULATION

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CASE THREE- CIRRHOTIC WITH A GI BLEED ON ANTICOAGULATION

You are the ACNP working night shift, providing cross coverage for the hospitalist service, Liver/GI service and Hematology Oncology service. At 2200 you receive a call from the RN caring for Mr. Smith, a 59 y/o Caucasian male informing you that he had an episode of hematemesis while coming to his room from the ER.

Upon review of the EMR, you note that Mr. Smith has a history of alcoholic cirrhosis, hepatic encephalopathy, hepatopulmonary syndrome, Chronic Kidney Disease and is admitted to the hepatology service with a supratherapeutic INR, and acute kidney injury from taking Lasix 60mg. He was taking Coumadin and Lovenox at home for a pulmonary embolus which was diagnosed 5 months ago. He has not experienced any other venous thromboembolism.

Labs done in the ED were 6 hours ago and are as follows: WBC 4.0, H&H 10/30.4, Platelets 110,000, BUN 30, creatinine 2.5, INR 8.6. He was discharged about 2 weeks ago on a Coumadin dose of 7.5mg and Lovenox 100mg BID, after having being treated for a supratherapeutic INR.


Upon evaluating the patient he reports that he is having periumbilical pain that is constant, sharp, and has been increasing in intensity over the last week. He notes he has an umbilical hernia and says his ascites is pressing on the hernia causing the pain.

He reports that he was instructed to stop his Coumadin 3 days ago but to continue Lovenox 100mg BID. He is unclear why he was told to stop the Coumadin. He was taking 20mg of Coumadin because he was confused on the dosage. He denies having a history of hematemesis or black tarry stools.

Currently he has only had one bout of hematemesis, however he is not sure if he coughed this up or he vomited. He denies black tarry or red stools. He reports that he had an EGD 2 months ago that was negative but a report is not in the system.


Vitals: 96.8-84-18-119/72Alert and oriented x3, no acute distressHeart rate regular, no murmurLungs clearAbdomen distended, rounded, firm, shifting dullness present, fluid wave present, no bruising of the abdomen noted or hematoma present 2+ edema of lower extremities

Upon additional review of the chart, you notice he has not received any treatment for the elevated INR. You order stat labs which come back as follows:WBC is 4.1, H&H is 10.5/31.8, platelets 123,000, Fibrinogen level 105INR 9.6, PTT 50.8

Case Analysis: Risks for bleeding? & What is good?

HOW DO ANTICOAGULANTS IMPAIR THE COAGULATION CASCADE?CASE THREE: CIRRHOTIC WITH A GI BLEED ON ANTICOAGULATION

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¡ How should his anticoagulation therapy and coagulopathy be managed?

MANAGEMENT OF BLEEDING IN ACUTE VTE

Mild Bleed

Hold 24-48 hours & resume when resolved

Continued bleed • Reversal agent • Treat the source

Resolved Bleed & VTE < 1 month old

• Restart anticoagulation

Continued Bleed & VTE is >3months old

• Discontinue anticoagulant therapy

permanently

MANAGEMENT OF BLEEDING IN ACUTE VTE

Moderate to Severe Bleed

• Reversal agent • Treat the bleed

Continues to bleed or rebleeds & < VTE is 1

month old • Place IVC Filter

Bleed requires surgery to treat • IVC Filter

• Remove when safe to restart anticoagulation

Continues to bleed or rebleeds & VTE & >

3months old • Discontinue

anticoagulation

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a. What is things should we consider when deciding to reverse his coagulopathy?

• Pharmacotherapeutics • Lovenox & Warfarin • He is stable• Duration of treatment

CASE THREE CIRRHOTIC WITH A GI BLEED ON ANTICOAGULATION

a. How do the ACCP 2012 Antithrombotic Guidelines recommend a supratherapeutic INR be managed?

• INR between 4.5-10 and no bleeding. No treatment recommended• INR > 10.0 and no bleeding. Give oral vitamin K• Major bleeding (Life threatening) • Use 4 factor PCC with vitamin K 5-10mg IV• General Considerations


a. Can any of the new oral anticoagulant medications be reversed?

• Dabigatran (Pradaxa) • Idarucizumab (Praxbind)• 2.5mg IV x 2 doses 15 minutes

apart

a.Can any of the new oral anticoagulant medications be reversed?

• 4 Factor PCC • Not standard of care• Effects clear in 5 half lives with

normal renal function • Reserve for life threatening situations


a. Per the AASLD 2016 Guidelines: Portal Hypertensive Bleeding in Cirrhosis, what additional treatments are needed?

• GI Consult• Endoscopic evaluation within 12

hours of presentation • Replace fibrinogen

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a. Per the AASLD 2016 Guidelines: Portal Hypertensive Bleeding in Cirrhosis, what additional treatments are needed?

• Recommend against using Factor VIIa or FFP to reverse INR• Octreotide therapy • PPI therapy • Do not transfuse hemoglobin above 10g/dL • Antibiotic therapy • Cirrhotics have infection or will develop inpatient• Ceftriaxone 1g IV daily

• Monitor for hepatic encephalopathy • Monitor renal function

CASE THREE CIRRHOTIC AND GI BLEED ON ANTICOAGULATION

a. Are platelets indicated in a cirrhotic patient with thrombocytopenia with a variceal bleed?

• AASLD 2016 does not make any recommendations for or against the use of platelet transfusions

• Clinical judgment

THANK YOU

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8/15/17 - cdn.ymaws.com...does not know why her elbow is hurting. Upon evaluating the patient she is crying, holding her right arm and is restless. She describes the pain as constant,