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Hemostatics: Nursing Pharmacology

Notes

Notes

HEMOSTATICS, PART 1
DRUG NAME
aminocaproic acid (Amicar)
tranexamic acid 
(Lysteda, Cyklokapron)
CLASS
Antifibrinolytics
MECHANISM OF ACTION
Inhibit conversion of plasminogen to plasmin → inhibits clot breakdown and stops the bleeding
INDICATIONS
  • Control perioperative bleeding after surgeries (e.g., CABG)
  • Prevent bleeding due to cirrhosis
  • Hemophilia
  • Menorrhagia
ROUTE(S) OF ADMINISTRATION
  • PO
  • IV
  • IM
  • SubQ
SIDE EFFECTS
  • Malaise
  • Muscle weakness
  • Bradycardia
  • Hypotension
  • Injection site reactions
  • Abdominal cramps
  • Nausea
  • Diarrhea
  • Myopathy with rhabdomyolysis
  • Acute renal failure
  • Headache
  • Seizures
  • Impaired color vision
  • Abdominal pain
  • Nausea
  • Diarrhea
  • Deep vein thrombosis
  • Pulmonary embolism
CONTRAINDICATIONS AND CAUTIONS
  • Disseminated intravascular coagulation
  • Cardiac, renal, and hepatic diseases
  • Pregnancy
  • Existing impaired color vision
  • History of thromboembolism
  • Active intravascular clotting
HEMOSTATICS, PART 2
DRUG NAME
phytonadione 
(Mephyton, Aquamephyton)
gelatin (Gelfoam), microfibrillar collagen (Avitene), bovine thrombin (Evithrom, Thrombostat), human fibrin sealant (Artiss, Evicel)
CLASS
Vitamin K analogues
Topical hemostatics
MECHANISM OF ACTION
Used for the synthesis and activation of clotting factors
Activate the coagulation cascade locally → clot formation
INDICATIONS
  • Vitamin K deficiency
  • Hemorrhagic disease of the newborn
  • Control bleeding intraoperatively
  • Tissue injuries
ROUTE(S) OF ADMINISTRATION
  • PO
  • IV
  • IM
  • SubQ
  • TOP
SIDE EFFECTS
  • Shortness of breath
  • Chest tightness
  • Injection site reaction
  • Anaphylaxis
  • Skin infection
  • Impaired wound healing
CONTRAINDICATIONS AND CAUTIONS
  • Hypoprothrombinemia
  • Pregnancy
  • Neonates
  • IV administration
  • Bovine allergy
NURSING CONSIDERATIONS: HEMOSTATICS
DRUG NAME
aminocaproic acid
thrombin
ASSESSMENT AND MONITORING
Assessment
  • Location, amount of bleeding
  • Signs of blood loss:  pallor, cyanosis, sluggish capillary refill, hypotension, tachycardia, weak peripheral pulses
  • Laboratory test results: CBC, CPK, BUN, creatinine, coagulation studies
  • Confirm IV site
Monitoring
  • Coagulation studies
  • Signs of thromboembolic complications; e.g., chest pain, dyspnea, leg pain
  • Signs of muscle breakdown; reddish brown urine, client report of muscle pain or weakness
  • After administration: evaluate for controlled bleeding, laboratory values within normal limits, absence of side effects
  • Assist with preparation  and delivery to surgeon; maintain sterility
  • Assist with suctioning or sponging before application of the medication
  • Postoperatively: continue to monitor for signs of hemorrhage and thrombosis
CLIENT EDUCATION
  • Purpose of medication to stop bleeding

Transcript

Hemostatics are medications used to induce hemostasis, which is a physiological process that results in clot formation to prevent or stop a hemorrhage.

Primary hemostasis first starts when platelets are activated and aggregate to form a platelet plug at the site of an injured blood vessel.

Next, secondary hemostasis starts with the coagulation cascade, when clotting factors become consecutively activated to ultimately activate prothrombin into thrombin.

The activated thrombin then cleaves fibrinogen into fibrin, which binds with other fibrin proteins to form a fibrin mesh that reinforces the platelet plug.

Now, when the tissue has healed, the endothelial cells produce an enzyme called tissue plasminogen activator, or tPA, which in turn converts plasminogen into its active form plasmin.

Plasmin then acts as a protease by cutting fibrin into smaller pieces, called fibrinolysis, and ultimately dissolving the clot.

Now, the most commonly used hemostatics include antifibrinolytics, such as aminocaproic acid and tranexamic acid, and vitamin K analogues like phytonadione, which can be administered orally, intravenously, intramuscularly, or subcutaneously; as well as topical hemostatic agents, such as gelatin, microfibrillar collagen, bovine thrombin, and human fibrin sealant, which are applied topically.

Let’s first focus on antifibrinolytics, which work by inhibiting the conversion of plasminogen to plasmin, which ultimately prevents fibrinolysis.

Now, aminocaproic acid is primarily used as prophylaxis to prevent bleeding after cardiac surgeries, like coronary artery bypass surgery, or CABG, as well as to prevent bleeding in clients with cirrhosis, in which the liver is unable to synthesize clotting factors, and to prevent recurrence of subarachnoid hemorrhage.

Some side effects of aminocaproic acid include malaise and muscle weakness, bradycardia, hypotension, as well as injection site reactions.

Less commonly, aminocaproic acid can cause gastrointestinal side effects like abdominal cramps, nausea, and diarrhea.

Finally, prolonged use of aminocaproic acid may lead to myopathy with rhabdomyolysis, which may ultimately result in acute renal failure.

As far as contraindications go, aminocaproic acid is contraindicated in clients who experience disseminated intravascular coagulation, or DIC; this is a state of widespread clot formation in the body associated with platelet consumption and thrombocytopenia, making the client more prone to severe hemorrhage.

Caution should also be taken in clients with cardiac, renal and hepatic diseases, as well as during pregnancy, as its effects on the fetus are not well known.

Alright, the next antifibrinolytic is tranexamic acid, which can be used to stop or prevent bleeding in clients with hemophilia, as well as in clients with menorrhagia, or heavy menstrual bleeding.

Now, side effects of tranexamic acid include headache, seizures, impaired color vision, as well as abdominal pain, nausea, diarrhea.

On rare occasions, it can result in excessive clotting, which increases the risk of deep vein thrombosis and pulmonary embolism.

For these reasons, tranexamic acid is contraindicated in clients who already have impaired color vision and a history of thromboembolism, as well as active intravascular clotting.

Next, we have vitamin K analogues, such as phytonadione, which is used by the liver as cofactor for the synthesis and activation of certain clotting factors.

Phytonadione is typically administered to clients with vitamin K deficiency, which makes them more susceptible to bleeding.

Specifically, phytonadione is given shortly after birth intramuscularly as prophylaxis to prevent hemorrhagic disease of the newborn.

Vitamin K analogues can cause side effects like dyspnea, chest tightness, and injection site reaction. When given intravenously or intramuscularly, phytonadione has a boxed warning for severe anaphylaxis that can result in shock.

Sources
  1. "Focus on Nursing Pharmacology" LWW (2019)
  2. "Pharmacology" Elsevier Health Sciences (2014)
  3. "Mosby's 2021 Nursing Drug Reference" Mosby (2020)
  4. "Saunders Comprehensive Review for the NCLEX-RN Examination" Saunders (2016)
  5. "Aminocaproic Acid" StatPearls (2021)
  6. "Phytonadione (Vitamin K1)" StatPearls (2021)
  7. "Overview of topical hemostatic agents and tissue adhesives" UpToDate (2021)
  8. "Thrombin" StatPearls (2021)
  9. "Hemostatic Agents: A Guide to Safe Practice for Perioperative Nurses" AORN Journal (2014)