CYANOSIS, ISCHEMIA MEANING, HEPARIN , USES, COMPLICATIONS, CALUCULATION FORMULAS FORINTENSIVE NURSES

CYANOSIS, ISCHEMIA MEANING, HEPARIN , USES, COMPLICATIONS, CALUCULATION FORMULAS FORINTENSIVE NURSES

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  CYANOSIS , HEPARINIV INFUSION,IV CALUCULATION FORMULAE,NURSING MANAGEMENT PREPARED BY MURUGESH HJ RN. ICU 02 ( HAYATH) , KFCH HOSPITAL JIZAN , SAUDI ARABIA
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  CIRCULATORY SYSTEM…  Thecirculatory system, also called the cardiovascular system or the vascular system, is an organ system that permits blood to circulate and transport nutrients (such as amino acids and electrolytes), oxygen, carbon dioxide, hormones, and blood cells to and from the cells in the body to provide nourishment and help in fighting diseases, stabilize temperature and pH, and maintain homeostasis.  The cardiovascular (from Latin words meaning "heart" and "vessel") system comprises the BLOOD, HEART & BLOOD VESSELS…  THERE IS TWO MAIN TYPES OF CIRCULATION  1.SYSTEMIC CIRCULATION  2.GENERAL CIRCULATION..
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  IMPORTANT TERMS…. HOMEOSTASIS- ITSAN STATE OF EQUILIBRIUM BETWEEN ALL THE SYSTEMS WORKS NORMALLY , PERSON WILL BE HEALTHY… VASCULAR DISEASES -DISEASES PERTAINING TO CIRCULATORY SYSTEM, LIFE THRETNING WITH HIGH AFFINITY TO DISABILITY OR MORTALITY.. The most common vascular diseases are stroke, peripheral artery disease (PAD), abdominal aortic aneurysm (AAA), carotid artery disease (CAD), arteriovenous malformation (AVM), critical limb-threatening ischemia (CLTI), pulmonary embolism (blood clots), deep vein thrombosis (DVT), chronic venous insufficiency (CVI), and varicose veins…In this cases there should be strict close monitoring required for HAEMOSTATITICS( LAB VALUES) eg: Coagulation profile, platelet count, etc….
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  IMPORTANT ABREVIATIONS,,,,, CYANOSIS-Cyanosis refersto a bluish-purple hue to the skin. It is most easily seen where the skin is thin, such as the lips, mouth, earlobes and fingernails. Cyanosis indicates there may be decreased oxygen attached to red blood cells in the bloodstream. It may suggest a problem with the lungs or heart. ISCHEMIA-Ischemia is a condition in which the blood flow (and thus oxygen) is restricted or reduced in a part of the body. Example; cardiac ischemia is the name for decreased blood flow and oxygen to the heart muscle… NECROSIS-Necrosis is the death of body tissue. It occurs when too little blood flows to the tissue. This can be from injury, radiation, or chemicals. Necrosis cannot be reversed. When large areas of tissue die due to a lack of blood supply, the condition is called gangrene.
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  IMPORTANT ABREVIATIONS,,,,,  APOPTOSIS-Apoptosisis the process of programmed cell death. It is used during early development to eliminate unwanted cells; for example, those between the fingers of a developing hand. In adults, apoptosis is used to rid the body of cells that have been damaged beyond repair. Apoptosis also plays a role in preventing cancer.  THROMBECTOMY- SURGICAL REMOVAL OF THROMBUS( CLOTS)  ANTICOAGULANTS-Anticoagulants, or blood thinners, and thrombolytics are medicines commonly used to treat VTE. Anticoagulants, or blood thinners, keep blood clots from getting larger and stop new clots from forming. Conventional blood thinners include warfarin and heparin EXAMPLES- Warfarin,Apixaban,Dabigatran,Rivaroxaban,Apixaban, and,Edoxaban etc……
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  HEPARIN IV INFUSION….. HEPARIN IV INFUSION-Unfractionated heparin (UFH) is a mixture of sulfated glycosaminoglycans, some of which possess anticoagulant properties. It is rapidly removed from the body with a half-life of 30 to 60 minutes, however the half-life may increase with increasing dosage or in renal impairment. Due to this short half-life it must be given by continuous intravenous infusion with monitoring of APTT and appropriate dosage adjustments for conditions requiring full anticoagulation…..  PRECAUTIONS while giving heparin ( POINTS TO BE KEEP IN MIND)  ▪ Thrombocytopenia –  ▪ Severe uncontrolled hypertension (BP greater than 200/120) – use with great care.  ▪ Intrathecal or epidural analgesia or anaesthesia, or lumbar puncture –at risk of epidural haematoma which can cause paralysis. ______________________________________________________
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  INDICATIONS FOR HEPARININFUSION..  INDICATIONS-  Heparin sodium is indicated for: • Prophylaxis and treatment of venous thromboembolism(VTE) and pulmonary embolism(PE) • Atrial fibrillation with embolization; • Treatment of acute and chronic consumptive coagulopathies (disseminated intravascular coagulation); • Prevention of clotting in arterial and cardiac surgery; • Prophylaxis and treatment of peripheral arterial embolism; • Anticoagulant use in blood transfusions, extracorporeal circulation, and dialysis procedures.
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  SIDE EFFECTS OFHEPARIN….  What are side effects of Heparin in skin& iv site  Common side effects of Heparin are:  easy bleeding and bruising;  pain, redness, warmth, irritation, or skin changes where the medicine was injected;  itching of your feet; or  bluish-colored skin.
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  HEPARIN IS CONTRAINDICATED IN FOLLOWING CONDITIONS…  CONTRAINDICATIONS FOR HEPARIN INFSUION…  ▪ History of Heparin-induced thrombocytopenia (HIT) –  Renal impairement.  ▪ Ongoing full anticoagulation with another agent.  ▪ Severe thrombocytopenia (platelets less than 50 x 109/L).  ▪ Active bleeding or disease states with an increased risk of bleeding.  ▪ History of haemorrhagic stroke.  ▪ Recent large thromboembolic stroke.  ▪ Severe hepatic disease or impairment (with elevated INR), including oesophageal varices.  ▪ Subacute or acute bacterial endocarditiS
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  METHOD FOR IVHEPARIN CALCULATION  METHOD FOR IV HEPARIN CALCULATION  FARMULA 01  The following method of calculation is to be used when calculating Heparin doses:   Total Units of Heparin = Units/hour  Total Amount of infusion (mLs) mLs/hour   ****adjust from the current dose not from the initial dose..  ****increase or decrease it should be based on LAB APTT VALUE….  **** INFUSION NEED TO START WITH 80UNITS/KG IV STAT BOLUS, LATER ACCORDING HEPARIN IV INFUSION PROTOCAL…  Increase by 2units /kg======2X 80KG=160UNITS, Eg: 1440units+160units=1600units/hr……  Decrease by 2units /kg =====2x 80KG=160units Eg: 1440units-160units=1280units/hr …..  
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  INITAIL DOSE CALUCULATION SIMPLE CALUCULATIONS FOR INITIAL DOSE 80UNITS/KG IV STAT BOLUS……  HEAPARIN 1AMPOULE =25,000UNITS IN 500ML NSS IT MEANS 250000/500 = 50UNITS I mean 1ml = 50units ….  80units/KG IV STAT BOLUS MEANS , Example patient weight is 60kg , TOTAL STRENGTH 25000UNITS,SOLUTION IS 500ML  FORMULA IS  Total Units of Heparin = Units/hour  Total Amount of infusion (mLs) mLs/hour   25,000/500=4800/X  50=4800X  X=4800/50  X=97.6ml
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  EXAMPLE….  EXAMPLE:   Order:Heparin 1400 units q hour IV  Standard Solution 25,000 units of Heparin in 500 mL D5W  How many mLs/hr will you administer   25,000 total units of Heparin = 1400 units/hr  500total amount of infusion (mLs) X mLs/hr   25000 = 1400  500 X   50 = 1400  1 X  Cross multiply   50 x = 1400  X=1400/50  X = 28mL/hr
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  HEPARIN CALUCULATION…. FOR IVHEPARIN CALCULATION   FORMULA; 02  HEPARIN DOSE X 500ML ML NSS /25,000UNITS  INITIAL DOSE 80UNITS/KG/IV BOLUS,,  IF PATIENT WEIGHT IS 80KG , SOLUTION IS 500ML NSS, STRENGTH 25,000UNITS EXAMPLE:  18units X 80KG = 1440UNITS/Hr,,  1440UNITS X 500ML NSS/25000UNITS =28.8ML/Hr  Increase by 2units /kg=2X 80=160UNITS, Eg: 1440units+160units=1600units/hr……  Decrease by 2units /kg =2x 80=160units Eg: 1440units-160units=1280units/hr …..  ****adjust from the current dose not from the initial dose..  ****increase or decrease it should be based on LAB APTT VALUE….  **** INFUSION NEED TO START WITH 80UNITS/KG IV STAT BOLUS, LATER ACCORDING HEPARIN IV INFUSION PROTOCAL… 
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  Heparin iv infusionprotocol….
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  APTT VALUE ISKEY FOR HEPARIN IV INFUSION,,,,,,  Laboratory Monitoring: HEPARIN  Activated partial thromboplastin time (aPTT) is used most commonly to determine the most effective  dosage of UFH and other anticoagulants.  Clinically, we are mostly interested in the aPTT to monitor unfractionated heparin therapy.  The aPTT is normally 25 – 35 seconds, but varies from lab to lab. Therapeutic anticoagulation is  determined based upon your patient’s weight. It is often ordered to be maintained at 1.5 to 2.5 times the  upper limit of the normal values (Valentine & Hull, 2012).  Material protected by Copyright  Initially, the aPTT drawn prior to initiation, four to six hours after initiation of heparin, & four to six hours  after a dose change. When the aPTT is within a therapeutic range for your patient’s weight and disease  process, the frequency of testing is decreased, usually to every 12-24 hours per hospital protocol.  Because UFH therapy causes different responses in different patients, the aPTT must be monitored  during heparin therapy to monitor the effects of heparin.
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  Management of Heparin Overdose..PROTAMINE Management of Heparin Overdose  Protamine sulfate works to reverse heparin induced bleeding by binding to heparin ions to block  anticoagulant activity.  It can be administered in a slow intravenous infusion (not greater than 20mg/min and no more than  50mg over any 10 minute period).  The appropriate dose of protamine sulfate is dependent upon the dose of heparin given and the  elapsed time since the last heparin dose.  Full neutralization of heparin effect is achieved with a dose of 1mg protamine sulfate/100units of  heparin. Dose varies with heparin dose and time elapsed since administration of heparin.  If heparin had been given by subcutaneous injection, repeated small doses of protamine may be  required because of prolonged heparin absorption from the various subcutaneous sites.  (Valentine & Hull, 2011)
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  NURSING RESPONSIBILITIES….  AvoidingHeparin Errors…..  Tips to avoid heparin associated errors include:  • Have another nurse double check all of your heparin calculations independently prior to the  administration of the heparin.  • Ask another nurse to. verify the right drug, right dose, the right client (with two identifiers), the  right route, right documentation, and the right time  • If multi-dose supplies of heparin are still available on your nursing unit, ask your nurse manager  to check into having single dose supplies ordered instead.  • Never rely on the color of a label or it being located in a familiar place. Always read the label on  the vial, and check this against the order.  • Always get another nurse to review your orders if unclear.  • When unsure about a particular dose, always check with the physician and/or pharmacy.  • Know the normal doses for your patients.
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  Cont…  ***Watch forbleeding , changes in vital signs , neuro observation, LAB values..  ***obtain the blood sample from the non IV CANULLATED hand, ;avoid sample errors…  ***assess skin for bruising, any minute bleeding….
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  References….  Reference  1.Lackie CL, Luzier AB, Donovan JA, Feras HI, Forrest A. Weight-based heparin dosing: clinical response  and resource utilization. Clin Ther. 1998 Jul-Aug;20(4):699-710.  2. Raschke RA, Reilly BM, Guidry JR, Fontana JR, Srinivas S. The weight-based heparin dosing nomogram  compared with a "standard care" nomogram. A randomized controlled trial. Ann Intern Med. 1993 Nov  1;119(9):874-81.  3. Myzienski AE, Lutz MF, Smythe MA. Unfractionated heparin dosing for venous thromboembolism in  morbidly obese patients: case report and review of the literature. Pharmacotherapy. 2010 Mar;30(3):324.  4. Smith ML, Wheeler KE. Weight-based heparin protocol using antifactor Xa monitoring. Am J Health Syst  Pharm. 2010 Mar 1;67(5):371-4. Links / References  CUH IV Heparin prescription chart  CUH IV Heparin policy addendum 20210315  How to Anticoagulation. Drug and Therapeutics Bulletin 1992; 30: 77-80  St Vincents University Hospital. Procedure to standardise management of SVUH patients on an unfractionated heparin infusion. Version 06 – 13-03-2009.  Guy’s and St Thomas’ NHS Foundation Trust. Clinical Guideline. Adult guidelines for Unfractionated Heparin infusions for systemic anticoagulation for APTT 2 – 2.5. Review date 30 May 2015.
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  THANK U ALL