Thrombin Inhibitors
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Outline
Overview
I. Overview
A. Thrombin inhibitors = clot prevention
B. Alter platelet function, thrombin inactivation
II. Mechanism of Action
A. Direct = Inactivate circulating and clot-bound thrombin
B. Indirect = Inhibit thrombin / Factor Xa
C. Clot prevention and clot limitation
D. = Increased risk for bleeding
III. Types
A. Direct
1. Bivalirudin (parental)
2. Argatroban (parental)
3. Desirudin (parental)
4. * Dabigatran (oral)
B. Indirect
1. Heparin
2. Enoxaparin
IV. Indications
A. DVT/PE prophylaxis
B. DVT/VTE treatment
C. Atrial fibrillation
D. Acute coronary syndrome
E. Heparin-induced thrombocytopenia
F. Percutaneous coronary intervention (PCI)
V. Contraindications
A. Recent trauma
B. Active internal bleeding
C. Bleeding disorders
D. Intracranial hemorrhage
E. Severe HTN
F. Liver failure
G. Kidney failure
VI. Side Effects
A. Bleeding
1. Localized
2. Systemic
B. Red or brown urine
C. Black or bloody stool
D. Severe headache or stomach pain
E. Joint pain, discomfort or swelling (after injury)
F. Hemoptysis
G. Hematemesis
H. Bruising
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Transcript
Welcome back and today we will discuss thrombin inhibitors.
Thrombin inhibitors are used to prevent clot prevention. They work by preventing the conversion of fibrinogen to fibrin. Fibrin is what is involved in the clotting of blood and strengths platelet plugs. Fibrin is on the common pathway in the clotting cascade. These drugs interrupt this cascade with a goal of clot prevention. See NRSNG clotting cascade cheat sheet for complete breakdown.
Thrombin inhibitors works by inactivating the very things that make platelets form. The goal is clot prevention and limitation of clot formation. All of which will cause an increased risk of bleeding. I had a patients on these medications and they happened to trip at home and hit their head. Guess what? Yes, intracranial bleeding surely occured. Big bleeding risk with these medications.
Now the types of thrombin inhibitors include indirect and direct classes. You probably see indirects at the hospital bedside. You’ve probably given enoxaparin (sq). Now directs are usually in the setting of cardiac procedures (parenterals), they serve their purpose but have lesser risk for increased bleeding afterward. Dabigatran is a PO med alternative to warfarin and doesn’t require frequent monitoring via blood work.
Indications include processes revolving around the heart and clots, an easy way to remember this list is HAP DAD. ACS, PCI, DVT/PE prevention, A fib and DVT/PE treatment are all indications for thrombin inhibitors. HIT is special case, for once it is suspected – you would then switch to direct thrombin inhibitors as heparin was the culprit.
Now, if we are preventing clots from forming and inhibiting thrombin, we are thinning the blood = increase bleeding risk. The following ALL are various bleeding situation. These patients are already at a high-risk for re-bleeding. We wouldn’t want to increase their chances and cause harm with giving this medication.
You see a common trend here yet? Yes! Bleeding all day, all over the body. When you prevent clotting, you increase bleeding risks significantly. So as nurses, we must focus on monitoring and performing detailed head to toe assessments in this patient population. So with these side effects in mind, we as nurses would place our patients on bleeding precautions – which include soft toothbrushes and the use of electric razors. The goal is not to exacerbate or provoke further bleeding to the best of our ability. As side effects are bleeding based, we need to monitor the therapeutic effects. In terms of heparin, monitoring is in the blood work using PTT levels. Again was want therapeutic responses but we don’t want our patients bleeding internally due to a drug overdose.
Priority nursing concepts for a patient receiving thrombin inhibitors include clotting, perfusion and pharmacology.
Let’s review, the goal of thrombin inhibitors is clot prevention. There are two types indirect and direct. Indications include HAP DAD, which all revolve around heart and clotting. Contraindication and side effects focus on bleeding throughout the body. Bleeding a huge concern with this drug class and we wouldn’t want to give someone who is already a high-risk for bleeding this medication. Side effects include local and systemic bleeding. So if bleeding is a concern and your see bleeding in someone receiving thrombin inhibitors, you should notify the provider immediately.
Now you know all you need to know about thrombin inhibitors, now go out and be your best self and happy nursing.
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