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What do you do if a patient's INR < 5, but above therapeutic range with NO significant bleeding?
Lower dose, or omit single dose and restart at lower dose when INR is therapeutic
What do you do if patients INR is > 5 < 9 with NO significant bleeding?
Omit 1 -2 doses and resume at lower dose when INR is therapeutic. If more rapid reversal desired, omit dose and give < 5 mg Vit K orally, then restart at lower dose when INR is therapeutic.
What do you do if patient's INR is > 9, but no significant bleeding?
Hold warfarin and give 2.5 -5 mg Vit K orally. Use additional Vit K if necessary. Resume warfarin at lower doses when INR is therapeutic.
What do you do if patient has significant bleeding at ANY elevation of INR?
Hold warfarin, give 10 mg Vit K IV via slow infusion. Supplement with FFP, rVIIa (NovoSeven), or prothrombin complex. Repeat Vit K 10 mg IV Q 12H if necessary.
What do you do if patient is experiencing LIFE-THREATENING bleeding?
Hold warfarin. Give FFP, Prothrombin complex, or rVIIa with vitamin K 10 mg via slow infusion. Repeat as necessary.
What is the heparin dose for TE prophylaxis?
5000 units SC Q8-12H
What is the treatment dose of heparin?
Bolus with 80 units/kg IV x 1 then 18 units/kg/h IV - adjust based on aPTT nomogram
What is the prohylactic dose of Lovenox?
30 mg SQ Q12H or 40 mg SQ Q24H (abd surgery)
renal adj: CrCL < 30 ml/min - 30 mg SQ Q24H
What is the treatment dose of Lovenox?
1 mg/kg Q12 HR or 1.5 mg/kg Q24H
What is the dosing for Fondaparinux?
- > 50 kg: 5 mg Q24H
- 50-100 kg: 7.5 mg Q24H
- <100 kg: 10 mg Q24H
*DOES NOT cause HIT