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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
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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.
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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.
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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.
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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.
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What is the heparin dose for TE prophylaxis?
5000 units SC Q8-12H
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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
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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
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What is the treatment dose of Lovenox?
1 mg/kg Q12 HR or 1.5 mg/kg Q24H
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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
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