Antikoagulan pada pasien HD

Ade Mirza

Peserta Pelatihan Hemodialisis RSCM April- Juni 2018

Identitas

 Nama : Ny. R
 Umur : 58 tahun
 No. Rekam Medis: 329-62-58
 Alamat :
 Pembiayaan : BPJS
 HD pertama kali : Agustus 2013
 Etiologi :
Anamnesis
 Pasien laki-laki 50 tahun, dengan diabetes
melitus dan telah menjalani dialisis 2x
seminggu, 5 jam, dengan akses AV fistula
selama 3 tahun. Setiap dialisis menggunakan
heparin bolus 2000 unit, dan kontinyu heparin
1000 unit per jam. Pasien mendapatkan
ascardia 1x80 mg. Pasien mengeluh BAB
berdarah dalam 2 hari terakhir. Pada
pemeriksaan Hb 6.2 g/dl. Sebelumnya Hb 8
g/dl. Bagaimana skema pemberian heparin
yang kita anjurkan?
Pemeriksaan Fisik
 KU : tampak sakit sedang, kesadaran CM
 BBK = 49,5 kg TB = 167 cm
 T = 156/50 mmHg N = 71 x/mnt RR = 18 x/mnt
 Conjuntiva anemis (+), sklera ikterik (-)
 JVP 5–2 cmH2O
 Jantung: BJ I-II dbn, gallop (-), murmur (-)
 Paru : vesikuler, ronchi (-), wheezing (-)
 Abdm : datar, supel, nyeri tekan (-), Hepar/Lien tak teraba,
shifting dullness (-), BU dbn.
 Ekstremitas: edem kaki (-), hangat. Ekstremitas edem (-),
nyeri tekan (-), merah (-).
 Akses vaskular: AV fistula lengan kanan : aneurisma(-), thrill
(+), bruit (+)
 Status gizi : IMT = 23 kg/m2; SGA : A
RPD
 DMT2 (sejak 1997)
 Post amputasi digiti II pedis dekstra
 CKD 5HD (sejak tahun 2006)
 Hipertensi
 CAD post PCI (thn 2012)  aspirin &
clopidogrel. CPG diganti dgn ticagrelor.
Ticagrelor dihentikan krn tjd perdarahan AV
fistula.
 Trombosis vena subklavia kanan (thn 2014)
Riwayat Hemodialisis

 Mulai HD : 15 September 2006 (seminggu 2 x)

 BB kering : 61,5 kg
 Akses Vaskular :
 Thn 2006: CDL I, Cimino lengan kiri (hanya
bertahan 4 thn)
 Thn 2011: CDL II, Cimino lengan kanan (sampai
sekarang)
 Riwayat perdarahan AV fistula lengan kanan (Okt
2014):
 Perdarahan AV fistula selama > 1 jam
 Heparin minimal mulai Okt 2014  perdarahan
hanya 15 mnt & dilanjutkan atas permintaan
bagian Kardiologi
Riwayat Hemodialisis
 Resep HD saat ini :
 Lama HD : 5 jam
 UF goal : 5000 ml
 UF rate : 1000 ml/jam
 Qb : 300 ml/menit
 Qd : 500 ml/menit
 Kt/V : 2,39
 Heparin : minimal (bolus: (-), kontinyu 1000 U,
sirkuit 4000 U)
 Dializer : B Braun, Polysulphone Low Flux 15,
high Ca (>1,3 mmol/L)
, suhu = 370C
 Hasil Pemantauan HD (23/4/2018)
Pre 1 2 3 4 5 Post HD
HD
Waktu 07.05 07.30 09.3 10.30 11.30 12.40
0
BB (kg) 54,5 49,8
TD 182/10 164/10 136/ 125/6 130/8 143/9
(mmHg) 8 6 95 7 5 5

Suhu (oC) 36 36 Kt/V : 2,39

RR 20 18 18 18 18 UF goal= 4630
(x/mnt) ml

Nadi 83 80 98 87 87 80 HD aff durasi 5

(x/mnt) jam

Qb 220 250 200 200 150

(ml/mnt)
Qd 500 500 500 500 Lama
(ml/mnt) Perdarahan

Tek.vena 111 134 132 132 132 AV Fistula 10

mnt
TMP 132 79 58 58 58
Vol.yg 52 274 3243 4243 4630
Pemeriksaan Penunjang (PreHD
03/04/2018)
Hb = 11,3 g/dl Ferritin = 425 µg/L Ca = 7,9 mmol/L
Ht = 34 % As.urat = 5,6 md/dl P = 8, 2 mmol/L
WBC = 8400/µL Kolest.Tot = 214 Hbsag : non
mg/dL reaktif
PLT = 214.000/µL TG = 189 mg/dL Anti HCV : Reaktif
Protein = 7,2 g/dL LDL = 156 mg/dL Anti HIV : Non
Reaktif
Albumin = 4,34 HDL = 47 mg/dL
g/dL
Globulin = 2,86 GDP = 80 mg/dL
g/dL
SGOT = 22 µ/L Ureum pre= 194 Ureum post= 44
mg/dL mg/dL
SGPT = 13 µ/L Kreat pre= 13,3 Kreat post= 4,3
mg/dL mg/dL
SI = 57 µg/dL Na = 141 mmol/L
Terapi
 Obat rutin yang diminum pasien:
 Amlodipin 10 mg 1 x I tablet
 Valsartan 80 mg 1 x I tablet
 Ascardia 80 mg 1 x I tablet
 Asam folat 5 mg 1 x III tablet
 Vit. B12 50 mcg 2 x I tablet
 CaCO3 500 mg 2 x I tablet
 Simvastatin 20 mg 1 x I tablet
 Obat yang diberikan setelah selesai HD:
 Hemapo 3000 U
 Neurobion 5000 U
Masalah Pasien
 CKD 5HD ec Diabetic Kidney Disease
 CAD post PCI (PCI thn 2012)
 Trombosis vena subklavia kanan
 Anemia renal
 DMT2
 Peripheral Vascular Disease (post amputasi)
ec DM
 Hipertensi tak terkontrol
 Riwayat Perdarahan dari AV Fistula post HD
Pendahuluan
 Anticoagulation is essential to hemodialisis and UFH is the
most commonly used anticoagulant. (Am. J Kidney Dis.
2012)
Pendahuluan

THE CARI GUIDELINES 2004

Pendahuluan

 Thrombogenicity is one of the most important biocompatibility markers

of artificial material. Anticoagulation is commonly used to reduce
thrombogenicity of the extracorporeal circuit (ECC) during intermittent
hemodialysis (IHD). Richtrova P, Artif Organs. 2010.

 Anticoagulant drugs interfere with clotting and are used to prevent and
treat thrombosis. Anticoagulation is essential during haemodialysis to
prevent clotting of the dialyser and extracorporeal circuit (Nasstrom et
al.2005)

.
Pendahuluan
Pendahuluan
Pendahuluan

Blood clotting in the extracorporeal circuit

Pendahuluan

These surfaces exhibit a variable degree of

thrombogenicity and may initiate clotting of blood
Signs of clotting in
the extracorporeal circuit

 Causes of Clotting
 - Wrong and/or inadequate anticoagulation.
- Low blood flow rate
- Air in the extracorporeal circuit.
Signs of clotting in
the extracorporeal circuit

 Extremely dark blood.

 Shadows or black streaks in the dialyzer.
 Foaming with subsequent clot formation in
drip chambers and venous trap.
 Rapid filling of transducer monitors with
blood.
 (blood in the post dialyzer venous line
segment that is unable to continue into the
venous chamber but falls back into the line
segment).
 Presence of clots at the arterial-side
Measuring blood clotting
during dialysis
Clotting tests used to monitor heparin therapy.
Anticoagulation techniques
 Unfractionated heparin
 Routine heparin prescriptions:
 In one method, a heparin bolus is followed by a
constant heparin infusion.
 In the second, a heparin bolus is followed by repeated
bolus doses as necessary.
Heparin mode of action
 Binds itself to antithrombin (a natural
anticoagulant) heparin enhances its activity
by inactivating thrombin and clotting factors
Xa, IXa, XIa and XIIa
Routine heparin prescriptions
 Rx: Routine heparin, constant-infusion method.
 The initial heparin dose is best administered to
the patient via the venous access tubing and
flushed in with saline (rather than being infused
into the arterial blood line).
 Rx: Routine heparin, single-dose-only or repeated-
bolus method.
 Administer the initial bolus dose (e.g., 4,000
units).
 Then give an additional 1,000- to 2,000-unit
bolus dose if necessary.
Heparin Administration
Heparin administration
 Effect of body weight on the size of the
heparin dose.
 When to terminate the heparin infusion.
 Posttherapy needle puncture site bleeding.
Management of heparin –
induced thrombocytopenia (HIT)

 Type 1 HIT is characterised by a reduction in

platelet count occurring within 5 days after
initiation of heparin.
 It is transient on continuation of heparin and has
no clinical consequences
 Type II HIT a more severe complication of heparin
treatment that is antibody mediated. Despite
thrombocytopenia, thrombosis is the main risk to
the patient.
How to administer protamine sulphate in an emergency
Evaluation of clotting
during routine heparinization.
clotting of the extracorporeal system is
expected.
 clotting occurs it is useful to evaluate the
likely cause.
Technical or operator-induced
factors (resulting in clotting)
 Dialyzer Priming
Retained air in dialyzer (due to inadequate priming or poor
priming technique)
Lack of or inadequate priming of heparin infusion line
 Heparin Administration
Incorrect heparin pump setting for constant infusion
Incorrect loading dose
Delayed starting of heparin pump
Failure to release heparin line clamp
Insufficient time lapse after loading dose for systemic
heparinization to occur.
 Vascular Access
Inadequate blood flow due to needle/catheter positioning or
clotting
Excessive access recirculation due to needle/tourniquet
position
Bleeding complications of
routine heparinization

 High-risk patients with bleeding

gastrointestinal lesions.
 The tendency to bleed is potentiated by
uremia-associated defects in platelet function
and possibly by endothelial abnormalities.
Heparin-associated complications
 Tight heparin
 Tight heparinization schemes are recommended for patients who
are at slight risk for bleeding, when the risk of bleeding is
chronic and prolonged, and where use of heparin-free
dialysis has been unsuccessful due to frequent clotting.
 Rx: Tight heparin, constant-infusion method
 Obtain baseline clotting time (WBPTT or ACT).
 Initial bolus dose = 750 units.
 Recheck WBPTT or ACT after 3 minutes.
 Administer a supplemental bolus dose if needed to prolong WBPTT
or ACT to a value of baseline plus 40%.
 Start dialysis and heparin infusion at a rate of 600 units per hour.
 Monitor clotting times every 30 minutes.
 Adjust the heparin infusion rate to keep WBPTT or ACT at baseline
plus 40%.
 Continue heparin infusion until the end of the dialysis session
Heparin-associated complications
 complications of note are increase in blood
lipids, thrombocytopenia, and the potential for
hypoaldosteronism and exacerbation of
hyperkalemia, especially in patients with
substantial residual renal function
Heparin-associated complications

 Lipids.
 Heparin-associated thrombocytopenia.
 Pruritus.
 Anaphylactoid reactions.
 Hyperkalemia.
 Osteoporosis.
Heparin-free dialysis

 Heparin-free dialysis is the method of choice

in patients who are actively bleeding.
 moderate to high risk of bleeding.
 heparin is contraindicated (e.g., persons with
HIT).
The heparin-free prescription
 Rx: Heparin-free dialysis.
 Heparin rinse. (This step is optional. Avoid if
heparin-associated thrombocytopenia is present.)
Rinse extracorporeal circuit with saline containing
3,000 units .
 High blood flow rate. 400 ml/min.
Bicarbonate dialysis solution with low-concentration
citrate (Citrasate)
 Citric acid is used instead of acetic acid as the
acidifying agent.
 the acid and base concentrates are mixed.
Other anticoagulation techniques
 LMWH inhibits factor Xa, factor XIIa, and
kallikrein.
 is not widely used there because it is more
expensive.
Heparinoids (danaparoid and fondaparinux)
 The half-life is prolonged in renal failure, such
that monitoring is sometimes used to check
anti-Xa activity prior to the succeeding dialysis
session.
Regional (high-concentration) citrate
anticoagulation
 alternative to heparin-free dialysis is to
anticoagulate the blood in the
extracorporeal circuit by lowering its
ionized calcium concentration.
Kesimpulan
 UFH masih menjadi antikoagulan yang sering
digunakan.
 Evaluasi stratifikasi risiko perdarahan menjadi
hal penting dalam adjsting dosis UFH.
 Efek samping dari pemberian UFH seperti
perdarahan, HIT, anafilaksis.
 Alternative selain UFH seperti LWMH juga
dapat digunakan dalam hemodialisis.
 Secara umum penggunaan yang tepat serta
monitoring yang baik, penggunaan UFH
adalah relatif aman dan biaya yang tidak
mahal.