Hematology - Anesthesia Review Flashcards by Brent Long

The extrinsic pathway is initiated by the release of a group of proteins known as _________when tissues are damaged?

Tissue Factor when tissues are damaged.

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Tissue Factor forms a complex with and

Factor VII, and in an enzymatic reaction requiring calcium, catalyzes the activation of Factor X.

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Proaccelerin is the other name for factor

Factor V

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Exposure of the blood to collagen can initiate the

intrinsic pathway.

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Fibrinogen is another name for

factor I.

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Sickle cell and hematocrit

Sickle cell and hematocrit results in the destruction of red blood cells which lowers the hematocrit

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Labs that are elevated in acute DIC

PT
PTT
Thromboplastin time
D-dimer
Fibrin degradation products

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The circulating levels of what components will be increased by DDAVP administration in a patient with von Willebrand disease? 2 answers

Von Willebrand disease

Factor VIII

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Medications that are considered safe for use in patients with porphyria.

Nitrous oxide, neostigmine, morphine, fentanyl, succinylcholine, pancuronium, and propofo

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Medications that are NOT considered safe and should all be avoided for patients with Porphyria?

Ketorolac
thiopental
thiamylal
etomidate, pentazocine, methohexital, and nifedipine s

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Factor X deficiency is _______deficiency

Stuart-Prower

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Aspirin and other NSAIDs on platelet

acetylate and inactivate platelet cyclooxygenase.

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Aspirin inactivates cyclooxygenase for

the life of the platelet

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Unlike ASA, NSAIDs inactivate them how and how long does it last?

Reversibly, and the effect lasts only about 24 hours.

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In the extrinsic coagulation pathway, disruption of the endothelium leads to exposure of tissue factor which binds to

factor VII

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Tissue Factor forms a complex with Factor VII, and in an enzymatic reaction requiring

calcium, catalyzes the activation of Factor X.

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Porphyria is a disorder of

Heme

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Why are Heme pigments essential?

are essential elements in the construction of hemoglobin, myoglobin, and the cytochrome

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Many pharmacologic agents (especially those that induce the cytochrome p450 system) can precipitate a porphyric crisis such as

BarbSulfaPhenyEtha
Barbiturates
Sulfonylureas
Sulfonamides
Estrogens, phenytoin, tolbutamide, and ethanol.

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The underlying cause of organ failure due to disseminated intravascular coagulation is

organ ischemia due to thrombosis

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What is the second most common cause of hospitalization in sickle cell patients and accounts for 25% of all sickle cell related deaths.

Acute chest syndrome

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How is acute chest syndrome diagnosed?

It is diagnosed by the development of new infiltrates on chest film and may be caused by atelectasis, pulmonary microembolic episodes, or pulmonary infection.

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Acute chest syndrome is a potential complication of sickle cell disease. When it develops, it is typically ___days following surgery and

2-3

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Treatment of acute chest syndrome

Aggressive hydration
oxygenation, transfusions to treat anemia
antibiotics to treat pulmonary infection, and occasionally nitric oxide may be used to treat pulmonary hypertension.

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Which form of hemoglobin is most commonly found in the normal, adult bloodstream?

hemoglobin A

Hemoglobin C is implicated in a type of

hemolytic anemia,

2 agents would be appropriate to administer in the treatment of a patient with von Willebrand disease?

Cryoprecipitate AND Desmopressin

What is the dose of desmopressin?

0.3mcg/kg

Desmopressin given for mild to moderate hemophilia will increase what factors

increase plasma levels of factor VIII and vWF

Cryoprecipitate vs FFP which one is preferred for hemophilia A?

Cryoprecipitate preferred because it is hard to increase the factors level with FFP alone.

3 treatments for hemophiliac patients : Other than desmopressin

Cryoprecipitate Tranexamic acid Epsilon aminocaproic acid.

Synthetic Arginine analog of Vasopressin

Desmopressin

Cryoprecipitate is made how?

Collected off the top of FFPs at it being thawed

In the intrinsic pathway, what is the component required to convert factor XII to factor XI?

Prekallikrein

Romponents like High Molecular Weight Kininogen required to activate

Factor XI.

Commonly given medication to avoid porphyria crisis

Ketorolac

Both hemophilia A and hemophilia B exhibit a

prolonged PTT and a normal PT.

The primary function of von Willebrand factor is

To promote platelet aggregation and adhesion to collagen

Potential side effect of DDAVP administration in the treatment of von Willebrand disease?

HoTN

What treatment regimens are effective in ameliorating the symptoms of von Willebrand disease? (select two)

Desmopressin and concentrated von Willebrand Factor are both effective in treating the symptoms of von Willebrand disease.

Factor IX-PCC is used in the treatment of

Hemophilia B

Major surgery --> how to replace vWF

achieve 100% vWF preoperatively and maintain trough levels of 50% until adequate wound healin

In treating type 1 vWD which agent is preferred?

Desmopressin because it produces a complete partial response in more than 90% of patients

In treating type 2 and type 3 vWD which agent is preferred?

Type 2 and type 3 require vWF concentrate administration.

Heparin-Induced Thrombocytopenia (HIT) Type I and Type II

type I non immune mediated, onset 1-4 days | type II immune mediated (immunoglobulin G) 5-14 days

Blood component therapy for HIT | 1. Indications: active bleeding or high risk for bleeding

1. Fresh frozen plasma 2. Platelets 3. In some cases, consider cryoprecipitate, antithrombin III

Most events of acute stent thrombosis occur within the

first 30 days after stent placement

Absolute contraindication to neuraxia

Thrombolytics

When is there no contraindication for heparin SC dosing for neuraxial.

No contraindication with twice-daily dosing and total daily dose < 10,000 units

Upper endoscopy and colonoscopy with or without biopsy --> Warfarin stop?

NO NEED for interruption in therapy

• Endoscopic retrograde cholangiopancreatography (ERCP) without sphincterotomy Warfarin stop ?

NO NEED for interruption in therapy

Do not need to stop warfarin for these procedures?

Prosthetics | Cataracts

Elective noncardiac surgery should be delayed______after bare metal stent and _______after DES

30 days after bare metal stent (BMS) implantation and optimally 6 months after drug eluting stent (DES) implantation

Discontinue ticlopidine _____days prior to neuraxial

14 days

Discontinue clopidogrel ____Days prior to neuraxial

7 days

Discontinue GP IIB/IIIa inhibitors _______prior to neuraxial.

8–48 hours in advance

A powerful vasodilator, also interferes with platelet formation and aggregation is ______

prostacyclin

Anatomy of a platelet

Platelets contain alpha (α) granules that store proteins (e.g., vWF, fibrinogen, fibronectin, platelet factor 4, and platelet growth factor) and dense granules that store nonproteins (e.g., serotonin, ADP, adenosine triphosphate [ATP], histamine, and epinephrine).

Converts to plasmin

Plasminogen

3 Vasoconstrictors of vessesl

Thromboxane A2 ADP Serotonin

3 Vasodilators of vessels

Nitric oxide | Prostacyclin

Vessel Injury contracts after injury leading to

a tamponade, decreasing blood flow. This contraction is a result of autonomic nervous system reflexes and the expression of thromboxane- A2 and ADP. The area adjacent to the injury vasodilates and distributes blood to the surrounding organs and tissues

After injury to the vessel , contraction leads to what

Contraction is followed by three separate stages in the formation of a primary plug: adhesion, activation, and aggregation.

Factor not produced by the liver

III

Substance synthesized vascular wall and extravascular cell membranes; released from traumatized cells

vonWillebrand

Bleeding time Normal

3-7 minutes

Normal ACT

80-150

Normal PT

12-14 sec

Normal PTT`

25-33

Extrinsic (Warfarin vs Heparin)

Heparin

Intrinsic (Warfarin vs Heparin)

Warfarin

A normal platelet count is

150,000 to 300,000/mm3.2

Adhesion is associated with

Vonwillebrand

Activiation and aggregation associated with

ADP and thromboxane A2

When are PRBCs transfused? are

transfused to improve tissue oxygenation

The major reasons for transfusion therapy in the operating room are to

replace volume and coagulation factors and improve oxygen-carrying capacity.

The recommended dose for platelet replacement is

one plateletpheresis pack per each 10 kg of patient weight

Protamine sulfate dosing

1 mg neutralizes 100 units of heparin

1 unit of platelet is ______ml

250 mL

1 unit of plate increases the platelet count by

30,000–60,000/mm3

FFP unit = _____ml

200-250 ml

Hypofibrinogenemia, massive hemorrhage --> what is used

Cryoprecipitate.

Hemophilia, massive hemorrhage

Factor VII

1 unit single- donor apheresis platelets comes from how many platelet concentrates?

Four to five platelet concentrates,

Laboratory analysis will reveal the need for FFP by a

PT and aPTT prolonged more than 1.5 times normal.

Cryoprecipitate is then refrozen and thawed on use. It is rich in.

fibrinogen Factors VIII Factor XIII Fibronectin

The recommended dose of factor VII for hemophilia is

90 to 120 mcg/kg

Cryoprecipitate Infusion Guidelines

1) When a test of fibrinogen activity indicates a fibrinolysis (2) When the fibrinogen concentration is less than 80 to 100 mg/dL IN THE PRESENCE OF EXTENSIVE BLEEDING (3) As an adjunct in massively transfused patients when fibrinogen concentrations cannot be measure in a timely fashion; (4) For patients with congenital fibrinogen deficiencies.

Transfusion of cryoprecipitate is rarely indi- cated if fibrinogen concentration is

greater than 150 mg/dL in non- pregnant patients.

A sickle cell crisis may be triggered by

hypoxemia, hypothermia, infection, dehydration, venous stasis, and acidosis.

P2Y12 ADP Receptor Inhibitors: name 3

ticlopidine, clopidogrel, prasugrel

Platelet Glycoprotein IIb/IIIa Receptor Blockers: Name 3

abciximab, tirofiban, eptifibatide

Heparin half life

1.5 hours

Warfarin half life

2-4 days

Abciximab half life

30 minutes

ASA half life

20 minutes

NSAIDs half life

2-10 hours

COX-1 receptor inhibition by is responsible for the gastric irritation,

NSAIDs

COX-1 receptor inhibition by NSAIDS is responsible for the

Gastric irritation | Decrease in renal blood flow, and platelet inhibition associated with nonselective NSAIDs.

The removal of multiple units of blood from the patient right before surgery and replacement of the removed blood volume with crystalloid is referred to as

Acute normovolemic hemodilution

Preoperative autologous donation is most effective when it is

combined with erythropoietin therapy

Which of the following are disadvantages to storing blood? (select two)

Adenosine triphosphate levels decrease in stored blood | . 2, 3 DPG levels decrease in stored blood

Which of the following are disadvantages to storing blood? (select two)

Adenosine triphosphate levels decrease in stored blood | 2, 3 DPG and ATP levels decrease in stored blood

The potassium present in the plasma in

packed red blood cells stored for 21 days can reach levels as high as 35 mEq/L.

COX-1 receptors in the body

distributed throughout the body

Which COX inhibition results in inhibition of thromboxane A2?

COX-1 receptor. By doing so, it disrupts thromboxane A2's ability to promote platelet aggregation.

COX-2 receptors are present in the

kidneys and central nervous system and can be synthesized in response to inflammatory processes.

What are the effects of COX-2 receptor inhibition?

reduce prostacyclin release from the vascular epithelium and can result in increased platelet aggregation.

The ability of coagulation factors to function correctly decreases

10 percent with every 1 degree Celsius drop in body temperature. Rapid transfusions of cold blood products can increase the likelihood of further bleeding.

Which infectious disease has the highest risk of transmission via blood transfusion?

CMV

Acute hemolytic transfusion reaction is an _____ mediated reaction.

IgM

Phosphodiesterase inhibitors increase the level of cyclic AMP which is an

inhibitor of platelet aggregation.

What sign is consistent with an acute hemolytic transfusion reaction?

Hematuria

Transfusion-Associated Cardiovascular Overload (TACO) refers to the development of

pulmonary edema due to blood product administration. It is not immune-related or due to an alteration in the permeability of pulmonary capillary membranes and is responsive to diuretics and reduction of afterload.

During preoperative assessment, a patient reveals a prolonged PT due to vitamin K deficiency. How long does it take for intravenous vitamin K to improve the PT?

6-8 hours

Vitamin K oral administration exhibits the highest bioavailability, it can take up to ___hours to see effects.

24 hours to exhibit significant clinical effects.