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Heme Flashcards

1
Q

What are the effects of sodium bicarbonate ?

A
  1. Increased preload
  2. Decreased left ventricular contractility
  3. Increased hemoglobin affinity for oxygen
  4. Intracranial hemorrhage with rapid administration
  5. Increased lactate production
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2
Q

How does sodium bicarbonate increase preload?

A

It is very hypertonic

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3
Q

How does it cause intracranial hemorrhage?

A

Through rapid administration due to volume expansion

Increased PaCO2 and subsequent cerebral vasodilation due to conversion of bicarbonate to PaCO2

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4
Q

How does bicarbonate cause decreased left ventricular contractility?

A

Decrease in serum ionized calcium

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5
Q

What is the Bohr effect?

A

Increased H or CO2 concentration reduces the oxygen affinity of hemoglobin

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6
Q

What is R time?

A

The time to the start of clot formation from initiation of the test
Normal = 1-3 minutes

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7
Q

What does R time reflect?

A

Heparinization

Factor deficiencies

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8
Q

What is the alpha angle or K time?

A

The time from clot initiation to clot thickness of at least 20 mm
RELIES ON FIBRINOGEN

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9
Q

What is MA?

A

Maximal clot thickness/strength as measured by platelet number and function
MEASURE OF PLATELET FUNCTION

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10
Q

What does the alpha angle, k time, and MA indicate?

A

Fibrin polymerization

Platelet function

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11
Q

What is LY30?

A

The ratio of clot thickness at 30 minutes post MA relative to MA

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12
Q

What does LY30 tell you?

A

The degree of fibrinolysis

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13
Q

What happens in altitude sickness?

A

The increase in minute ventilation causes a respiratory alkalosis from decreased PaCO2 and increased CSF bicarbonate. Over the next 48-96 hours the CSF normalizes it’s oh by decreasing bicarbonate production allowing the chemoreceptors to be more sensitive to high PaCO2.

The kidneys increase bicarbonate excretion over the week to restore normal blood ph

There is also an increase in 2,3DPG in response to respiratory alkalosis and thus a shift of the oxygen dissociation curve to the right.

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14
Q

Why and when do you start making more hemoglobin for oxygen transport at higher altitudes?

A

After a while the decrease in PaCO2 and PaO2 cause a left shift in the oxygen dissociation curve. Renal hypoxia triggers erythropoeitin secretion. This happens over 1-3 weeks

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15
Q

How can you diagnose CO poisoning?

A

Blood sample (stable levels for several days after exposure)
Co-oximetry
Exhaled CO
Carboxyhemoglobin levels over 5% in no smoker
Over 10-15% in smoker

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16
Q

What is the treatment of choice for methemoglobinemia in a patient with G6PD deficiency?

A

Vit C because it functions as an electron acceptor and aids in reduction of Fe 3+ to Fe 2+

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17
Q

What does methylene blue do in G6PD patient?

A

It causes hemolysis

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18
Q

Why does the pulse ox read 85% in methemoglobinemia?

A

Because methemoglobin has an absorbance of 630 nm

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19
Q

What is used to treat cyanide toxicity?

A

Amyl nitrite

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20
Q

How does indigo carmine affect pulse oximetry?

A

Causes a decrease in the oximetry due to absorption at 600 mm

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21
Q

What medications does methylene blue interact with?

A

MAOi because it is a potent MAOi. Careful for serotonin syndrome

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22
Q

What electrolyte abnormality occurs in hyperventilation?

A

Hypocalcemia because hydrogen unbinds albumin and calcium then can bind albumin

Hypokalemia due to hydrogen being pumped out of cell and K pumped in

Hypophosphatemia due to increased glycolysis with increased Ph

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23
Q

Which coagulation factors does PT measure?

A

Factors I, II, V, VII, IX, X

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24
Q

Where is factor 13 made and what does it do?

A

Stabilizes fibrin

Made by megakaryocytes, macrophages, platelets and liver

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25
What is factor I?
Fibrinogen
26
what is factor II?
Prothrombin
27
What are the 4Ts?
Thrombin, Timing of platelet decrease (5-11 days after heparin), oTher things have been ruled out, TCP
28
What is involved in a type and cross?
Mixing patient red cells with antibodies A, B, AB to determine ABO status, mix patient red cell with anti-D to determine RH status, mix patient serum with donor red cells, mix patient serum with red cells with known antigens on the surface.
29
What does Factor V do?
Increases thrombin levels
30
What does factor II do?
Converts fibrinogen to fibrin to strengthen a clot
31
What is Factor V Leiden deficiency?
A mutation in the factor V gene that makes it resistant to inactivation by protein C
32
When should a patient with Factor V leiden deficiency have lifetime anticoagulation?
1. 2 or more spontaneous thromboses 2. Life-threatening thromboses 3. Has another prothrombotic disorder 4. Gets clot in an unexpected place (cerebral, mesenteric)
33
What is the initial treatment for a first time clot with a normal patient?
3-6 months anticoagulation
34
What is leukoreduction?
The process of depleting donor blood products of leukocytes
35
What are the advantages of leukoreduction?
Reduced CMV transmission Reduced febrile reactions Reduced alloimmunization Reduced proinflammatory mediators in the storage Reduced LOS, mortality, transfusion-related tumor occurrences
36
What are the risk factors of heparin resistance?
Platelet count > 300K Previous use of heparin or LMWH Antithrombin III levels < 60% Age over 65
37
What is heparin resistance?
ACT <480 after giving 500 U/kg of heparin | ACT < 400 s with heparin anytime during CPB
38
How much citrate is in 1 unit of blood?
3 g
39
Where is citrate metabolized?
The liver converts it to bicarbonate
40
When does hypocalcemia begin to happen?
When infusion of blood exceeds 1 unit per 10 minutes
41
What does a decrease in MA mean?
Platelet dysfunction
42
What is a normal MA?
50-60 mm
43
How does a TEG work?
A sample of citrated blood is injected into a sample cup with a stationary pin attached to a torsion wire. The cup oscillates at a set rate When fibrin and platelets form, they cause connection of the inner wall of the cup to the pin, causing the pin to oscillate within the phase of the clot. The pin is attache d to a transducer to an electrical signal
44
What are the effects of garlic?
Potentiates the action of warfarin Inhibits platelet aggregation Used in HTN and HLD
45
What are the effects of St. John's Wort?
Antibacterial Antioxidant Potent inhibitor of CYP3A4 - may potentiates NMB because blocks this metabolism ****does not effect bleeding***
46
What are the effects of ginkgo?
Potent antagonist of platelet activating factor
47
What is ginkgo used for?
Dementia PVD CAD Reynaud's
48
What are the effects of ginger?
Inhibition of platelet function in high doses Antispasmodic Antinausea
49
What are the effects of vitamin E?
Inhibits platelet aggregation Enhances wound healing Decreases thromboembolic events, synergistic with warfarin because blocks epoxide reductase at high levels Antioxidant
50
Why might patients with cystic fibrosis have prolonged prothrombin time?
Due to inability to absorb fat soluble vitamins (K, E)
51
How does warfarin work?
It inhibits gamma-glutamyl carboxylase which is the enzyme that allows the carboxylation of vitamin K dependent clotting factors and protein C and S
52
What is type I vWD?
Quantitative defect: decreased vWF production, shortened VIII half life
53
what is the treatment for type I vWD?
1st line: Desmopressin | 2nd line: Factor VIII-vWF
54
What is vWF 2A?
Qualitative defect: decreased ability of vWF to bind to platelet glycoprotein-1 Unable to bind and form multimers
55
What is vWF 2B?
Enhanced bind of vWF to platelets and formation of multimers --> rapid clearance, potential for TCP
56
What is the treatment for vWD 2A/B?
Factor VIII-vWF concentrate
57
What is vWF 2M?
Decreased ability for vWF to bind to platelet glycoprotein1
58
What is the treatment for vWF 2M/2N?
1st line: Factor VIII-vWF concentrate | 2nd: Desmopressin
59
What is vWF 2N?
Decreased ability to bind factor VIII, may be mistaken for hemophilia A
60
What is vWF 3?
Complete absence of vWF with resultant severe factor VIII deficiency
61
What is the treatment for vWF 3?
Factor VIII-vWF concentrate | Recombinant factor VIII
62
What is platelet-type vWF?
Platelet defect where glycoprotein 1b has higher affinity for binding vWF --> rapid clearance of multimers, TCP common
63
Why are morbidly obese patients at risk for DVT?
They have increased levels of fibrinogen, factor VII, and factor VIII, plasminogen activating factor
64
What is the test with the high specificity for HIT?
Serotonin assay
65
What is the test with the highest sensitivity?
detection of anti platelet factor 4 antibodies
66
What are the CV effects of acute normovolemic anemia?
Increased CO from increased SV due reduced blood viscosity and venoconstriction
67
What are the effects of chronic anemia?
Increased CO: Increased SV due to reduced blood viscosity and venoconstriction, increased HR and contractility due to increased catecholamines Increased oxygen offload to tissues (right shift) Decreased after load due to decreased blood viscosity
68
What are the most unstable factors in FFP?
Factor VIII and factor V
69
What is TRALI?
Noncardiogenic pulmonary edema occurring within 6 hours of transfusion due to donor leukocytes attacking recipient leukocytes in the pulmonary microcirculation
70
What is the most common source for TRALI?
FFP from multiparous women (alloimmunization)
71
What are the clinical features of TRALI?
Pa/Fi ratio between 200-300 mm Hg Sudden hypoxia Bilateral infiltrates on CXR No other source for pulmonary edema (normal cardiac filling pressures)
72
What are the contraindications to acute normovolemic hemodilution?
Pre-op anemia, cardiac disease, recent MI, recent CVA, renal or liver disease, active infection
73
What is the mechanism of action of a febrile transfusion reaction?
Donor leukocytes are attacking recipient leukocytes, the binding of these antibodies cause hemolysis and cytokine release (IL1 and TNF alpha) which increase the temperature set point in the hypothalamus to cause shivering and fever
74
What is the test for diagnosing hemolytic reactions?
Direct Coombs:
75
What is TRIM?
Transfusion related Immune modulation that occurs because of leukocyte mediators in product (more common in older product). Increases cancer occurrence and recurrence
76
How much fibrinogen is in 1 unit of cryo?
200 mg | So there is 2 grams in the 10 unit pack
77
How is cryo precipitate made?
Thawed FFP - high in factor VIII, factor XIII, vWF
78
What is an acute hemolytic reaction due to?
IgM antibody mediated complement activation from ABO incompatibility leading to massive hemolysis --> release of bradykinin and histamine --> flushing, bronchospasm, renal failure, DIC, death
79
How long can blood be stored at room temperature in the OR?
Up to 6 hours
80
What does metformin do?
Inhibits pyruvate dehydrogenase and other reducing factors forcing anaerobic metabolism and lactic acidosis.
81
How is metformin metabolized?
it is excreted unchanged in the urine 90%
82
What is the recommended dose of FFP for reversal of warfarin?
10-15 ml/kg for INR goal of 1.4-1.7
83
What are the contraindications to using FFP?
1. Sole use for plasma volume expander 2. To correct INR that can be corrected by vit K 3. To correct a factor deficiency when recombinant is available
84
What are the indications of FFP?
1. To correct INR > 1.8 in a massive bleeding situation 2. To correct dilution coagulopathy 3. Heparin resistance 4. TTP 5. HUS
85
What drug should be used in patients undergoing cardiac surgery who have a history of HIT?
Bivalirudin (direct thrombin inhibitor)
86
What is Type I HIT?
Platelet glycoprotein 1B release ADP causing platelet aggregation --> mild TCP, no thrombosis Occurs within 2-5 days of heparin administration
87
What is type II HIT?
IgA, IgM, IgG mediated against heparin-antiplatelet 4 complexes causing platelet activation and clot formation. TCP < 100K 5-9 days after heparin administration
88
What blood product is most likely to cause sepsis?
Platelets because stored at room temperature
89
What happens to a patient with IgA deficiency given a blood transfusion?
Anaphylaxis from making anti-IgA antibodies from a previous transfusion
90
Which vWD should you not give desmopressin to and why?
Type 2B because it may cause severe TCP
91
What is CPDA-1?
Citrate - binds calcium so it cannot be used in clot formation P - phosphate for ATP and cellular function D - energy for glycolysis A- adenosine for ATP production
92
Why is FFP a treatment for TTP?
It replaces the missing enzyme ADAMST13, which normally degrades vWF multimers.
93
What is a direct Coomb's test?
anti-Ig antibody is added to the patient's serum. If + : will see agglutination of RBCs
94
What does factor V do?
Acts with calcium and factor X to convert prothrombin (factor II) to thrombin
95
What does factor V do?
Binds factor X to activate factor II (prothrombin to thrombin)
96
What does factor VIII do?
Bind factor IX to activate factor X
97
What is the intrinsic pathway?
Tissue factor secreted by endothelium binds with VII to form VIIa which activates factor X
98
What is the contact activation pathway?
Starts due to factor 12--> 11 --> 9 a--> 9+8 --> 10!
99
What happens in fibrinolysis?
Plasminogen is converted to plasminogen via tissue plasminogen activator Plasminogen binds fibrin causing degradation
100
What amino acid blocks fibrinolysis?
Lysine by binding to site on plasminogen
101
What are the two main things seen in acute hemolytic reactions?
Renal failure and DIC
102
How does an acute hemolytic reaction cause renal failure?
The hemoglobin accumulated in the distal tubules causing blockage and failure
103
What is the treatment for acute hemolytic renal failure?
IV fluids and diuretics
104
What happens to ABGs when they are corrected to a colder temperature?
The PaO2 and PaCO2 decreases and the ph increases PaO2: 5 mmHg per degree Celsius PaCO2: 2 mmHg per degree Celsius pH: 0.17 per degree Celsius decreases
105
What happens to the solubility of a gas in colder temperatures?
It increases
106
What happens when LMWH is used?
There is an increased antiXa-IIa ratio due to thrombin binding
107
Why does LMWH have a longer half life than heparin?
It has smaller segments that are not as bound by macrophage so it is cleared Renally
108
Which ADP receptor inhibitor has the longest half life?
Ticlodipine
109
How far out should you stop Ticlodipine before surgery?
10-14 days
110
What is the duration of action of argagroban?
2-4 hours Stop 4-6 hours before surgery
111
At what level of SNP do you see cyanide toxicity?
Greater than 100 mg/dl (1 mg/kg in less than 2 hours)

Anesthesia MM/TL (36 decks)

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