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Pharmacology II > Hemo Pharm Test 3 > Flashcards

Hemo Pharm Test 3 Flashcards

1
Q

Factor I

A

Fibrinogen ; Source Liver

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2
Q

Factor II

A

Prothrombin ; Liver

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3
Q

Factor III

A

Thromboplastin/Tissue Factor

Source: Platelet and Endothelium

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4
Q

Factor IV

A

Calcium

Source: Bone and GI

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5
Q

Factor V

A

Labile Factor aka Proccelerin

Source : Liver and Platelet

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6
Q

Factor VII

A

Proconvertin/ Serum Prothrombin Conversion Accelerator

Source: Liver and Platelet

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7
Q

Factor VIII

A

Anti-hemophillic Factor A

Source : endothelium

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8
Q

Factor IX

A

Christmas Factor

Source: Liver

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9
Q

Factor X

A

Stuart factor

Source; Liver

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10
Q

Factor XI

A

Plasma Thrombosplasmin Antecedent (PTA)

Source: Liver

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11
Q

Factor XII

A

Hageman Factor

Source: Liver

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12
Q

Factor XIII

A

Fibrin Stabilizing Factor

Source: Liver

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13
Q

Source Liver

A

Factors 1, 2, 7, 9 ,10, 11, 12, 13

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14
Q

Intrinsic Patheway

A

Factors : 9, 11, 12, (8)

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15
Q

Extrinsic Primarily Factor

A

7

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16
Q

Common Pathway

A

Primarily Factor 10 but also Factor 2 & 13

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17
Q

2 frequent test in peri -op other than blood

A

PT: Extrensic Pathway
APTT: Intrinsic Pathway

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18
Q

Initially for Critical Bleeding what do we use ?

A

Crystalloids, Colloids, PRBC

They do not improve coagulation because they have no coagulation factors

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19
Q

Severe Bleeding with require what treatment ?

A

1) FFP
2) PLT
3) Cryo
4) Factor concentrations : Fibrinogen and Prothrombin complex concentrates. PCC

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20
Q

What is the single minimal acceptable level of Hgb used to determine if we need PRBC

A

There is no single minimal acceptable level

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21
Q

Which is tolerated better ? Chronic or Acute

A

Chronic

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22
Q

In acute anemia, compensatory mechanism such as increased CO and improved oxygenation depends on

A

The patient’s cardiac reserve

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23
Q

What could limit compensation during acute anemia ?

A

Heart Failure and or Flow restrictions lesions.

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24
Q

Factors to consider for a transfusion

A

1) Intravascular Volume
2) Patient actively bleeding
3) Need to Improve O2 transport

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25
Q

ASA task force recommends for a blood transfusion of a young health patient

A

Hgb <6g/dL

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26
Q

Usually unecessary to transfuse with a PRBC when the Hbg is

A

> 10g/dL

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27
Q

When should the ASA task force parameters change ?

A

In the presence of 1) anticipated blood loss 2) active critical Ischemia 3) Target organ Ischemia

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28
Q

What are 5 factors that should be considered to determine the need for transfusion of Hbg 6 to Hbg 10 g/dL

A

1) Target Organ Ischemia
2) Potential and Actual bleeding including rate and magnitude
3) intravascular volume status
4) Risk factors for complication of inadequate Oxygen
5) Low cardiopulmonary reserve + high Oxygen consumption ( Low SaO2)

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29
Q

Transfusion parameters are absolute. True or False

A

False

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30
Q

Patient with inadequate myocardial oxygenation should be transfused. True or False

A

True

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31
Q

How long is PRBC stored?

A

1) For up to 42 days

For more than 14- 21 days stored PRBC may lead to adverse effects.

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32
Q

Storage Lesions is defines as

A

Changes in older PRBC

1) Depletion of ATP and 2,3,DPG
2) Membrane phospholipid vesiculation, blistering and shedding
3) Protein Oxidation and Lipid peroxidation of cell membrane
4) shape changes, increase in fragility, = impaired microcirculatory flow
5) Increased red cell endothelial cell interaction, bioactive lipids, may initiate inflamotory TRALI

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33
Q

TRALI aka Transfusion Related Acute Lung Injury

A

Any Acute Lung Injury that occurs minutes to 6 hours of transfusion of ANY blood products
***Rule out other ALI issues L Sepsis, Pneumonia, Aspiration
TRALI is under diagnosed

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34
Q

TRALI treatment

A

Supportive

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35
Q

If TRALI is suspected

A
  1. Stop the infusion
  2. Obtain WBC and CXR
  3. Quanrantine blood from the donor from other bloods
  4. Request other units to be given if needed
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36
Q

TRALI has ——-incidence with plasma from ______ who have not been ______

A

Decreased; male or female ; who have not need pregnant

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37
Q

What characterized TRALI

A

1) Onset : Minutes to 6 hours
2) Hypoxia w/o HF
3) Bil Pumonary Infiltrates

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38
Q

How to replace Coag during Massive Transfusion

A

Plasma/ FFP

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39
Q

Plasma FFP

A

1) used for Warfarin reversal
2) used for coagulation in massive transfusion
3) FFP is Frozen within 8 hours - cryo from that
4) FFP24 in US : within 24 hours- cannot collect Cryo from that
5) to treat and prevent further bleeding

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40
Q

FFP is

A

Plasma that remains that after RBC and platelets are removed

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41
Q

FFP contains

A

Blood Coagulation
Fibrinogen
Plasma proteins

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42
Q

What is volume of FFP. Can be stored up to

A

170- 250 ml

Stored up to 1 year

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43
Q

Most Plasma given in the Peri Op is actually

A

FP24

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44
Q

FFP should be administered

A

With a 170 micronfilter

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45
Q

After thawed can be transfused within ____Hrs; once relabeled thawed plasma can be stored for another ______

A

24 hrs; 4 days

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46
Q

Thawed Plasma maintains normal levels of all factors except?

A

Factor V: Labile/Proccerelin: falls to 80% of normal

Factor VIII : Antihemophilia A: falls to 60% of normal during storage

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47
Q

TXA complications

A

Seizure by blocking GABA in frontal cortex

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48
Q

In the USA TXA PO is used for

A

Heavy menstrual bleeding

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49
Q

Dose of TXA

A

Initial :1gm/10minutes then and 1gm q 8hrs

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50
Q

TXA inhibits ____at higher doses

A

Plasmin

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51
Q

TXA inhibits

A

Plasminogen

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52
Q

EACA, AProtinin and TXA are effective at reducing the need for

A

RBC Transfusion

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53
Q

Protamine is a

A

Polypeptide containing 70% arginine residues and only available reversal fir UFH

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54
Q

Excess protamine can contribute to coagulopathy . True or False

A

True

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55
Q

Protamine . How does it work?

A

Inhibits platelets and serine proteases

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56
Q

Lowest ACT values produced when given

A

Exact amount needed to reverse circulation heparin

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57
Q

Heparin rebound can occur after

A

Initial reversal, and is observed within 2 to 3 hours when pt in the ICU

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58
Q

Initial dose of protamine causes what to ACT

A

Large drop in ACT time

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59
Q

A repeat dose may well be less than the

A

50 mg commonly administered

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60
Q

Most pats may not need additional protamine doses within

A

30 minutes of initial administration

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61
Q

Protamine adverse reaction

A

Anaphylaxis
RVF
Hypotension
Pulmonary vasoconstriction = Pumonary HTN

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62
Q

Patients at an increased risk for adverse reaction are sensistized how

A

Neutral protamine in NPH -

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63
Q

Other protamine risk patients

A

Vasectomy
Multiple Drugs allergies
Protamine exposure

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64
Q

Desmopressin

A

Is a V2 analog arginine vasopressin that stimulates release of vWf multimers from endothelial cell , specific surgical patient that might benefit from DDAVP is not clear

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65
Q

Heparin Induced Thrombocytopenia . What happens

A

Decreased platelet caused by heparin
Hyper-coagulation
Antibodies against heparin in the form of IgG

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66
Q

Heparin and Antithrombin relationship

A

Antithrombin inactivates factors
Heparin makes Antithrombin on steroids and makes it work really well.
This will inactivate Factor II and X= block coagulation of common pathway

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67
Q

LMWH is a

A 
Short chained Polysaccharide 
Doesn’t need PTT
Decreased risk of HIT 
Lasts longer and works better because of increased half-time 
Does bing to plasma protein as much -
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68
Q

Unfractioned Heparin contains

A

Long, medium, small chain polysaccharides
Need to monitor PTT
Can be blocked with protamine sulfate

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69
Q

Hemophilia A

A

Factor VII deficiency
Factor can’t activate = fibrin polymer meshwork does not form *
* Normal BT and Normal platelet level
BUT increased PTT ( PTT measures Intrinsic pathway )

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70
Q

Treatment for Hemophilia A

A

Give Factor VIII

71
Q

Hemophilia B

A

Factor IX deficiency

Christmas tree disease

72
Q

Protein C inactivates

A

Factor Va and VIIIa

73
Q

Coumadin binds to

A

Vitamin K

Protein S makes Protein C and requires Vitamin K to work

74
Q

Vitamin K deficiency lab

A

Increase PT Extrensic pathway
Protein S makes protein C
Coumadin binds to Vitamin K

75
Q

PT PTT does not measure factor

A

13

76
Q

Intrinsic Factor : PTT

A

12 11 9 and 8

12 inactive converted to 12 a by Kallikrein

77
Q

Factor X is the ist factor in the

A

Common pathway

78
Q

Extrinsic Factor is

A

Factor XII , and is measured buy PT

7 to 7a buy Factor III aka tissue factor as a result of Trauma *

79
Q

Common pathway way is

A

Factor X , II, XIII
10a acts as a protease and converts factor 2(prothrombin ) to 2a ( Thrombin )
8 converted to 8a to form a fibrin polymer meshwork

80
Q

Fibrin Clot is broken down by

A

Fibrinolytics - Plasminogen to Plasmin is the ultimate breakdown of fibrinogen to fibrin clot

81
Q

DIC labs

A

Platelets and Fibrinogen = low

PT PTT D-Dimer = high

82
Q

Dose of DDAVP

A

0.3mg/kg over 15-20 minutes to avoid hypotension

Hypotension because it releases other vasoactive drugs in addition to vWF

83
Q

DDVAP treats which type of vWF

A 
Type 1 ( mild form)
and maybe 2 a as well
84
Q

DDAVP is not effective in which type

A

Type 3 and serve type 1 and 2

85
Q

Fibrinogen is synthesized in the___; substrate of 3 enzymes

A

Liver; TFP Thrombin (2a) , XIIa and Plasmin

86
Q

1/2 life of Fibrinogen

A

3.7 days = 4 days

87
Q

Cross linking of fibrin polymers induced by

A

Factor XIIIa is fundamental to the coagulation increasing elasticity of the clot and its resistance to fibrinolyis

88
Q

Fibrinogen also acts as the binding site for

A

Glycoproteins IIb/IIIa found on platelet surface which are responsible for platelet aggregation

89
Q

Fibrinogen forms fibrin monomers which are_____ to form a

A

Polymerized ; loose

90
Q

Platelet enmeshed

A

Withing the fibrin strands, stabilizing the growing clot

91
Q

Fibrinogen supplementation is key in Massive hemorrhage to restore

A

Plasma fibrinogen = normalizing clotting factor
Fibrinogen is under recognized coagulation factor critical for producing effective clot
Treating fibrinogen deficiency is critical for survival and has positive correlation ***

92
Q

Fibrinogen increases _____ in pregnancy

A

> 400mg/dL
Bleeding increased for each 100 mg drop
Consider transfusion BEFORE it fibrinogen level drops below 100…may not be fixed my FFP

93
Q

For adequate replacement of Fibrinogen give

A

Cryo or Fibrinogen concentrate not FFP

Cryo 1 unit/ 10 kg = increased Fibrinogen 50-70 mg/dL

94
Q

RFVIIa approved for

A

Hemophilia but off label for massive hemorrhage

95
Q

Important Final step in clot formation in

A

Factor XIII

96
Q

Prothrombin Platelets Concentrates

A

10 9 7 2
2 PCC for Vitamin K antagonist -induced Warfarin reversal are :
Kcentra
Octaplex

97
Q

3 other PCC approved in US for the use of hemophilia and contain mainly Factor 9*

A

FPB-9 VH or SD
FEIBA VH
ProfilnineSD
Bebulin VH

98
Q

In US warfarin reversal typically with

A

FFP

99
Q

Other countries reverse warfarin with

A

PCC
Guidelines recommende PCC in warfarin reversal when
1) life threatening bleeding
2) Increased INR when urgent reversal is required

100
Q

Gelfoam

A

Purified Pork skin gelatin
Increase contact activation
Help create topical clot

101
Q

Surgicel or Oxycel

A

Oxidized regenerated cellulose

Work like Gelfoam

102
Q

Gelatin Foam should be used near

A

1) near Nerves

2) in confined spaces

103
Q

UF heparin extracted from

A 
Porcine intestines ( majority ) or from 
Cow’s lungs where heparin is stored on mast cells
104
Q

Heparin anticogulant effects are produced by binding to

A

Antithrombin (AT)
AT is a circulation serine protease
Heparin binds to Antithrombin enhancing the rate of Thrombin- AT complex formation by 1,000 to 10,000 times

105
Q

What is inhibited by AT

A

10a , 9, 11, 12

106
Q

When swelling and expansion are not a concern what topical hemostatic used ?

A

Coseal

107
Q

Heparin potency is based on

A

in Vitro comparison with a known standard

108
Q

A unit of heparin is defined as

A

The volume of heparin containing solution that will prevent 1 ml of citrates sheep blood from clotting for 1 hour after the addition of 0.2 ml of 1:100 calcium chloride .

109
Q

Heparin 1 ml with 0.2 ml Ca chloride 1:100 will not clot in citrated sheep blood for

A

1 hour

110
Q

Heparin must contain

A

120 United States pharmacopeia USP per millimiter 120 units/ml

111
Q

uses for Heparin

A

Prevention and tx

1) DVT
2) PE
3) ACS
4) peri op anti coag for ECMO -bypass

112
Q

IV heparin onset

A

Immediate

SuQ is 1-2 hrs

113
Q

Labs on Heparin

A

APTT ( 30-35) 1 to 1.5 times

Therapeutic APTT : 45 sec to 87.5 seconds

114
Q

What is prolonged APTT

A

Greater and 120 seconds

Can be shortened by omitting the dose bc heparin has short 1/2 time

115
Q

Low dose heparin can be monitored using anti Xa -assay

A

True

116
Q

Activated CLotting time

A

Used for high heparin concentration

By Mixing whole blood with an activated substance with large surface such as Celite or Kaolin .

117
Q

Which ACT to use for AProtinin therapy

A

Kaolin ACT bc Kaolin binds to Aprotinin to minimize its effects .

118
Q

Most coagulation factors circulate in the body as inactive enzymatic precursors called

A

Zymogens

119
Q

What is the function of GP Ib

A

Receptor for vWF

120
Q

What is the function of GPIIb/IIIa

A

Receptor for fibrinogen that links platelet

121
Q

What is the function of fibrinogen (Factor I)

A

Acts like a bridge between platelet to platelet to GPIIb/IIIa

122
Q

ACT is reliable for

A

High heparin concentrations > 1 unit/ml

123
Q

Activator speeds up the clotting time of ACT to normal values of

A

100 - 150 seconds

1.5 to 2.5 minutes depending on the device

124
Q

ACT is based on detecting

A

The onset of clot formation

125
Q

Target ACT in CABG is

A

350 to 400 seconds

126
Q

ACT values are misleading in CABG because

A

1) Hypothermia

2) Dilution effects

127
Q

HIT develops

A

4-5 days of heparin therapy . Can begin within hours , caused by heparin defendant antibodies to platelet .

128
Q

If an immediate reaction to heparin is noted :

A

HIT should be suspected

129
Q

Reversal of HIT

A 
Protamine :
Strong alkaline 
Polycationic 
Low molecular weight protein 
In Salmon Sperm
130
Q

Protamine is

A

Positively charged alkaline combines with negatively charged acidic heparin tip form a stable complex that is devoid of anticoagulant activity

131
Q

Protamine heparin complex is removed by

A

Reticuloendilthelial system within 20 minutes

132
Q

Protamine Dose

A

1 mg for every 100 units of circulating heparin .

Protamine does not neutralize LMWH

133
Q

Heparin 1/2 time is

A 
1 hour. 
Protamine dosing 1 hour after heparin 10,000 given 
5,000 left after 1 hour
Protamine 1 mg for 100 units
500/100= 50 mg protamine
134
Q

2 LMW heparin

A

Enoxaparin and Dalteparin
By depolymerization of heparin
They bind less to protein than heparin does
Anti Xa 4:1 Anti IIa 2:1

135
Q

Prevention of Thromboembolism in high risk medical and surgical pts . Better treated with ?

A

Better treated with LWH than heparin

136
Q

Disadvantage of LWH

A

Prolonged in Renal failure

137
Q

Kidney Failure , which do you use?

A

UFH

138
Q

Surgery delayed _____after last dose of LWH if normal function
And delayed_______if renal dysfunction

A

12 hrs

>12 hrs

139
Q

Fondaparinux - Arixtra inhibits

A

Xa- Stuart factor
Synthetic anticoagulant LMWH
Used for HIT

140
Q

Fondaparinux - Arixtra dose

A 
Once daily *
15 hours 1/2 life *
Hold 2 days prior to surgery 
Given to HIT positive 
No metabolism
Do not use in renal failure patient*
141
Q

Should not be used in patients with renal pts

A

Fondaparinux
LWH
Danaparoid

142
Q

Danaparoid -Orgaran

A

From porcine intestinal mucosa
LMW heparinoid
Binds to AT and attenuates Fibrin formation
Elimination primarily in the kidneys

143
Q

Surgery increases VTE risk by

A

20 fold

144
Q

DVT incidence is ______% in general surgery patients

A

10- 40 %

145
Q

DVT risk is higher than 10 -20% in

A 
High risk surgery patients :
Ortho
Thoracic
Cardiac 
Vascular
146
Q

In renal failure patients Only _____and _____ are minimally affected because of non renal clearance

A

Heparin and Warfarin

147
Q

Which greater DVT risk HIP vs General

A

Hip > general

Surgical technique for hip surgery kinks the femoral vein

148
Q

Which is more likely to develop in either leg

A

Calf vein thrombosis.

149
Q

PE occurs in _____ %of pts with major trauma

A

2- 22%

150
Q

3rd MCC death in patients who survive the first 24 hours of trauma

A

Pulmonary Embolism

151
Q

Bivalirudin . Renal dose adjustment . 1/2 time / stop when/ who?

A

20 % dose adjustment for renal impairment
1/2 time is 25 minutes
STOP 4-6 Hrs before surgery **
For unstable angina undergoing PCTA ,
Heparin replacement for HIT + cardiac surgery on or off pump **

152
Q

Bivilirudin 1/2 time

A

25 minutes

153
Q

Bilvilirudin

A

For HIT and Cardiac Sx on or off pump

154
Q

Argatroban . SYnthetic

A

Stop 4-6 hours before surgery
For prophylaxis or treatment of thrombosis in pt with high risk for HIT
No need to adjust dose in renal impairment
Elimination by liver

155
Q

Lepirudin

A

Irreversibly inhibit thrombin
Stop 24 hrs before surgery
From leeches
Use in HIT

156
Q

Reopro Abciximab

A

Stop 72 hours pre op

12-24 hrs 1/2 time

157
Q

ASA

A

Stop 7 - 10 days before surgery

158
Q

Pradaxa

A

First 2 hours after catheter is removed

159
Q

Xarelto epidural Catheter

A

Wait 18 hours after last xarelto dose to remove it

Once catheter removed wait 6 hours to give Xarelto again

160
Q

Warfarin

A

Predictable Onset and Duration . But delayed onset

161
Q

Warfarin dose

A

starts at 5 - 10 mg average maintenance is 5 mg

162
Q

Warfarin delay of onset of anticoagulant

A

Oral or IV delayed 8 - 12 hrs

163
Q

Warfarin pharmacokinetics

A

97% bound to albumin , long elimination time 24-36 hrs
Very little Renal excretion
Crosses the placenta with exaggerated effects in fetus

164
Q

Oral anticoagulant before elective surgery

A

Major surgery : stop 1-3 days pre op to give prothrombin time to return to within 20% of normal range
Restart post op 1- 7 days

165
Q

Direct factor Xa inhibitor - Xarelto and Eliquis

A

Wait 18 hrs after xarelto to remove it

166
Q

Direct thrombin inhibitor - Pradaxa

A

First dose 2 hours after catheter is removed.

167
Q

Desirudin - SubQ administration for Hip and Knee prevent DVT

A

Close monitor with APTT

Plavix, Prasugrel ( Effient) argatroban .are prodrug

168
Q

Oral anticoagulants are derivatives of

A

4- hydroxycoumarin (Coumadin )

169
Q

Volume of FFP

A

170 - 250 ml

Stored up to 1 year

170
Q

Thawed Plasma maintains factor V and III

A

Factor V falls to 80% normal

Factor VII. Falls to 60% normal

Thawed can be stored for additional 4 days

171
Q

Cryo

A 
Fibrinogen 
Factor VIII
Factor XIII
VWF
Formed form FFP thaw at 1 C to 10C
172
Q

Apherisis

A

Sufficient Number from a single donor

173
Q

Significant risk of infection with platelet bc

A

Stored at 22C instead of 4C

174
Q

Platelet is only crossmatched to

A

RBC antigen

Pharmacology II (7 decks)

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