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Perf tech 3 > Pharmacologic Response to CPB > Flashcards

Pharmacologic Response to CPB Flashcards

1
Q

When CPB is employed in cardiac surgery it may profoundly affect

A

the way drugs are distributed and cleared by the body and how drugs interact with the body to produce their effects.”

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2
Q

Pharmacokinetics

A

What the body does to the drug

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3
Q

Pharmacodynamics

A

How a drug interacts with the body to produce its effects

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4
Q

First order kinetics

A

elimination of a drug occurs at a constant fraction of drug remaining in the body per unit of time

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5
Q

Zero order kinetics:

A

when drug administration exceeds the body’s ability to clear it, leading to drug accumulation

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6
Q

To prevent drug accumulation,

A

drug infusion rates should be adjusted according to patient response.

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7
Q

Changes in Pharmacokinetics due to CPB

A

• Hemodilution • Hypothermia • Perfusion • Acid-BaseStatus • Sequestration

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8
Q

Hemodilution causes

A
  • Reductionincirculatingproteinconcentration
  • ReductioninRBCconcentration
  • Reduction in concentration of free drug (unless your pump prime matches exactly)
  • Alterations in organ blood flow, affecting distribution and clearance
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9
Q

What happens if you add drugs to your prime BEFORE RAP or AFTER RAP??

A

changes concentration takes some away

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10
Q

Hypothermia fluid shifts

A

romintravasculartointerstitialspace • Alteredvolumeofdistribution • Increased 3rd spacing

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11
Q

hypothermia vasoconstriction

A

Changes in organ perfusion

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12
Q

hypothermia and enzymes

A

Reductionsinenzyme-mediatedbiotransformation

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13
Q

hypothermia and solubility of volatile anesthetics

A

Increased solubility

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14
Q

altered hepatic flow by these drugs

A

(Fentanyl, propofol)

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15
Q

lungs excluded from circulation so give these drugs

A

(Valium,propofol,opioids)

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16
Q

Acid Base Status alters

A

organ blood flow • pH stat = ↑ cerebral blood flow

• Alteredionizationandproteinbinding

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17
Q

Drugs may be taken up by various components of the CPB circuit

A

Coated tubing
• Oxygenators
• Hemofilters • Many factors influence the movement of drug across the
membrane • Degree of protein binding is a major determinant

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18
Q

Administering medications ensure that

A

• you have a physician’s order or standing protocol
authorizing you to administer the medication
• the patient is not allergic to the medication
• you have the correct medication, the correct concentration and the correct dosage
• Inspect the medication for expiration date, precipitates, and sterility

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19
Q

What is in your drug box?

A

Heparin • Neo-Synephrine • NaHCO3 • Lidocaine • MgSO4 • Calcium • Potassium • Mannitol

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20
Q

Heparin Sodium derived from

A

bovine lung tissue or porcine mucosa standardized for anticoagulant activity

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21
Q

heparin sodium potency is determined by

A

biological assay using a USP reference standard based on units of heparin activity per milligram
• 100 units = 1 milligram • Example: 5,000 units = 50mg

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22
Q

heparin sodium action

A

Action: stops coagulation by potentiating antithrombin III and inhibiting the action of activated Factors IX and XI

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23
Q

Heparin Pharmacokinetics

A
  • Eliminated by kidneys • Half life at CPB doses is 2 or more hours
  • Prolonged by hypothermia and renal blood flow alterations
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24
Q

Heparin Side Effects

A

• Activation of t-PA and platelets • Boluses decrease SVR by 10 to 20% • Anaphylaxisrarelyoccurs • HITandHITT

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25
Q

HLD

A

300 to 450 units/kg . Rarely need to exceed 35,000 to 40,000 units

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26
Q

Heparin distributes

A

primarily in plasma, so increasing dose with

increasing body weight is only relevant to a certain point

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27
Q

Priming solution should contain heparin at approximately the same

A

concentration of the patient’s blood stream

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28
Q

ACT is prolonged by

A

hypothermia and hemodilution • Target ACT controversial (300 to 480 seconds)

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29
Q

Most vials you will see for adult CPB will be

A

1000 units/mL Loading dose: 30,000 units

30,000 units x 1mL = 30 mL 1000 units

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30
Q

neo action

A

syntheticselectiveα1-adranergicagonistthat causes vasoconstriction in arterioles

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31
Q

neo duration

A

less than 5 minutes

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32
Q

neo other things

A

Titratedtoeffect • Start with a test dose

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33
Q

Neo-Synephrine Dosing IV bolus

A

• 100 micrograms/mL • 200 micrograms/mL • 400micrograms/mL

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34
Q

Neo-Synephrine Dosing IV infusion

A

10 or 15 mg in 250 mL IV fluid (40 to 60 micrograms/mL)

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35
Q

Sodium Bicarbonate

A

Asterile,nonpyrogenic,hypertonicsolutionofsodium bicarbonate (NaHCO3) in water for injection for administration by the intravenous route as an electrolyte replenisher and system alkalizer
• Also used to treat hyperkalemia

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36
Q

NaHCO3 Dosing

A
  • Dose (mEq) = 0.3 x Weight (kg) x BD (mEq/L) *Or just “1 amp” (50 mEq)
  • Hyperkalemia: • Adults:50mEq • Peds: 1-2 mEq/kg
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37
Q

Lidocaine actions

A

reduces cell membrane permeability for sodium and potassium which increases the stimulation thresholds in ventricles

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38
Q

lidocaine site of action

A

cellmembrane

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39
Q

lidocaine DOA

A

15 to 30 minutes post bolus

40
Q

Lidocaine IV bolus

A

-2 mg/kg • Usually 100 to 200 mg bolus at XC removal

• Not to exceed 300 mg/hr

41
Q

Mag sulfate action

A

controlstransmembraneelectrolytesandenergy metabolism

• Cardiacarrhythmiasmayoccurduringhypomagnesemia

42
Q

Hypomagnesemia can occur during CPB due to

A

Poor pre op health • Albuminadministration • Citrated blood product administration

43
Q

MgSO4 Dosing bolus

A

2 to 2.5 g initial bolus

44
Q

MgSO4 infusion

A

1.75 g/h infusion

45
Q

mgso4 xc removal

A
  • On CPB, usually given as 2 to 4 grams at XC removal with Lidocaine
  • Often 0.5 g/mL concentration
46
Q

calcium chloride action

A

Involved in myocardial contractility, blood clotting, neurotransmission and muscle contraction
• May be used for mixing with thrombin for platelet gel
• Levels drop during CPB • May be necessary to replenish before coming off CPB • Especiallyifcitratedbloodproductsgiven

47
Q

CaCl2 Dosing

A

200 to 1000 mg slow IV

• Often 100 mg/mL concentration

48
Q

CaCl2 given

A

post XC removal and before termination of CPB if levels are low

49
Q

CaCl2 Hyperkalemia:

A

Adults:0.5-1gCaCl2 • Peds: 20 mg/kg Calcium Gluconate

50
Q

Potassium Chloride

A
  • The major intracellular ion • Necessary for normal cardiac contractions
  • Hyperkalemia more of an issue than hypokalemia • Cardioplegia
51
Q

KCL dosing cardioplegia

A

: 15-30 mmol/L of solution delivered into the heart

• ie. 4 to 1 cdpg requires 5 times the delivery strength in the cardioplegia bag

52
Q

KCL hypokalemia dose

A

Dose (mEq) = weight (kg) x 0.3 x K+ deficit

• GIVE IT SLOWLY especially if XC not on • Usually 2 mEq/mL concentration

53
Q

mannitol action

A

osmoticdiureticpreventsreabsorptioninthe proximal tubule (also thought to be a free radical scavenger)

54
Q

mannitol dosing during cpb

A

0.5 to 1.0 g/kg

55
Q

mannitol dose during rewarming or in prime

A

12.5 g

56
Q

mannitol consideration

A

Inspect carefully for precipitate or crystals. • Use a filtered needle during administration

57
Q

What else is in your drug box?

A
  • THAM • Amicar • Trasylol • Thrombate III • Benadryl
  • Solu-Medrol • Dextrose • Albumin • Insulin
  • Forane
58
Q

tham action

A

creates an alkaline environment by combining with hydrogen ions to form bicarbonatecreates an alkaline environment by combining with hydrogen ions to form bicarbonate

59
Q

THAM Dosing Each 100 mL contains

A

tromethamine 3.6g (30mEq)

60
Q

tham dose

A

Dose (mL) = wt (kg) x Base Deficit (mEq/L) x 1.1

61
Q

Amicar (ε-aminocaproic acid) action

A

nhibits plasminogen activators to prevent conversion to plasmin
• Reduces bleeding caused by hyperfibrinolysis

62
Q

Amicar Dosing loading and infusion

A

Loading Dose: 5 g IV Infusion: 1-1.25g/hr (30g/day max)

63
Q

trasylol action

A

inhibits fibrinolysis and turnover of coagulation factors (serine protease inhibitor)

64
Q

Trasylol Dosing test loading infusion prime

A

Test dose: 1 mL at least 10 min before loading • Loading dose: 200 mL (280mg) over 20-30 min • Infusion dose: 50 mL/hr • Pump prime dose: 200 mL
*May artificially prolong ACT results

65
Q

Thrombate III (antithrombin) action and heparin

A
  • Action: inactivates thrombin and activated forms of clotting factors IX, X, XI, and XII which results in inhibition of coagulation
  • The anticoagulant effect of heparin is enhanced with Thrombate III in patients with antithrombin III (AT-III) deficiency
66
Q

thrombate dosing and vial contents

A

Dose (IU) = (desired-baseline AT-III level) x kg 1.4

• Each vial will contain approximately 500 IU

67
Q

thrombate Use within

A

3 hours of reconstitution

68
Q

benadryl action

A

antihistamine,sedative,antiemetic, anticholinergic

• Given on CPB after suspicion of allergic reaction

69
Q

benadryl dosing

A

10-50 mg

70
Q

solumedrol action and side

A

Action: Intermediate acting glucocorticoid used on bypass to combat inflammation, often during circulatory arrest cases
• May cause hyperglycemia

71
Q

solumedrol dosing

A

125mg–1g •

72
Q

solumedrol consideration

A

Sterile powder which must be mixed with the

accompanying diluent • Use within 48 hours of mixing

73
Q

Forane action

A

thers that modulate the GABAA receptor, used for induction and maintenance of anesthesia
• Potent vasodilators • Pungent odor

74
Q

forane Bottle must be used with appropriat

A

appropriate adaptor to fill forane vaporizer on your pump

• Spillage can cause structural degradation of plastic

75
Q

forane set vaporizer

A

0.5% to 2% after initiation of gas flow

76
Q

forane can be temporarily used

A

increased for blood pressure control
• Scavenge oxygenator gas outflow when using anesthetic gas (recommended by Prof
Gaspar and most people with a conscience)

77
Q

amsect Standard 6.8

A

An anesthetic gas scavenge line shall be employed whenever inhalation agents are introduced into the circuit during CPB procedures.

78
Q

why scavenge short term exposure

A 
Liverandkidneydisease
• Headache
• Irritability
• Fatigue
• Nausea
• Drowsiness
• Compromised performance
• Decreased vigilance • Slow reaction time
79
Q

why scavenge long term exposure

A

Miscarriage • Geneticdamage • Cancer

• Miscarriage and birth defects in the SPOUSES of exposed workers

80
Q

three approaches to scavenge

A

don’t do it, use a passive ventilation,activated charcoal

81
Q

1 more approach to scavenge

A

Suctiontubingattachedto oxygenator gas outflow
• With tiny holes cut into it • With a 1⁄4” 1⁄4” 1⁄4” Y connector
on it
• Attachedtowallsuctionor waste suction set at -100mmHg

82
Q

albumin Concentration of proteins derived

A

fromhumanblood

83
Q

albumin used to

A

Increases plasma volume or serum albumin levels

• May not be consented for by Jehovah’s Witnesses patients

84
Q

albumin concentrations

A

5%, 20%, 25% • 25% contains 250g of protein for every 1000mL

85
Q

albumin will increase CBV

A

3.5 times the volume injected, in an adequately hydrated individual

86
Q

Some give when serum albumin

A

< 3.5 g/dL

87
Q

ALBUMIN DOSING IN PRIME

A

12.5 to 25g in prime, or as needed

88
Q

INSULIN ACTION

A

stimulates glucose utilization by muscle and fat, and acts on the liver to inhibit glycogenolysis and gluconeogenesis

89
Q

INSULIN TARGET RANGE

A

of 110-180 mg/dL during cardiac surgery

• *VERY anesthesia and hospital protocol dependent

90
Q

INSULIN CONC

A

100 units/mL

91
Q

INSULIN DOSING

A

10-20 units IV on CPB

92
Q

INSULIN CONSIDERATIONS

A

Never shake vial, roll in your hands to mix

• Use 1 mL syringe or dedicated insulin syringe

93
Q

Insulin Dosing for Hyperkalemia ADULTS

A

Adults: 25g Dextrose + 10 units Insulin

94
Q

Insulin Dosing for Hyperkalemia PEDS

A

1-2 g/kg Dextrose + 0.3 units Insulin per gram of

Dextrose

95
Q

Dextrose “D-50”

A

Concentrated carbohydrate in the form of dextrose in water used to treat hypoglycemia

96
Q

Dextrose Dosing

A

10-25g

Perf tech 3 (14 decks)

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