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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
HLD
300 to 450 units/kg . Rarely need to exceed 35,000 to 40,000 units
26
Heparin distributes
primarily in plasma, so increasing dose with | increasing body weight is only relevant to a certain point
27
Priming solution should contain heparin at approximately the same
concentration of the patient’s blood stream
28
ACT is prolonged by
hypothermia and hemodilution • Target ACT controversial (300 to 480 seconds)
29
Most vials you will see for adult CPB will be
1000 units/mL Loading dose: 30,000 units | 30,000 units x 1mL = 30 mL 1000 units
30
neo action
syntheticselectiveα1-adranergicagonistthat causes vasoconstriction in arterioles
31
neo duration
less than 5 minutes
32
neo other things
Titratedtoeffect • Start with a test dose
33
Neo-Synephrine Dosing IV bolus
• 100 micrograms/mL • 200 micrograms/mL • 400micrograms/mL
34
Neo-Synephrine Dosing IV infusion
10 or 15 mg in 250 mL IV fluid (40 to 60 micrograms/mL)
35
Sodium Bicarbonate
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
36
NaHCO3 Dosing
* 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
37
Lidocaine actions
reduces cell membrane permeability for sodium and potassium which increases the stimulation thresholds in ventricles
38
lidocaine site of action
cellmembrane
39
lidocaine DOA
15 to 30 minutes post bolus
40
Lidocaine IV bolus
-2 mg/kg • Usually 100 to 200 mg bolus at XC removal | • Not to exceed 300 mg/hr
41
Mag sulfate action
controlstransmembraneelectrolytesandenergy metabolism | • Cardiacarrhythmiasmayoccurduringhypomagnesemia
42
Hypomagnesemia can occur during CPB due to
Poor pre op health • Albuminadministration • Citrated blood product administration
43
MgSO4 Dosing bolus
2 to 2.5 g initial bolus
44
MgSO4 infusion
1.75 g/h infusion
45
mgso4 xc removal
* On CPB, usually given as 2 to 4 grams at XC removal with Lidocaine * Often 0.5 g/mL concentration
46
calcium chloride action
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
CaCl2 Dosing
200 to 1000 mg slow IV | • Often 100 mg/mL concentration
48
CaCl2 given
post XC removal and before termination of CPB if levels are low
49
CaCl2 Hyperkalemia:
Adults:0.5-1gCaCl2 • Peds: 20 mg/kg Calcium Gluconate
50
Potassium Chloride
* The major intracellular ion • Necessary for normal cardiac contractions * Hyperkalemia more of an issue than hypokalemia • Cardioplegia
51
KCL dosing cardioplegia
: 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
KCL hypokalemia dose
Dose (mEq) = weight (kg) x 0.3 x K+ deficit | • GIVE IT SLOWLY especially if XC not on • Usually 2 mEq/mL concentration
53
mannitol action
osmoticdiureticpreventsreabsorptioninthe proximal tubule (also thought to be a free radical scavenger)
54
mannitol dosing during cpb
0.5 to 1.0 g/kg
55
mannitol dose during rewarming or in prime
12.5 g
56
mannitol consideration
Inspect carefully for precipitate or crystals. • Use a filtered needle during administration
57
What else is in your drug box?
* THAM • Amicar • Trasylol • Thrombate III • Benadryl * Solu-Medrol • Dextrose • Albumin • Insulin * Forane
58
tham action
creates an alkaline environment by combining with hydrogen ions to form bicarbonatecreates an alkaline environment by combining with hydrogen ions to form bicarbonate
59
THAM Dosing Each 100 mL contains
tromethamine 3.6g (30mEq)
60
tham dose
Dose (mL) = wt (kg) x Base Deficit (mEq/L) x 1.1
61
Amicar (ε-aminocaproic acid) action
nhibits plasminogen activators to prevent conversion to plasmin • Reduces bleeding caused by hyperfibrinolysis
62
Amicar Dosing loading and infusion
Loading Dose: 5 g IV Infusion: 1-1.25g/hr (30g/day max)
63
trasylol action
inhibits fibrinolysis and turnover of coagulation factors (serine protease inhibitor)
64
Trasylol Dosing test loading infusion prime
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
Thrombate III (antithrombin) action and heparin
* 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
thrombate dosing and vial contents
Dose (IU) = (desired-baseline AT-III level) x kg 1.4 | • Each vial will contain approximately 500 IU
67
thrombate Use within
3 hours of reconstitution
68
benadryl action
antihistamine,sedative,antiemetic, anticholinergic | • Given on CPB after suspicion of allergic reaction
69
benadryl dosing
10-50 mg
70
solumedrol action and side
Action: Intermediate acting glucocorticoid used on bypass to combat inflammation, often during circulatory arrest cases • May cause hyperglycemia
71
solumedrol dosing
125mg–1g •
72
solumedrol consideration
Sterile powder which must be mixed with the | accompanying diluent • Use within 48 hours of mixing
73
Forane action
thers that modulate the GABAA receptor, used for induction and maintenance of anesthesia • Potent vasodilators • Pungent odor
74
forane Bottle must be used with appropriat
appropriate adaptor to fill forane vaporizer on your pump | • Spillage can cause structural degradation of plastic
75
forane set vaporizer
0.5% to 2% after initiation of gas flow
76
forane can be temporarily used
increased for blood pressure control • Scavenge oxygenator gas outflow when using anesthetic gas (recommended by Prof Gaspar and most people with a conscience)
77
amsect Standard 6.8
An anesthetic gas scavenge line shall be employed whenever inhalation agents are introduced into the circuit during CPB procedures.
78
why scavenge short term exposure
``` Liverandkidneydisease • Headache • Irritability • Fatigue • Nausea • Drowsiness • Compromised performance • Decreased vigilance • Slow reaction time ```
79
why scavenge long term exposure
Miscarriage • Geneticdamage • Cancer | • Miscarriage and birth defects in the SPOUSES of exposed workers
80
three approaches to scavenge
don't do it, use a passive ventilation,activated charcoal
81
1 more approach to scavenge
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
albumin Concentration of proteins derived
fromhumanblood
83
albumin used to
Increases plasma volume or serum albumin levels | • May not be consented for by Jehovah's Witnesses patients
84
albumin concentrations
5%, 20%, 25% • 25% contains 250g of protein for every 1000mL
85
albumin will increase CBV
3.5 times the volume injected, in an adequately hydrated individual
86
Some give when serum albumin
< 3.5 g/dL
87
ALBUMIN DOSING IN PRIME
12.5 to 25g in prime, or as needed
88
INSULIN ACTION
stimulates glucose utilization by muscle and fat, and acts on the liver to inhibit glycogenolysis and gluconeogenesis
89
INSULIN TARGET RANGE
of 110-180 mg/dL during cardiac surgery | • *VERY anesthesia and hospital protocol dependent
90
INSULIN CONC
100 units/mL
91
INSULIN DOSING
10-20 units IV on CPB
92
INSULIN CONSIDERATIONS
Never shake vial, roll in your hands to mix | • Use 1 mL syringe or dedicated insulin syringe
93
Insulin Dosing for Hyperkalemia ADULTS
Adults: 25g Dextrose + 10 units Insulin
94
Insulin Dosing for Hyperkalemia PEDS
1-2 g/kg Dextrose + 0.3 units Insulin per gram of | Dextrose
95
Dextrose “D-50”
Concentrated carbohydrate in the form of dextrose in water used to treat hypoglycemia
96
Dextrose Dosing
10-25g

Perf tech 3 (14 decks)

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