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Pharmacologic Response to CPB- Exam 3 Flashcards

1
Q

Pharmacokinetics

A

What the body does to the drug

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2
Q

Pharmacodynamics

A

How a drug interacts with the body to produce its effects

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3
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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4
Q

Zero order kinetics

A

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

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5
Q

To prevent drug accumulation, what should be done?

A

Drug infusion rates should be adjusted according to patient response

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6
Q

To prevent drug accumulation, what should be done?

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-Base Status
Sequestration
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8
Q

Changes in Pharmacokinetics due to CPB

A 
Hemodilution
Hypothermia
Perfusion
Acid-Base Status
Sequestration
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9
Q

Hemodilution

A

Reduction in circulating protein concentration
Reduction in RBC concentration
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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10
Q

Hemodilution

A

Reduction in circulating protein concentration
Reduction in RBC concentration
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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11
Q

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

A

Lose some when you rap
most of the time you wont have time to add drugs after you rap
usually you’ll go on pump right after you rap

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12
Q

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

A

Lose some when you rap
most of the time you wont have time to add drugs after you rap
usually you’ll go on pump right after you rap

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13
Q

Hypothermia

A

Fluid shifts from intravascular to interstitial space
(altered volume of distribution, increased 3rd spacing)
Vasoconstriction (changes in organ perfusion)
Reduction in enzyme-mediated biotransformation
increased solubility of volatile anesthetics

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14
Q

Hypothermia

A

Fluid shifts from intravascular to interstitial space
(altered volume of distribution, increased 3rd spacing)
Vasoconstriction (changes in organ perfusion)
Reduction in enzyme-mediated biotransformation
increased solubility of volatile anesthetics

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15
Q

What are two important things to keep in mind regarding patient during perfusion?

A

Lungs excluded form circulation (valium, propofol, opioids)

Altered hepatic blood flow - vasoconstriction (fentanyl, propofol)

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16
Q

What are two important things to keep in mind regarding patient during perfusion?

A

Lungs excluded form circulation (valium, propofol, opioids)

Altered hepatic blood flow - vasoconstriction (fentanyl, propofol)

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17
Q

Acid Base Status

A

Altered organ blood flow (ph stat= increase cerebral blood flow)
altered ionization and protein binding

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18
Q

Sequestration

A

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

  • coated tubing
  • oxygenators
  • hemofilters (many factors influence the movmement of drug across the membrane; degree of protein binding is a major determinant)
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19
Q

When administering medications

A

Ensure you have physician’s order or standing protocol authorizing you to administer the medication

The patient is not allergic to the medication
you should have the correct medication, the correct concentration and the correct dosage

Inspect the medication for expiration date, precipitates and sterility

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20
Q

When administering medications

A

Ensure you have physician’s order or standing protocol authorizing you to administer the medication

The patient is not allergic to the medication
you should have the correct medication, the correct concentration and the correct dosage

Inspect the medication for expiration date, precipitates and sterility

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21
Q

What is in your drug box?

A 
Heparin
Neo-Synephrine
NaHCO3
Lidocaine
MgSO4
Calcium
Potassium
Mannitol
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22
Q

What is heparin sodium derived from?

A

Bovine lung tissue or porcine mucosa standardized for anticoagulant activity

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23
Q

How is the potency of heparin sodium determined?

A

By biological assay using a USP reference standard based on units of heparin activity per milligram

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24
Q

Units/Mg Heparin Conversation

A

100 units = 1 mg

Ex. 5,000 units = 50 mg

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25
What is the action of heparin sodium?
Stops coagulation by potentiating antithrombin III and inhibiting the action of activated Factors IX and XI
26
What is the action of heparin sodium?
Stops coagulation by potentiating antithrombin III and inhibiting the action of activated Factors IX and XI
27
How is heparin eliminated?
kidneys
28
What is the half-life of heparin?
At CPB doses is 2 or more hours; prolonged by hypothermia and renal blood flow alterations
29
What is the half-life of heparin?
At CPB doses is 2 or more hours; prolonged by hypothermia and renal blood flow alterations
30
Heparin Side Effects
Activation of t-PA and platelets Boluses decrease SVR by 10-20% Anaphylaxis rarely occurs HIT and HITT
31
Heparin Loading Dose
300-450 units/kg | Rarely needs to exceed 35,000 to 40,000 units
32
How does heparin distribute?
Primarily in plasma, so increasing dose with increasing body weight is only relevant to a certain point
33
How does heparin distribute?
Primarily in plasma, so increasing dose with increasing body weight is only relevant to a certain point
34
What concentration of heparin should be added to prime?
Priming solution should contain heparin at approx the same concentration of the patient's blood stream
35
What prolongs the ACT?
Hypothermia, and hemodilution
36
What is target ACT?
Controversial (300 to 480 seconds)
37
Most vials you will see for adult CPB will be what concentration?
1000 units/ mL Ex. Loading dose: 30,000 units 30,000 units x 1mL/1000units = 30 mL
38
Neo-Synephrine Action
Synthetic selective alpha 1- adrenergic agonist that causes vasoconstriction in arterioles
39
Neo-Synephrine Duration
Less than 5 minutes
40
How is Neo dosed?
Titrated to effect
41
What should you always do when giving neo?
Start with a test dose
42
Neo-Synephrine Dosing
IV bolus: 100 ug/mL 200 ug/mL 400 ug/mL IV infusion: 10 or 15 mg in 250 mL IV fluid (40-60 ug/mL)
43
Neo-Synephrine Dosing
IV bolus: 100 ug/mL 200 ug/mL 400 ug/mL IV infusion: 10 or 15 mg in 250 mL IV fluid (40-60 ug/mL)
44
How many mg typically in Phenylephrine vial?
10 mg Phenylephrine in 1 mL vial
45
How many mg typically in Phenylephrine vial?
10 mg Phenylephrine in 1 mL vial
46
Sodium Bicarbonate
A sterile, nonpyrogenic, hypertonic solution of sodium bicarbonate (NaHCO3) in water for injection for administration by the intravenous route as an electrolyte replenisher and system alkalizer Also used to treat hyperkalemia
47
NaHCO3 Dosing
Dose (mEq) = 0.3 x Weight (kg) x BD (mEq/L) | *Or just "1 amp" (50 mEq)
48
NaHCO3 Dose for Hyperkalemia
Adults: 50 mEq Peds: 1-2 mEq/kg
49
Lidocaine Action
reduces cell membrane permeability for sodium and potassium which increases the stimulation thresholds in ventricles
50
Lidocaine Site of Action
cell membrane
51
Lidocaine Duration of Action
15-30 minutes post bolus
52
Lidocaine Dosing
IV bolus: 1-2 mg/kg Usually 100 to 200 mg bolus at XC removal Not to exceed 300 mg/h r
53
Magnesium Sulfate Action
Controls transmembrane electrolytes and energy metabolism; cardiac arrythmias may occur during hypomagnesemia
54
What is heparin sodium derived from?
Bovine lung tissue or porcine mucosa standardized for anticoagulant activity
55
When can hypomagnesemia occur during CPB?
Poor pre op health Albumin administration Citrated blood product administration
56
MgSO4 Dosing
2 to 2.5 g initial bolus | 1.75 g/hr infusion
57
MgSO4 Dosing on CPB
usually given as 2 to 4 grams at XC removal with lidocaine | Often 0.5 g/L concentration
58
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; especially if citrated blood products are given
59
CaCl2 Dosing
200 to 1000 mg slow IV Often 100mg/mL concentration Given post XC removal and before termination of CPB if levels are low
60
Hyperkalemia CaCl2 Dosing
Adults: 0.5-1g CaCl2 Peds: 20 mg/kg Calcium Gluconate
61
Hyperkalemia CaCl2 Dosing
Adults: 0.5-1g CaCl2 Peds: 20 mg/kg Calcium Gluconate
62
Potassium Chloride
The major intracellular ion Necessary for normal cardiac contractions Hyperkalemia more of an issue than hypokalemia (cardiopleigia)
63
Potassium Chloride
The major intracellular ion Necessary for normal cardiac contractions Hyperkalemia more of an issue than hypokalemia (cardiopleigia)
64
KCl Dosing for Cardioplegia
15-30 mmol/L of solution delivered into the heart | i.e. 4 to 1 cdpg requires 5 times the delivery strength in the cardioplegia bag
65
KCl Dosing for Hypokalemia
Dose (mEq) = weight (kg) x 0.3 x K+ deficit
66
KCL Usual concentration
2 mEq/L | Give it slowly especially if XC not on
67
KCL Usual concentration
2 mEq/L | Give it slowly especially if XC not on
68
Mannitol Action
Osmotic diuretic prevents reabsorption in the proximal tubule (also thought to be a free radical scavenger)
69
Mannitol Action
Osmotic diuretic prevents reabsorption in the proximal tubule (also thought to be a free radical scavenger)
70
Mannitol Dosing
During CPB 0.5 to 1.0 g/kg Often given as 12.5 g vials in prime or during warming Inspect carefully for precipitate or cystals Use a filtered needle during administration
71
What else is in your drug box?
``` THAM Amicar Trasylol Thrombate III Benadryl Solu-Medrol Dextrose Albumin Insulin Forane ```
72
THAM
tromethamine
73
THAM Action
Creates an alkaline environment by combining with hydrogen ions to form bicarbonate
74
THAM Dosing
Each 100 mg contains tromethamine 3.6 g (30mEq) | Dose (mL) = wt (kg) x Base deficit (mEq/L) x 1.1
75
THAM Dosing
Each 100 mg contains tromethamine 3.6 g (30mEq) | Dose (mL) = wt (kg) x Base deficit (mEq/L) x 1.1
76
Amicar
Aminocaproic acid
77
Amicar Action
Inhibits plasminogen activators to prevent conversion to plasmin Reduces bleeding cased by hyperfibrinolysis
78
Amicar Dosing
Loading Dose: 5g IV | Infusion: 1 - 1.25g/hr (30 g/day max)
79
Trasylol Action
Inhibits fibronlysis and turnover of coagulation factors (serine protease inhibitor)
80
Trasylol Action
Inhibits fibronlysis and turnover of coagulation factors (serine protease inhibitor)
81
Trasylol Dosing Test Dose
1 mL at least 10 min before dosing
82
Trasylol Dosing Loading Dose
200 mL (280 mg) over 20-30 min
83
Trasylol Dosing Infusion dose
50 mL/hr
84
Trasylol Dosing Pump Prime Dose
200 mL
85
What's important to remember about trasylol?
may artificially prolong act results
86
What's important to remember about trasylol?
may artificially prolong act results
87
Thromate III (antithrombin) 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
88
Thrombate III Dosing
Dose (IU)= (desire-baseline AT-III level) x Kg / (1.4)
89
Each vial of thromate III will contain how many units?
500 units
90
You should use Thrombate III within how many hours of reconstitution?
within 3 hours
91
Benadryl Action
antihistamine, sedative, antiemetic, anticholinergic | Given on CPB after suspicion of allergic reaction
92
Benadryl Dosing
10-50 mg
93
Solu-Medrol Generic Name
methylprenisolone
94
Solu-Medrol Action
Intermediate acting glucocorticoid used on bypass to combat inflammation, often during circulatory arrest cases may cause hyperglycemia
95
Solu-Medrol Dosing
125 mg - 1g | Sterile powder which must be mixed with the accompanying diluent
96
Solu-Medrol must be used within how many hours of mixing?
48 hours
97
What are some examples of inhalation anesthetics?
Halothane Isoflurane Sevorflurane
98
Forane Action
ethers that modulate the GABA (A) receptor, use for induction and maintenance of anesthesia Potent vasodilators Pungent odor
99
Forane Dosing
Bottle must be used with appropriate adapter to fill forane vaporizer on your pump; spillage can cause structural degradation of plastic Scavenge oxygenator gas outflow when using anesthetic gas
100
Set Vaporizer of forane at what percent after initiation of gas flow?
0.5 % to 2% ; can be temporarily increased for blood pressure control
101
Set Vaporizer of forane at what percent after initiation of gas flow?
0.5 % to 2% ; can be temporarily increased for blood pressure control
102
AmSECT Standard for Scavenging Gases
Standard 6.8: An anesthetic gas scavenge line shall be employed whenever inhalation agents are introduced into the circuit during CPB procedures
103
AmSECT Standard for Scavenging Gases
Standard 6.8: An anesthetic gas scavenge line shall be employed whenever inhalation agents are introduced into the circuit during CPB procedures
104
Short Term Anesthetic Gas Exposure
``` Liver and kidney disease Headache Irritability Fatigue Nausea Drowsiness Compromised performance -Decreased vigilance -Slow reaction time ```
105
Low Term Anesthetic Gas Exposure
Miscarriage Genetic damage cancer miscarriage and birth defects in the spouses of exposed workers
106
Low Term Anesthetic Gas Exposure
Miscarriage Genetic damage cancer miscarriage and birth defects in the spouses of exposed workers
107
What are the three approaches to scavenging gases?
1. Nothing (adequate that air is being circulated) 2. Active ventilation system 3. Passive ventilation system
108
What is one more approach to gas scavening?
Suction tubing attached to oxygenator gas outflow -with tiny holes cut into it -with a 1/4'' x 1/4'' x 1/4'' Y connector on it Attached to wall suction or waste suction set at - 100 mmHg
109
Albumin
Concentration of proteins derived from human blood Increases plasma volume or serum albumin levels May not be consented for by jehovah's witnesses patients
110
Albumin Concentrations
Varying concentrations 5%, 20%, 25% | -25% contains 250 g of protein for every 1000 mL
111
Albumin will increase circulating volume how much?
3.5 x the volume injected, in an adequately hydrated individual
112
Albumin Dosing in Prime
12.5 to 25 g in prime, or as needed
113
Most vials you will see for adult CPB will be what concentration?
1000 units/ mL Ex. Loading dose: 30,000 units 30,000 units x 1mL/1000units = 30 mL
114
What should you always do when giving neo?
Start with a test dose
115
Sodium Bicarbonate
A sterile, nonpyrogenic, hypertonic solution of sodium bicarbonate (NaHCO3) in water for injection for administration by the intravenous route as an electrolyte replenisher and system alkalizer Also used to treat hyperkalemia
116
Magnesium Sulfate Action
Controls transmembrane electrolytes and energy metabolism; cardiac arrythmias may occur during hypomagnesemia
117
Serum Albumin
118
Insulin Action
stimulates glucose utilization by muscle nad fat, and acts on the liver to inhibit glycogenolysis and gluconeogenesis
119
Insulin Action
stimulates glucose utilization by muscle nad fat, and acts on the liver to inhibit glycogenolysis and gluconeogenesis
120
Glucose Target Range During Cardiac Surgery
110-180 mg/dL
121
Insuling Dosing
Very anesthesia and hospital protocol dependent 100 u/mL 10-20 units IV on CPB Never shake vial, roll in your hands to mix Use 1 mL syringe or dedicated insulin syrgine
122
Insulin Dosing for Hyperkalemia
Adults: 25 g Dextrose + 10 units INsulin Peds: 1-2 g/ kg Dextrose + 0.3 units Insulin per gram of Dextrose
123
Dextrose D-50
Concentrated carbohydrate in the form of dextrose in water used to treat hypoglycemia
124
Dextrose Dosing
10-25g

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