PROCOAGULANTS AND ANTIFIBRYNOLYTICS

Question 1

PROTAMINE BINDS TO HEPARIN IN A _ RATIO

Answer 1

1:1

Question 2

Protamine by itself is an anticoagulant: it decreases thrombin generation by inhibiting

Answer 2

FACTOR V

Question 3

Why is protamine given in a 1.3:1 ratio

Answer 3

Protamine is eliminated rapidly from the plasma (faster than heparin)

Question 4

protamine half life

Answer 4

under 5 minutes compared to heparin half life of 1-2 hours

Question 5

what causes increased bleeding after normal act

Answer 5

Free” heparin released from the protamine:heparin complex?

• Heparin’s variable half-life outlives protamine’s ~2 hour clinical effect?
• Heparin from tissue stores?
• Too much “reversal” protamine given (and given, and given, and given…)
• Some data suggests heparin rebound may not really occur at all (Prolene deficiency?

Question 6

protamine bolus is inferior

Answer 6

to small calculate doses

Question 7

protamine is a component oF NPH so

Answer 7

increased reactions in patients on NPH

Question 8

PROTAMINE OTHER USES WITH LMWH

Answer 8

Only partially/unpredictably reverses LMWH. (which sort of limits LMWH’s use.)
*Protamine has no effect on fondaparinux

Question 9

rotamine

Precautions & Problems

Answer 9

1) Protamine is an anticoagulant. -You will find many older perfusionists
have forgotten that! #2) Protamine reactions
-You WILL encounter these during your careers (and Mr. Hoerr will discuss them with you at length…)

Question 10

Contributing Factors to Protamine Reactions

Answer 10

• Rapid administration, Sensitization to Protamine (it carries a Black Box warning)
• Redo Surgeries (patients who have had protamine)-Fish allergies -Diabetics (why?)(protamine in NPH) -Vasectomy (why?) -”Excessive” dosage (

Question 11

PROTAMINE REACTIONS MANIFEST THEMSELVES

Answer 11

as anaphylaxis &/- extreme hypotension, pulmonary hypotension, and cardiovascular collapse.
• Often necessitates “crashing” back on CPB. *Minimized by:
-Slow administration
-Intra-aortic administration (why?)
-Administration with steroids and antihistamines.

Question 12

VITAMIN K

Answer 12

Vitamin K is to Warfarin as protamine is to heparin (a little, sort of, OK, not really…maybe a little?)
• A fat soluble vitamin essential for the production of Factors II, VII, IX, & X.
• Remember, this is a classic “Boards” question!

Question 13

TWO TYPES OF VITAMIN K

Answer 13

1) K1: Phytonadione (Mephyton) VEGETABLES INJECTION SUPPS. 2) K2: Menaquinone (MEAT POULTRY EGGS AND BUTTER)

Question 14

How, what, and why does Vitamin K play a huge part in patient management & survivability ON A VAD???

Answer 14

vitamin K helps to prevent bleeding

Question 15

k dosage for warfarin overdose

Answer 15

1. 0-2.0 mg of K1 is given by injection for warfarin overdosage.
   - This dose will lower the PT but not completely eliminate the desirable warfarin effects.

Question 16

HOW TO GIVE vitamin K

Answer 16

MUST be given slow IV (anaphylaxis is a common side effect).

• Requires at least six hours to be effective

Question 17

*So…what do you give to quickly reverse warfarin in a hemorrhagic emergency?

Answer 17

Typical FFP dose for warfarin overactivity is 15ml/kg.

Question 18

Aminocaproic Acid (EACA) TRANEXAMIC ACID

Answer 18

(AMICAR) (Cyklokapron, Lysteda) Antifibrinolytics. *Both are synthetic derivatives of the amino acid lysine.
*Statistically clinically indistinguishable(SIMILAR EFFICACY), except. TRANEXAMIC ACID IS 10X MORE POTENT THAN AMICAR

Question 19

Antifibrinolytics MOA

Answer 19

Both drugs prevent plasminogen activation and directly inhibit plasmin which prevents fibrinolysis.

Question 20

ANTIFIBRINOLYTIC CLEARANCE AND how they are given

Answer 20

Both drugs cleared renally. • Both commonly used in “pump primes”.

Question 21

how much amicar in prime

Answer 21

5 or 10 grams

Question 22

Aprotinin

Answer 22

(traysol) serine protease inhibitor. Blocks plasmin and does other ill-defined “stuff” to prevent post-op bleeding

Question 23

aprotinin bad stuff

Answer 23

kidney failure, strokes, anaphylaxis. may be used for compassionate therapy

Question 24

Desmopressin MOA

Answer 24

(DDAVP) A synthetic form of Antidiuretic Hormone
(ADH or Vasopressin), a small protein.
• MuchlesspressoractivitythanVasopressin
• Causes the release of von Willebrand’s Factor from vascular endothelium which increases Factor VIII and Factor XII activity.
• Useful for mild Hemophilia A and von Willebrand’s Disease (duh!)

Question 25

DESMOPRESSIN LAYMANS TERMS

Answer 25

Causes platelets adhesiveness to increase in patients with platelet dysfunction 2° to uremia or hepatic dysfunction.
• Available in many forms including a nasal spray.
***”Evidence-Based Note”: There is NO research that indicates the use of DDAVP for bleeding post-bypass decreases the use of blood products (may be somewhat beneficial when administered in advance.)

Question 26

FRESH FROZEN PLASMA HOW ITS SEPARATED AND WHEN ITS GIVEN

Answer 26

Plasma (what’s this?) is separated from whole blood and stored at < 0 degrees Fahrenheit within eight hours of donation.
• FFP’s use has skyrocketed…often given “for bleeding” post-bypass.
• Preferably given with ABO cross-matching
• The use of TEG’s and availability of more specific treatments may alter the use-habits of FFP in the future.

Question 27

FFP HAS FACTORS

Answer 27

-FFP contains Factors I, II, V, VII, IX, X, XI, XIII, AT-III, and proteins C & S…
…but at what concentrations?? VARIABLE

Question 28

FFP USES

Answer 28

Used for “bleeding”

• Used for immediate warfarin reversals (why? why not Vitamin K?) CUZ ITS IMMEDIATE
• Used for AT-III deficiency (why not AT-III? what’s the dosage?) CHEAPER
• Used with large volumes of PRBC administration (why?) BEVAUSE IT HAS PLASMA
• Used for colloidal volume replacement

Question 29

**20ml/kg of FFP raises a patient’s AT III levels by

Answer 29

20%

Question 30

What risks do you think FFP presents?

Answer 30

Dont know if AT3 is present. variable. virus or bacterial contamination

Question 31

cryoprecipatate comes from and is given

Answer 31

Derived from the precipitate that forms after FFP is thawed and centrifuged.
• Usually given as a “pooled” (4-6 units) product but ABO cross-matching is considered desirable. (A single Cryo unit is virtually never given!)

Question 32

cryoprecipitate used for

Answer 32

Used for Factor I, VIII, and von Willebrand’s replacement (what’s Factor I?) fibrinogen
• BUT, levels of VIII and VWF are “iffy” and cryoprecipitate is NOT treated in any way whatsoever to decrease the risk of viral exposure!!!

Question 33

cryoprecipitate unit=

Answer 33

15ml

Question 34

15ml of cryoprecipitate= how much fibrinogen

Answer 34

15 ml ~ 250-350 mg fibrinogen