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2-Pharm Final > Procoagulants/Blood Products > Flashcards

Procoagulants/Blood Products Flashcards

1
Q

What is the onset of Direct-Acting Non-Vit K Oral Anticoagulants?

A

Rapid onset of action; therapeutic anticoagulation occurs within hours of administration

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2
Q

What needs to be monitored with Direct-Acting Non-Vit K Oral Anticoagulants?

A

Don’t need routine monitoring

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3
Q

When is PCCs recommended?

A
  • PCCs recommended for immediate INR reversal along w/vitamin-K administration
  • PCCs also used for managing bleeding in patients receiving Xa inhibitors (apixaban, edoxaban, & rivaroxaban)
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4
Q

What can FFP be used for Management of Direct-Acting Non-Vit K Oral Anticoagulants?

A
  • FFP can be used
  • carries transfusion-related risk & risk of volume overload
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5
Q

What is the MOA of Platelet Inhibitors: Aspirin?

A

Irreversibly acetylates cyclooxygenase & prevents formation of thromboxane A2

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6
Q

How long do the effects of Platelet Inhibitors: Aspirin last?

A

Effects on platelets irreversible & last for life of the platelet: 7-10 days

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7
Q

Aspirin reduces incidence of ___________

A

occlusive arterial vascular events

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8
Q

Review cell membrane destruction.

A
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9
Q

What is the drugs in the class of Platelet Inhibitors: Thienopyridines?

A

clopidogrel (Plavix), prasugrel (Effient), & ticagrelor

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10
Q

What do Platelet Inhibitors: Thienopyridines (clopidogrel, prasugrel, & ticagrelor)?

A

These drugs irreversibly bind/antagonize platelet receptors which block adenosine diphosphate (ADP) binding which inhibits ADP-mediated platelet activation & aggregation

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11
Q

What are drugs involved in the Platelet Glycoprotein IIb/IIIa Antagonists?

A

abciximab (ReoPro), tirofiban (Aggrastat), eptifibatide (Integrilin)

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12
Q

What is the MOA of Platelet Glycoprotein IIb/IIIa Antagonists?

A

Drugs: abciximab (ReoPro), tirofiban (Aggrastat), eptifibatide (Integrilin)

  • Block fibrinogen binding to platelet GP IIb/IIIa receptors that are a common pathway of platelet aggregation & inhibit platelet aggregation
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13
Q

What effect do Platelet Glycoprotein IIb/IIIa Antagonists have on platelet response?

A

Drugs: abciximab (ReoPro), tirofiban (Aggrastat), eptifibatide (Integrilin)

  • Inhibit platelet function which inhibits platelet response to vascular injury & clot formation
  • prevent thrombus formation initiated by platelets in acute coronary syndrome (unstable angina, myocardial infarction)
  • angioplasty failure
  • stent thrombosis
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14
Q

What is the Perioperative management of patients on platelet inhibitors?

A

(coming to the OR; having procedures requiring anesthesia) requires careful coordinated care between cardiology, surgeon, & anesthesia

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15
Q

What is the MOA of Thrombolytic Drugs?

A

These drugs act as plasminogen activators to convert endogenous plasminogen to plasmin which causes fibrinolysis (clot lysis)

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16
Q

What does Thrombolytic Drugs administration restore?

A

circulation through occluded artery or vein (usu coronary artery)

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17
Q

What is a risk with Thrombolytic Drugs?

A

Risk of bleeding (particularly intracranial hemorrhage) & hemorrhagic complications

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18
Q

What are Antifibrinolytic agents?

A

are procoagulants, promote hemostasis

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19
Q

What is the use for Antifibrinolytic Agents?

A
  • used to treat bleeding perioperatively
  • reduce need for transfusion (cardiac & orthopedic surgery, trauma)
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20
Q

What are examples of Antifibrinolytic Agents?

A

Synthetic lysine analog antifibrinolytic agents: aminocaproic acid (Amicar) & tranexamic acid (TXA)

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21
Q

What is the MOA of Antifibrinolytic Agents?

A

Antifibrinolytic Agents: Lysine Analogs

  • These agents competitively inhibit activation of plasminogen to plasmin (enzyme that degrades fibrin clots) & fibrinogen
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22
Q

What can TXA cause?

A

TXA inhibits plasmin at high doses; risk of seizures

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23
Q

What is not a property of Antifibrinolytic Agents: Lysine Analogs?

A
  • These agents are not prothrombotic
  • they are clot stabilizers
  • prevent compensatory responses of inflammatory injury & clot lysis
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24
Q

What does Antifibrinolytic Agents: Aprotinin?

A

Inhibits plasmin

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25
Q

What is the use for Antifibrinolytic Agents: Aprotinin?

A

Used in cardiac surgery to reduce bleeding & transfusion requirement

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26
Q

What is the properties of Antifibrinolytic Agents: Aprotinin?

A

Demonstrated a procoagulant state; resulted in declined use

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27
Q

What is Protamine formed from?

A

Commercially produced from the sperm of salmon

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28
Q

What is a potential allergic reaction from Protamine?

A

considered that persons who have an allergy to fish could be at risk of protamine reactions

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29
Q

What can protamine reverse?

A

Only agent to reverse unfractionated heparin (acid-base interaction)

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30
Q

What does Protamine not reverse?

A

Does not reverse low molecular weight heparin

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31
Q

What can excessive Protamine cause?

A

Excess should be avoided (common) as too much can contribute to coagulopathy

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32
Q

What can occur with Protamine?

A

Patients can have heparin rebound 2-3 hrs after initial dose (ACT not always a sensitive indicator)

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33
Q

What are adverse reactions of Protamine?

A

anaphylaxis, acute pulmonary vasoconstriction, right heart failure, hypotension

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34
Q

Which patients are increased risk for adverse reactions?

A

Patients at increased risk for adverse reactions: exposure to NPH insulin, vasectomy, prior protamine exposure, multiple allergies

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35
Q

What are the administration components of Protamine?

A
  • Give test dose of 10 mg
  • Administer slow IV
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36
Q

What is the MOA of Desmopressin (DDAVP)?

A

analog of arginine vasopressin, stimulates the release of vWF from endothelial cells

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37
Q

What does vWF mediate?

A

vWF mediates platelet adherence to vascular subendothelium

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38
Q

When is Desmopressin (DDAVP) often used?

A

Often used in cardiac surgery

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39
Q

What does Desmopressin (DDAVP) shorten?

A

Shortens bleeding time of patients with mild hemophilia A or von Willebrand disease

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40
Q

What is the administeration of Desmopressin (DDAVP)?

A

slowly to prevent hypotension

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41
Q

Where is Fibrinogen synthesized?

A

Synthesized in the liver, critical component of clot formation

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42
Q

What is Fibrinogen a substrate?

A

thrombin, factor XIIIa, plasmin

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43
Q

What forms the cross-linking of fibrin polymers?

A
  • Thrombin cleaves fibrinogen to form fibrin that creates a network to trap red cells and begin a clot
  • cross-linking of fibrin polymers induced by factor XIIIa
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44
Q

What is an important binding site of Fibrinogen?

A

Acts a binding site for GpIlb/IIIa receptors on platelet surfaces; responsible for platelet aggregation

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45
Q

What causes decreased Fibrinogen level?

A
  • During major hemorrhage, hemodilution after blood loss & subsequent volume replacement leads to reduced fibrinogen levels (hypofibrinogenemia)
  • impairs fibrin polymerization & reduces clot stability
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46
Q

What are fibrogen levels usually replaced with?

A

Replaced usually with cryoprecipitate or fibrinogen concentrates

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47
Q

How much does cryoprecipitate increase Fibrinogen level?

A

Cryoprecipitate: 1 unit/10kg increases fibrinogen by 50-70mg/dL

48
Q

What are the normal levels of Fibrinogen?

A

Normal level is 200-400 mg/dl

49
Q

What is cruical for bleeding patients?

A

Bleeding patient (surgical, trauma): crucial to measure & replenish fibrinogen

50
Q

When is Recombinant Activated Factor VIIa used for?

A

Used in patients w/ hemophilia A or B; increasing off-label use for life-threatening emergencies and cardiac surgery

51
Q

What does •Recombinant Activated Factor VIIa produce?

A

Produces prohemostatic effect by complexing with TF at site of vascular injury to produce thrombin

52
Q

What is true about Recombinant Activated Factor VIIa?

A

Expensive and concerns with procoagulant state in causing MI, thrombotic events

53
Q

What is the Factor XIII important in?

A

Important in final step and stabilization of clot

54
Q

When can Recombinant Activated Factor VIIa levels be reduced?

A

Levels may be reduced after cardiac bypass

55
Q

What are the Prothrombin Complex Concentrates (PCC’s) are concentrations of?

A

coagulation factors II, VII, IX, X

56
Q

What is the use of Prothrombin Complex Concentrates (PCC’s)?

A

Prevention and control bleeding for hemophilia B & warfarin reversal

57
Q

What does warfarin inhibit?

A

Warfarin inhibits vitamin-K dependent cofactors (II, VII, IV, X) in addition to protein C and protein S

58
Q

Where does Warfarin act?

A

Warfarin acts across both the extrinsic and intrinsic pathways to prevent thrombus formation.

59
Q

When are Prothrombin Complex Concentrates (PCC’s) recommended?

A

PCCs recommended for life-threatening bleeding & increased INR when urgent reversal is required

60
Q

What is the off label use for Prothrombin Complex Concentrates (PCC’s)?

A

Off-label use for managing other bleeding in patients receiving non-vitamin K oral anticoagulant direct factor Xa inhibitors (i.e., rivaroxaban & abixaban)

61
Q

What does critical bleeding perioperatively requires?

A

volume replacement therapy

  • Crystalloid, colloid, & RBCs
62
Q

What do Crystalloid, colloid, & RBCs not provide?

A

These products don’t provide coagulation factors or platelets

63
Q

What can administering Crystalloid, colloid, & RBCs exacerbate?

A

coagulopathy

64
Q

Severe bleeding requires use of _________

A

massive transfusion protocol

65
Q

What is the goal of management in major bleeding in surgical & trauma patients?

A
  • restore circulating levels of hemostatic factors
  • Monitoring: thromboelastography
66
Q

_______ & _____ must be monitored & abnormality corrected during blood product transfusion

A

Temperature & pH

67
Q

What is important about Decision to transfuse?

A

weigh risks of transfusion against the need for improved oxygen-carrying capacity

68
Q

What is the ASA Task Force on Perioperative Blood Transfusion & Adjuvant Therapies recommendations?

A
  • Transfusion of RBCs should usually be administered when the Hgb is low (<6 g/dL in a young, healthy patient), esp. when anemia is acute
  • RBCs are usually unnecessary when Hbg > 10g/dL
69
Q

Determining whether to transfuse RBC for Hbg 6-10 g/dL should be based on?

A
  • ongoing indication of organ ischemia
  • potential or actual ongoing bleeding
  • the patient’s intravascular volume status
  • patient’s risk factors for complications of inadequate oxygenation (low cardiopulm reserve, high O2 consumption)
70
Q

How long are RBC’s stored?

A

42 days after donation

71
Q

What can RBC’s stored >14-21 days cause?

A

those stored >14-21 days may lead to adverse effects (RBC storage lesions) due to degradation and metabolic changes & depletion of ATP and 2, 3 diphosphoglycerate (2,3 DPG)

72
Q

What are the effects of 1 unit of RBC’s increases?

A

Hct ~ 3% & Hbg by 1g/dL

73
Q

When is Fresh Frozen Plasma used?

A
  • Used w/surgical patients to:
    • replace coagulation factors during massive transfusion
    • tx or prevent future bleeding during surgery & invasive procedures
    • reverse warfarin therapy
    • tx coagulation factor abnormalities where specific concentrates are not available
74
Q

What does Fresh Frozen Plasma contain?

A

Contains factors II, VII, IX, & X, protein C, protein S, antithrombin, & fibrinogen

75
Q

What is true about FFP after thawing?

A

FFP should be transfused within 24 hours; if not used after thawing, can be relabeled as “thawed plasma” & stored (1-6 degrees C) for additional 4 days

76
Q

How is Fresh Frozen Plasma administered?

A

Must be transfused using 170 micron filter, must be ABO compatible

77
Q

What is the average volume of Fresh Frozen Plasma?

A

Average volume is 200-250 mL

78
Q

What are the uses of Fresh Frozen Plasma?

A
  • Used to treat coagulopathies with PT/PTT > 1.5 normal
  • Used to reverse effects of warfarin
  • the lowest INR obtainable w/FFP is approx.1.5 (the INR of plasma/FFP)
79
Q

What can overuse of Fresh Frozen Plasma lead to?

A

Overuse in surgery can result in fluid overload and TRALI

80
Q

When is FFP recommended?

A

Recommended to start FFP administration early in transfusion protocols along with RBC’s for massive hemorrhage

81
Q

Most common cause of bleeding after surgery is _______

A

platelet dysfunction

82
Q

What is the lifespan of platelets?

A

Life span of a donated platelet only 4-5 days

83
Q

What is the range of platelets?

A

Normal range: 150,000 – 400,000

84
Q

What is the transfusion components of platelet?

A

Platelets used in transfusion either pooled random-donor or single-donor apheresis; can be stored up to 5 days

85
Q

How much does 1 unit of platelets increase your levels?

A

1 unit (250mL) increases platelet count by 30,000 – 60,000

86
Q

When is platelet transfusion usually indicated?

A

for platelet count < 50,000 in presence of hemorrhage/surgery

87
Q

When are platelets incidated prophylactically?

A

Indicated prophylactically for patients with platelets counts < 10,000-20,000 due to risk of spontaneous hemorrhage

88
Q

Cryoprecipitate is a a _________ blood product

A

multidonor

89
Q

What factors are contained in Cryoprecipitate?

A

Contains factors VIII, XIII, & fibrinogen

90
Q

What does Cryoprecipitate replenish?

A

Replenishes fibrinogen levels during coagulopathies

91
Q

What is not contained in Cryoprecipitate?

A

Does not contain factor V and should not be sole replacement for DIC

92
Q

When should fibrinogen levels be elevated?

A

in bleeding patients, esp following multiple transfusions

93
Q

What are the guidelines for Cryoprecipitate?

A
  • With fibrinolysis
  • Use when fibrinogen levels less than 80-100 mg/dL
  • Adjunct for massive transfusion
  • Congenital fibrinogen deficiencies
94
Q

What do fluid solutions contain?

A

Fluid solutions containing ion salts & other low molecular weight substances

95
Q

What are Crystalloids characterized by?

A

Crystalloids categorized based on tonicity or osmotic pressure of the solution

96
Q

What can large amounts of NS cause?

A

Administering large volumes of NS can result in hyperchloremic metabolic acidosis

97
Q

What is the components of “Balanced” or “physiologic” crystalloid?

A

solutions contain composition close to extracellular fluid (LR or Plasma-Lyte)

98
Q

What can administration of of lg volumes of balanced salt solution result?

A

can result in hyperlactatemia, metabolic alkalosis, & hypotonicity

99
Q

Review common crystalloid solutions.

A
100
Q

What is the current ASA guidelines of Crystalloids?

A

Current ASA guidelines recommend moderately liberal approach w/overall positive fluid balance of 1-2L at end of surgery, minimized preop fasting times, close hemodynamic monitoring to guide volume resuscitation

101
Q

What is the advantage of balanced of Crystalloids?

A

Balanced crystalloid solutions (LR, Plasma-Lyte) may offer advantage of less adverse kidney events than NS

102
Q

What are the solution components of colloids?

A

are solutions that are macromolecules (plant or animal polysaccharides or polypeptides)

103
Q

________ remain in plasma compartment longer than _______ solutions

A

Colloids; crystalloid

104
Q

What are the components of Semisynthetic colloid solutions?

A

are metabolized & excreted, have a shorter duration of effect than human albumin solutions

105
Q

What is albumin?

A
  • produced from human blood & suspended in saline
  • studies have found no significant clinical difference in ICU patients treated with albumin or saline
106
Q

What is an example of Semisynthetic colloids?

A

hydroxyethyl starch (HES)

107
Q

What is the FDA black box warning for Semisynthetic colloids: hydroxyethyl starch (HES)?

A
  • Do not use in critically ill adult patients incl those w/sepsis, those admitted to the ICU
  • avoid use in patients w/renal dysfunction
  • avoid use in patients undergoing CPB d/t excess bleeding; DC at first sign of coagulopathy
108
Q

What are commonly used for in the OR as biomarkers?

A

Imaging Dyes

109
Q

What are common OR Imaging Dyes?

A
  • Indocyanine Green
  • Methylene Blue
  • Indigo Carmine
110
Q

What effect does Indocyanine Green have on SPO2?

A

artificially lower SpO2 readings (transient) - (based on Beer-Lambert law)

111
Q

What effect does methylene blue have on SPO2?

A

artificially lower SpO2 readings (transient

112
Q

When is Methylene Blue commonly used?

A

Commonly given in cardiac surgery; important to remind surgeon and perfusionist that the blood will be very dark

113
Q

When should caution be used with Methylene blue?

A

Caution with patients taking SSRIs (serotonin syndrome) and methemoglobinemia (concern with higher doses)

114
Q

What imaging dyes turn urine blue?

A
  • Methylene Blue
  • Indigo Carmine
115
Q

What effect does Indigo Carmine have on SPO2?

A

artificially lower SpO2 readings (transient

116
Q

What are the CV effects of Indigo Carmine?

A
  • CV effects are transient alpha-receptor stimulation, namely
    • increased total peripheral resistance
    • diastolic and systolic blood pressure
    • and central venous pressure with concomitant decreased cardiac output
    • stroke volume and heart rate
117
Q

What have been reported with Indigo Carmine?

A

Have been hypersensitivity reports

2-Pharm Final (10 decks)

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