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Advanced Pharm > Exam 3 Material > Flashcards

Exam 3 Material Flashcards

1
Q

List the 4 steps of hemostasis

A
  1. Vascular spasm
  2. Formation of platelet plug (primary hemostasis)
  3. Coagulation and fibrin formation (secondary hemostasis)
  4. Fibrinolysis
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2
Q

Platelets contain the following components

A

Actin
Adenosine diphosphate
Calcium

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3
Q

Where and how are platelets produced

A

By megakaryocytes in the bone marrow

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4
Q

Normal platelet levels

A

150,000-300,000mm3

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5
Q

How long do platelets live

A

8-12 days (1-2weeks)

apex

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6
Q

How are platelets cleared

A

Macrophages in the reticuloendothelial system and the spleen

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7
Q

What’s the function of actin

A

Helps the platelet contract to form a platelet plug

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8
Q

What is the function of glycoproteins

A

Adheres to injured endothelium, collagen and fibrinogen

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9
Q

What is the function of ADP

A

Platelet activation and aggregation

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10
Q

What is the function of serotonin in the platelet

A

Activates nearby platelets

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11
Q

What is the function of growth factor in the platelet

A

Helps repair damaged vessel walls

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12
Q

Which substance is responsible for adhering the platelet to the damaged vessel

A

Von Willebrand Factor

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13
Q

What substance is responsible for platelet activation and aggregation

A

ADP
Thromboxane A2

apex

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14
Q

list the 3 steps required to produce a platelet plug

A

adhesion
activation
aggregation

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15
Q

Von Willebrand factor binds to the platelet during which step

A

adhesion (step 1)

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16
Q

How does the injured blood vessel initially activate the platelet plug

A

endothelial injury exposes collagen which activates platelets

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17
Q

what are the vitamin K dependent factors

A

2
7
9
10

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18
Q

What is the first coagulation factor activated in the extrinsic pathway?

A

Tissue Factor (3)

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19
Q

what factors are part of the extrinsic pathway

A

3 and 7

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20
Q

how fast can a clot form via the extrinsic pathway

A

~ 15 seconds

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21
Q

what is the first factor to be depleted in the patient with vit K deficiency

A

factor 7

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22
Q

a deficiency of what factor causes hemophilia A

A

factor 8

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23
Q

how long does it take to form a clot via the intrinsic pathway

A

up to 6 min

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24
Q

what factors make up the intrinsic pathway

A

12
11
9
8

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25
Q

what is the role of thrombin

A

it converts fibrinogen to fibrinogen monomer

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26
Q

what must be present to convert fibrinogen monomer to fibrin fibers

A

calcium (factor 4)

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27
Q

2 true statements regarding fibrinolysis

A
  • D dimer measures fibrin split products
    -alpha 2 antiplasmin inhibits the action of plasmin on fibrin
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28
Q

what are 4 mechanisms that counterbalance clot formation

A
  1. vasodilation and washout of ADP and TxA2
  2. Antithrombin inactivating thrombin
  3. tissue factor pathway inhibitor neutralizes tissue factor
    4 release of protein C and S
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29
Q

what are 2 enzymes that convert plasminogen to plasmin

A

1 tPa
2 Urokinase

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30
Q

what 2 enzyme inhibitors turn off the fibrinolytic process

A
  1. tPa inhibitor (TPAI)
  2. alpha 2 antiplasmin
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31
Q

how are plasmin activators used therapeutically

A

they help dissolve thrombi to restore blood flow

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32
Q

Identify the best predictor of bleeding during surgery

A

History and physical

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33
Q

What is a normal platelet count

A

150,000-300,000mm3

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34
Q

A platelet count less than 20,000mm3 increases the risk of?

A

Spontaneous bleeding

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35
Q

What lab test measures for fibrinolysis

A

D dimer

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36
Q

Heparin inhibits which pathway(s)

A

Intrinsic and common pathway

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37
Q

Where is endogenous heparin produced

A

Liver
Basophils
Mast cells

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38
Q

On what part of the coagulation cascade does heparin work

A

Intrinsic and common pathways

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39
Q

Where should the aPTT be maintained for active VTE

A

1.5-2.5 times normal

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40
Q

What is a normal ACT

A

90 seconds

Apex

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41
Q

What are 3 contraindications to heparin administration

A
  1. Neurosurgical procedures
  2. HIT
  3. Regional anesthesia
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42
Q

Warfarin inhibits factors

A

2, 7, 9, 10
Proteins C and S

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43
Q

Where do we obtain inactive vitamin K?

A

Diet
Manufactured in the gut via bacteria

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44
Q

How does warfarin work

A

Inhibits vitamin K epoxide reductase complex 1 (an enzyme)

This directly inhibits production of vitamin K dependent factors 2,7,9,10 and proteins C and S

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45
Q

What are the antidotes for warfarin

A

Vitamin k
FFP

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46
Q

What is the therapeutic level for PT/INR for patient on warfarin

A

2-3 times normal

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47
Q

What is the dose for exogenous vitamin K

A

10-20mg PO, IM or IV

Apex

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48
Q

What risk is associated with IV phytonadione

A

Life threatening anaphylaxis

IV admin is best avoided, if have to give IV rate should not exceed 1mg/min

Apex

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49
Q

What is MOA for clopidogrel

A

ADP receptor antagonist

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50
Q

What is MOA of Abciximab

A

GpIIb/GpIIIa receptor antagonist

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51
Q

Warfarin MOA

A

Vitamin K antagonist

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52
Q

Enoxaparin MOA

A

Antithrombin cofactor

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53
Q

A patient scheduled for coronary revascularization is diagnosed with type 3 von willebrand disease. What is the best treatment for this patient?

A

vWF/ factor 8 concentrate

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54
Q

Which type of vWF disease responds best to desmopressin?

A

Type 1

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55
Q

What is the first line agent for patient with type 3 vWF disease?

A

Purified 8-vWF concentrate

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56
Q

What coagulation factors are in cryoprecipitate

A

8
13
Factor 1 (fibrinogen)
vWF

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57
Q

Cryo is useful in treating which type of vWB disease

A

Type 1,2,3

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58
Q

What coagulopathies present with prolonged PTT and normal PT

A

Hemophilia A and B

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59
Q

Hemophilia A and B affect what factors?

A

8 hemophilia A

9 hemophilia B

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60
Q

Which type of hemophilia is more severe

A

Hemophilia A

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61
Q

Which pathway in coag cascade is affected by hemophilia A and B?

A

Intrinsic pathway

PTT will be prolonged with severe disease, slightly prolonged with mild disease

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62
Q

What should always be performed before surgery with a severe hemophilia?

A

Type and cross

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63
Q

6 treatments for hemophilia A

A

Factor 8
FFP
Cryo
DDVAP
Antifibrinolytics
Recombinant factor 7

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64
Q

Recombinant factor 7 increases risk of

A

Arterial thrombosis (MI and stroke)

Venous thrombosis (DVT and PE)

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65
Q

Define DIC

A

Disordered clotting and fibrinolysis that leads to hemorrhaging and systemic thrombosis

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66
Q

Conditions with high risk of DIC

A

Sepsis
Ob
Cancer (adenocarcinoma, leukemia, lymphoma)

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67
Q

Signs of DIC

A

Ecchymisis
Petechiae
Mucosal bleeding
Bleeding at Iv site
Prolonged PT/PTT
Increased D dimer and fibrin split products
Decreased fibrinogen and antithrombin

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68
Q

Side effects of cisplatin

A

Acoustic nerve injury

Nephrotoxicity

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69
Q

Side effect of vincristine

A

Peripheral neuropathy

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70
Q

Side effect of bleomycin

A

Pulmonary fibrosis

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71
Q

Side effect of doxorubicin

A

Cardiotoxic

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72
Q

Side effects of methotrexate

A

Bone marrow suppression

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73
Q

What meds can increase risk of hyperkalemia when used with K sparing diuretics?

A

ACE
ARBs
NSAIDs
Beta blockers

Apex says beta blockers, his ppt said the others

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74
Q

Which potassium sparing diuretic antagonizes aldosterone at the mineral cortical is receptors

A

Spironolactone

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75
Q

Side effects of potassium sparing diuretics

A

Hyperkalemia
Metabolic acidosis
Gynecomastia
Libido changes
Nephrolithiasis

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76
Q

How can loop diuretics affect nondepolarizing neuromuscular blockade

A

Potentiates it

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77
Q

What cross sensitivity can happen with furosemide

A

Cross sensitivity with allergies to sulfunamides

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78
Q

Thiazide diuretics can ___ nondepolarizing neuromuscular blockade

A

Potentiate

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79
Q

NSAIDs and thiazide diuretics

A

NSAIDs decrease effectiveness of thiazide diuretics

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80
Q

Which hormones are released by the anterior pituitary gland

A

Prolactin
Luteinizing hormone
Melanin
Growth hormone
ACTH
Tsh

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81
Q

Anesthetic considerations for the patient with diabetes insipidus

A

DDAVP to treat

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82
Q

When compared to T4 which statements best describe T3

A

T 3 has:

Shorter half life
Higher potency
Less protein bound
Smaller conc in the blood

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83
Q

What are 2 CV side effects of hypocalcemia

A

-hypotension
-prolonged QT interval

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84
Q

What are the 4 Bs when treating the patient with thyroid storm?

A
  1. Block synthesis (methimazole, carbimazole, PTU, potassium iodine)
  2. Block release (radioactive iodine, potassium iodine)
  3. Block T3 to T4 conversion (PTU, propranolol, glucocorticoids)
  4. Beta-blocker (propranolol, Esmolol)
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85
Q

List 4 ways the body responds to hypocalcemia

A

-parathyroid gland releases PTH
-osteoclasts in bone release Ca2+
-Ca is reabsorbed in the kidneys
-Ca absorption in the gut increases in the presence of vitamin D

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86
Q

How does aldosterone affect renal function

A

-increases Na and water reabsorption
-increases K and H excretion

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87
Q

How much cortisol does the body produce each day

A

Average cortisol production is 15-30mg/day, dr p s says 10 to 20
with a normal serum level of 12 mcg/dL

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88
Q

How does cortisol production change in response to perioperative stress

A

Major perioperative stress can increase cortisol production upwards of 100mg/day, with serum level up to 30-50mcg/dL

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89
Q

what are the hemodynamic effects of cortisol

A

cortisol improves myocardial performance by increasing the number and sensitivity of beta receptors on the myocardium

cortisol is also required for the vasoconstrictive effects of catecholamines

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90
Q

what are the 3 most relevant endogenous steroids

A

cortisol
cortisone
aldosterone

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91
Q

what steroid has the greatest mineralocorticoid effect

A

aldosterone

its 3000 times more potent than cortisol

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92
Q

which synthetic steroid is best suited to treat addisons disease

A

Prednisone

of all the synthetic steroids, it most closely resembles cortisol

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93
Q

what herbal supplement can cause a syndrome that resembles hyperaldosteronism

A

Licorice

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94
Q

4 signs of Cushing’s syndrome

A

HTN
HYPOkalemia
metabolic alkalosis
hyperglycemia

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95
Q

a patient with adrenal insufficiency and sepsis requires an emergency intubation in the intensive care unit. which drug should be avoided

A

etomidate

by inhibiting 11BH a single induction dose of etomidate can cause adrenocortical suppression for >8hrs

this could cause acute adrenal crisis.

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96
Q

what is protamine typically used for

A

reversing heparin

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97
Q

what is the MOA for the antifibrinolytic agents TXA and EACA

A

Competitively inhibit activation of plasminogen to plasmin

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98
Q

low factor 13 puts patient at risk for?

A

bleeding

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99
Q

what is the preferred treatment for vitamin K antagonist reversal in emergent situations

A

PCC or FFP

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100
Q

fibrinogen levels can increase lab measures of hemostasis including prothrombin time and partial thromboplastin time which may not be corrected with transfusing FFP. What product is better suited for transfusion in this situation

A

Cryoprecipitate

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101
Q

what is a potential risk for giving TPA for an ischemic stroke

A

conversion from ischemic stroke to hemorrhagic stroke

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102
Q

true or false: protamine works to neutralize LMWH

A

False

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103
Q

what two sites do most anticoagulants work on

A

10a and 2a

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104
Q

which medication primarily targets the chemoreceptor trigger zone

A

ondansetron

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105
Q

when should ondansetron be given in surgical patients

A

30 min before emergence

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106
Q

true or false: H2 receptor antagonists have an influence on pH of gastric fluid that is already present in stomach

A

False

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107
Q

when should oral omeprazole be given before anticipated induction of anesthesia for chemoprophylaxis (PONV)

A

> 3 hrs before

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108
Q

what is the site of action for loop diuretics

A

thick ascending loop of henle

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109
Q

true or false: Metoclopramide and other prophylactic drugs (antacids/ H2 antagonists) can replace the need for an artificial airway due to its strong effects in GI motility and pH neutralization

A

False

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110
Q

rapid administration of metoclopramide can induce what

A

abdominal cramping

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111
Q

what is the MOA for carbonic anhydrase inhibitors

A

noncompetitive inhibitors of enzyme activity in the PROXIMAL CONVOLUTED TUBULE

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112
Q

what diuretic should you avoid in a patient with gout

A

thiazide diuretics

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113
Q

which pump do the aldosterone antagonists work on

A

sodium/potassium pump in collecting duct

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114
Q

what side effect would require d/c in statin medications

A

muscle weakness side effects

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115
Q

true or false: statin medications decrease LDL levels through alterations in cholesterol synthesis and uptake of LDL in the liver

A

true

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116
Q

which statin would increase the risk of muscle myopathy and rhabdo with use if fibrates

A

lovastatin

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117
Q

what is the half life and onset for regular insulin

A

half life: 5-10min
onset 30-60 min

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118
Q

what are side effects of systemic corticosteroids

A

HTN
HYPERglycemia
adrenal suppression
increased risk of infections
peptic ulcers

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119
Q

when would a systemic corticosteroid be given

A

copd/asthma exacerbation

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120
Q

what nerve is at risk of damage during parathyroid or thyroid surgery

A

recurrent laryngeal nerve (vocal cord closure)

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121
Q

what type of anesthesia technique is preferred during parathyroid/thyroid surgery

A

TIVA

allows nerves to still respond to make sure recurrent laryngeal nerve is working during surgery

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122
Q

what type of anesthesia would be avoided if trying to monitor nerve function

A

paralytic

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123
Q

what is the onset, peak and duration of regular insulin

A

onset: 30-60 min
peak: 2-4 hrs
duration: 5-8 hrs

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124
Q

what type of insulin is used preop and post op

A

regular insulin

easier to have tighter control without long term effects

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125
Q

what are risk factors for thyroid storm

A

surgery
pregnancy
trauma
acute illness

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126
Q

what are symptoms of thyroid storm

A

T3 and T4 elevated, TSH low

fever, tachycardia, confusion, sweating

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127
Q

how can thyroid storm affect anesthesia

A

increases metabolism of drugs- need to increase drug administration

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128
Q

how can you treat thyroid storm

A

propylthiouracil
beta blockers- propanolol/esmolol
plasmapheresis/dialysis to remove thyroid hormone

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129
Q

what can severe hypothyroidism lead to and what are the symptos

A

myxedema coma

hypothermia, loss of conciousness

give thyroxine

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130
Q

what is the most common acute complication of pituitary disorders

A

diabetes insipidus

give DDAVP

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131
Q

what is a disease for acute adrenal insufficiency

A

addisonian crisis

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132
Q

what are three recommended induction agents during thyroid surgeries/hyperthyroidism

A

fentanyl
propofol
dexmeditomodine

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133
Q

true or false: general anesthesia is recommended for thyroid surgeries

A

false

TIVA

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134
Q

what meds can be given for HPA suppression

A

hydrocortisone, dexamethasone

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135
Q

what drug class is good at preventing opioid induced nausea/vomitting

A

antipyschotics- perphenazine

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136
Q

what are the four extrapyramidal symptom groups

A

acute dystonic
drug induced akathisia
drug induced parkisonism
tardive dyskinesia

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137
Q

what electrolyte imbalances can diuretics cause that potentiate NMB drugs

A

HYPOkalemia
HYPOcalcemia

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138
Q

what can diuretics cause during operation with blood pressure

A

hypovolemia=hypotension

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139
Q

true or false; daily diuretics should not be taken the day of surgery?

A

TRUE

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140
Q

where does osmotic diuretics work

A

proximal convoluted tubule

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141
Q

where does loop diuretics work

A

thick ascending loop of henle

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142
Q

where do thiazide diuretics work

A

early distal tubule/distal convoluted tubule

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143
Q

where do sodium channel blocker diuretics work

A

collecting tubule

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144
Q

where do aldosterone antagonist diuretics work

A

collecting tubule

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145
Q

what can omega 3 fatty acid (fish oil) cause

A

increased risk of bleeding

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146
Q

what can vitamin B3 (niacin) in nondiabetic patients cause

A

HYPERglycemia

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147
Q

how long should fish oil be d/c’d for surgery

A

at least a week

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148
Q

true or false: pt can continue statins all the way up to surgery

A

true

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149
Q

what can happen if you touch scopolamine patch and dont wash your hands then touch eyes

A

dry eyes and dilate them

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150
Q

what anesthetics increase PONV

A

NO
opioids
volatiles
neostigmine

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151
Q

what surgical factors increase risk of PONV

A

length/type of surgery

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152
Q

what patients are more at risk for PONV

A

women
non-smoker
hx motion sickness
past episode of PONV

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153
Q

when should you not give metoclopramide

A

small bowel obstruction
major bowel surgery
intrabdominal surgery where high motility will cause problem

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154
Q

what patients may benefit from metoclopramide before a surgery

A

DM
obese
pregnant
trauma
any pt recently ingested food

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155
Q

what does activation of the HPA axis in response to surgical stimulus cause

A

increased secretion of catabolic hormones

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156
Q

what is the pathway for HPA axis to release more cortisol

A

1- hypothalamus- corticotrophin releasing hormone stimulates
2-anterior pituitary to release adrenocorticotropin releasing hormone (ACTH) which stimulates
3- adrenal cortex to release cortisol

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157
Q

cortisol has what effects?

A

mineralocorticoid and glucocorticoid effects

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158
Q

how does cortisol promote HYPERglycemia

A

promotes gluconeogenesis in liver
protein catabolism
reduces peripheral glucose utilization

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159
Q

what are four meds that can affect release of adrenocortical hormones

A

opioids
midazolam
dexmedetomidine
etomidate

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160
Q

what are two ways to suppress release of cortisol to prevent surgical stimulus

A

high dose opioids
extensive dermatological blockade during regional anesthesia

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161
Q

what disease causes excessive release of growth hormone from pituitary gland

A

acromegaly

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162
Q

what are anesthetic considerations during acromegaly surgery

A

difficult airway
blood sugar monitoring
hydrocortisone replacement post op

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163
Q

what is the drug of choice for preop optimization for thyroidectomy

A

carbimazole

optimize hormone levels

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164
Q

what are anesthetic considerations for thyroidectomy

A

carbimazole preop
difficult airway equipment
atropine/glyco to dry secretions
opioid/dex/propofol
monitor NMB for myasthenia gravis
multiple endocrine neoplasia syndrome

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165
Q

what are three keys in periop management of DM

A

normal glucose, electrolytes, and volume

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166
Q

what medication should be avoided in patients with HYPERkalemia

A

succs

use ROC

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167
Q

what med can decrease cortisol levels and suppress hyperglycemic response to surgery

A

midazolam

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168
Q

what opioid if preferred in DM pt with kidney disease

A

fentanyl

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169
Q

true or false: pain can lead to increased glucose levels in DM patient

A

TRUE

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170
Q

true or false: metformin and ace inhibitors should be avoided periop in DM patient

A

TRUE

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171
Q

what electrolyte imbalances may need treatment post op parathyroid surgery

A

HYPOcalcemia
HYPOmagnesemia

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172
Q

what patient population is more likely to have hypoglycemia during surgery

A

geriatric patients

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173
Q

who has an increased allergic reaction risk to protamine

A

fish allergy
vasectomy
DM

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174
Q

what are the indirect Xa inhibitors

A

LMWH
heparin

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175
Q

what are the direct IIa inhibitors

A

bivalirudin
argatroban
dabigatran

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176
Q

what are the direct Xa inhibitors

A

rivaroxaban
apixaban

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177
Q

what are the indirect IIa inhibitors

A

heparin

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178
Q

what lab should be monitored with heparin

A

PTT
ACT

179
Q

how is LMWH different from heparin

A

binds to less proteins so more bioavailability

180
Q

what med is used for risk of HIT

A

bivalirudin or argatroban

181
Q

when should coumadin be stopped before surgery

A

1-3 days

182
Q

what factors does warfarin inhibit

A

2
7
9
10

183
Q

what test should be preformed pre-op for pt on xarelto

A

anti XA

184
Q

what is reversal agent for dabigatran

A

idarucizumab

185
Q

how do you treat bleeding while on TPA

A

cryo and platelets

186
Q

what is an anticholinergic antiemetic

A

scopolamine

187
Q

true or false: propofol has antiemetic properties

A

true

188
Q

when should decadron vs ondansetron be given

A

decadron-after induction
ondansetron- prior to induction or 15-20 min before emergence

189
Q

true or false: benadryl is a primary PONV agent

A

FALSE

190
Q

how do NSAIDs effect platelets

A

increases inhibition of platelet aggregation

191
Q

how long does aspirin inhibit platelet aggregation

A

7 days from last dose

192
Q

what is the most powerful anti-inflammatory

A

glucocorticoid

193
Q

what is a type of glucocorticoid

A

hydrocortisone, dexamethasone

194
Q

what reduced inflammation and tissue damage

A

steroids

195
Q

what is the prodrug for steroids

A

hydrocortisone

196
Q

what are steroids derived from

A

cholesterol

197
Q

where are steroids secreted from

A

gonads
placenta
adrenal cortex

198
Q

what are the two types of steroids

A

mineralocorticoids
glucocorticoids

199
Q

what steroid controls and influences metabolic processes such as BP, immunosuppression and temp

A

glucocorticoid

200
Q

what steroids help balance water, Na and K

A

mineralocorticoids

201
Q

what is the proposed MOA of steroids

A

phospholipase A2

202
Q

what is the most commonly used steroid in OR

A

dexamethasone

203
Q

why is dexamethasone commonly used in anesthesia

A

less fluid retention
long half life
more potent

204
Q

what are steroid used for in anesthesia

A

regional
epidural
PONV
reduce airway swelling after intubation

205
Q

what is steroid PONV dose

A

4-8mg before surgery or after induction (better before surgery)

206
Q

how do steroids work

A

inhibit prostaglandin synthesis which leads to reduction in inflammation and vascular permeability to prevent edema

207
Q

what is thought for using steroids in anesthesia

A

reduce tissue edema and nerve transmission created by inflammation
reduce PONV

208
Q

how do steroids prevent PONV

A

reduce afferent stimulation from incision and reduce trigger response in brain for PONV- not totally sure why it works

209
Q

what is risk with chronic steroid use

A

adrenal suppression

need stress dose of steroids even though they are on steroids

210
Q

diuretics can increase risk of which arrhythmia

A

VTACH

211
Q

how does phenytoin cause hyperglycemia

A

inhibits insulin secretion

212
Q

how does hypothermia affect bleeding

A

increases bleeding

platelets cant work

213
Q

in what ways do procoagulants help

A

prevent clot lysis
reduce bleeding
reduce blood transfusion requirements

214
Q

what are the lysine analogs

A

TXA
epsilon aminocaproic acid (EACA)

215
Q

what medication competitively inhibits activation of plasminogen to plasmin

A

epsilon aminoproic acid (EACA)

216
Q

what is the enzyme that breaks down fibrin clots and fibrinogen

A

plasminogen

217
Q

are lysine analogs prothrombic or clot stabilizers

A

clot stabilizers

prevents clot lysis

218
Q

what are general risks for TXA and EACA

A

thrombosis

219
Q

what is a risk of using TXA with general anesthesia

A

seizures

220
Q

how does TXA help in orthopedic surgeries

A

bloodless surgical field for visualization
reduce blood loss

221
Q

what is the heparin rebound effect

A

protamine iv 1/2life is 5 min, heparin 1/2 life is 1 hr

222
Q

what procoagulant is typically used in cardiac cases

A

protamine

223
Q

what is only agent that can reverse UF heparin

A

protamine

224
Q

how does protamine work

A

decreases activated clotting time

225
Q

what medication is a polypeptide that contains 70% arginine residues

A

protamine

226
Q

what on protamine inactivates acidic heparin molecule

A

protein

227
Q

what does excess protein do

A

increases clotting time, inhibits platelets and serine proteases

228
Q

what are the side effects of protamine

A

anaphylaxis
RV failure
hypotension
pulm htn

229
Q

what happens when pt receives too much protamine

A

coagulopathy

platelet inhibition, increased clotting time

230
Q

what does desmopressin stimulate release of

A

von Willebrand Factor

231
Q

what is the role of von Willebrand Factor

A

mediates platelet adherence to vascular endothelium

232
Q

what med is used for hemophilia A and von Willebrand disease

A

Desmopressin

233
Q

what are side effects of desmopressin

A

hypotension
MI

234
Q

why is fibrinogen important

A

clot formation

235
Q

how does fibrinogen work

A
  1. thrombin splits fibrinogen, which exposes polymerization sites
  2. networks are formed at polymerization sites
  3. RBCs get trapped in network
  4. 13a initiates cross linking of fibrin polymers
236
Q

what initates cross linking of fibrin polymers

A

factor 13a

237
Q

what increases elasticity of clot and its resistance to fibrinolysis

A

factor 13a

238
Q

what are normal fibrinogen levels

A

200-400mg/dL

239
Q

what does hypofibrinogenemia raise the risk of

A

bleeding

240
Q

how can you increase fibrinogen levels

A

cryo
fibrinogen concentrates

241
Q

in the transfusion algorithm, what is the target increase of fibrinogen levels

A

150-200 mg/dL

242
Q

what are some topical hemostatic agents

A

surgicel
oxycel
gelfoam
coseal
bioglue

243
Q

when would you use topical hemostatic agents

A

intraoperatively to promote hemostasis

244
Q

what factor provides stability to new clots

A

factor 13a

245
Q

what is recombinant activated factor VIIa used for

A

hemophilia a and b
glanzmann thombasthenia
battlefield injuries

246
Q

what are the factors included in the prothrombin complex concentrates

A

2
7
9
10

247
Q

what are the prothrombin complex concentrates used for

A

vitamin K antagonist reversal
prevent/control bleeding
hemophilia

248
Q

what is the actual standard of care in US to reverse acute bleeding on warfarin

A

FFP

249
Q

what is the MOA for TXA and EACA

A

competitively inhibit activation of plasminogen to plasmin

250
Q

what site does rivaroxaban, apixaban and edoxaban work

A

Xa

251
Q

what sites does LMWH, heparin, and fondaparinux work

A

Xa

252
Q

what site does argatraban, bivalrudin, dabigatran, lepirudine and heparin work

A

IIa

253
Q

what does heparin bind to

A

anti thrombin III

254
Q

is heparin acidic or basic

A

acidic

255
Q

what is the IV 1/2 life of heparin

A

1 hour

256
Q

what is the onset of subQ heparin

A

1-2 hrs

257
Q

what lab do you use to monitor heparin

A

aPTT

258
Q

what is a normal aPTT

A

25-35 seconds

259
Q

what other labs can be used to monitor heparin besides aPTT

A

ACT

260
Q

when is activated clotting time used

A

during Cardiopulmonary bypass

261
Q

what is heparin used for

A

PE DVT
acute coronary syndromes
periop anticoag
HD

262
Q

what is normal ACT and therapeutic ACT

A

normal 70-120
therapeutic 150-600

263
Q

how is LMWH different from heparin

A

binds less to proteins, more bioavailability

264
Q

what does renal failure do to LMWH

A

prolongs the effects

265
Q

how long should surgery or epidural/spinal be delayed after last dose of lmwh?

A

12 hrs

longer with renal dysfunction

266
Q

what surgery has unique risk of venous thrombosis

A

hip replacement

kinks femoral vein

267
Q

how do direct thrombin inhibitors work

A

bind to two sites on thrombin
-catalytic site
-fibrinogen binding site

268
Q

examples of direct thrombin inhibitors

A

bival, dabigatran, argatroban

269
Q

what is the half life of warfarin

A

24-36 hrs

270
Q

What medication do you use to correct central anticholinergic syndrome

A

Physostigmine

15-60mcg/kg IV q 1-2 hrs

271
Q

what is the therapeutic anti xa range

A

0.6-1 units/ml

272
Q

what is the preferred treatment for vitamin k antagonist reversal in emergent situations

A

FFP or PCCs

273
Q

how does hypoalbuminea affect warfarin

A

increases amount of warfarin in circulation

274
Q

why does lmwh have higher bioavailability than heparin

A

less protein bound

275
Q

what are benefits of using decadron

A

less fluid retention
long half life
more potent
reduce inflammation
PONV

276
Q

how do steroids reduce PONV

A

reduce inflammation triggered by the stimulation of the PNS

277
Q

what stimulates platelet aggregation

A

thromboxane

278
Q

what stabilizes clots that are already present

A

txa

279
Q

what prevents plasminogen from forming plasmin so the clot isnt broken down

A

txa

280
Q

what breaks down a clot

A

plasmin

281
Q

what are normal fibrinogen levels

A

200-400 mg/dl

282
Q

what can increase fibrinogen levels

A

cryo

283
Q

what factors are in PCC

A

2, 7, 9, 10

284
Q

what is the intrinsic pathway activated by

A

blood trauma/ surface contact (exposure to collagen)

285
Q

what does tissue trauma activate

A

factor 3 and factor 7

286
Q

what factors are in the intrinsic pathway

A

12
11
9
8

287
Q

what factors are in the extrinsic pathway

A

3 (tissue factor “thromboplastin”)
7

288
Q

what factors are in the common pathway

A

10
5
2
1

289
Q

what factors does thrombin activate

A

5
8
11
13

290
Q

what turns fibrinogen (factor 1) into fibrin

A

thrombin

291
Q

what is the onset of subQ heparin

A

1-2 hrs

292
Q

what is therapeutic aPTT

A

60-100 sec

293
Q

what pt factor can cause prolonged effects of lmwh

A

renal disease

294
Q

how long should surgery be delayed after dose of lmwh

A

12 hrs

295
Q

what are benefits of coumadin

A

predictable onset
duration of action
bioavailability

296
Q

what is the half life of coumadin and how long to d/c before surgery

A

24-36 hrs
1-3 days before surgery

297
Q

what lab do you check in preop for coumadin

A

INR

298
Q

what does idarucizumab reverse

A

dabigatran

299
Q

what lab do you check for rivaroxaban

A

anti xa

300
Q

what can reverse warfarin beside ffp

A

PCC

301
Q

what anticoagulant medication class is used for CAD and vascular patients

A

platelet inhibitors

302
Q

what anesthesia technique should be avoided when pt has been on platelet inhibitors

A

regional anesthesia

need to be off meds for 5-7 days before regional anesthesia can be done

303
Q

what clotting factor does lmwh work on

A

Xa

304
Q

what has a decreased risk of inducing HIT

A

lmwh

305
Q

what meds can be used in risk of HIT

A

bival, argatroban

306
Q

what coag factors does heparin inactivate

A

Xa and IIa (thrombin)

307
Q

what is factor 1

A

fibrinogen

308
Q

what is factor 2

A

prothrombin

309
Q

what is factor 3

A

tissue thromboplastin or tissue factor

310
Q

what is factor 4

A

calcium

311
Q

what is factor 5

A

labile factor

312
Q

what is factor 7

A

stable factor

313
Q

what is factor 8

A

anti hemophilic factor

314
Q

what is factor 9

A

Christmas factor
plasma thromboplastin component

315
Q

what is factor 10

A

stuart-prower factor

316
Q

what is factor 11

A

plasma thromboplastin antecedent

317
Q

what is factor 12

A

Hageman factor

318
Q

what is factor 13

A

fibrin stabilizing factor

319
Q

what is a high risk in PCCs vs ffp post reversal

A

clotting complications

320
Q

why do we give protamine slow

A

to prevent hypotension; anaphylactoid rxn

321
Q

what is a p2y platelet inhibitor

A

clopidogrel

322
Q

what drugs make up dual antiplatelet therapy

A

ASA and clopidogrel

323
Q

what medications work on Xa

A

rivaroxaban
apixaban
endoxaban
LMWH
fondaparinux
UFH

324
Q

what medications work at IIa

A

argatroban
bivalirudin
dabigatran
lepirudin
UFH

325
Q

side effects of heparin

A

hemorrhage
HIT
allergic rxn
hypotension
decreased antithrombin concentration

326
Q

what are contraindications for heparin

A

neurosurgery procedures
hx HIT
regional anesthesia

327
Q

what is dose of protamine

A

1mg for every 100 units of circulating heparin

0.75mg for every 100 units if at least 30 min after heparin dose

328
Q

advantages of LMWH

A

-more consistent to dose
-better VTE prophylaxis
-rapid onset
-greater bioavailability than UFH
-can be self administered
-fixed dose without lab monitoring
-better dose to anticoag response correlation

329
Q

how long after being stopped does anticoag go back to normal on argatroban

A

4 hrs

330
Q

what lab do we use to monitor argatroban

A

aPTT

331
Q

what lab do you use to monitor Bivalirudin

A

ACT

332
Q

true or false: warfarin crosses the placenta?

A

TRUE
dramatic effects on the fetus

333
Q

what labs are used to monitor warfarin

A

INR and PT

334
Q

what can effect vitamin K levels in a patient

A

antibiotics
IV fluids
liver disease
age
diet

335
Q

where is vitamin K synthesized

A

in GI by bacterial synthesis, need good gut flora

336
Q

when do you stop warfarin for surgery

A

1-3 days

337
Q

what is exogenous vitamin k called

A

phytonadione

338
Q

when can neuroaxial anethesia be used after rivaroxaban (Xarelto)

A

18 hrs after last dose to remove catheter

do not restart med until 6 hrs after catheter removed

339
Q

what are side effects of chronic steroid use

A

-suppression of HPA axis
-electrolyte and metabolic changes
-osteoporosis
-PUD
-skeletal muscle myopathy
-CNS dysfunction
-peripheral blood changes
-inhibition of normal growth

340
Q

anesthesia considerations for thiazide diuretics

A

-can increase effects of non depolarizing neuromuscular blockade
-NSAIDs decrease effectiveness of thiazides
-lithium increases reabsorption and risk for toxicity with thiazides

341
Q

side effects of loop diuretics

A

hypokalemia
hyperglycemia
increase risk of digitalis toxicity
hypotension
“braking phenomenon”
ototoxicity

342
Q

What effect does the PNS stimulation have on insulin release?

A

Increased insulin release

343
Q

What effect does beta 2 stimulation have on insulin release

A

Increased insulin release

344
Q

What effect does alpha 2 stimulation have on insulin release

A

Decreased insulin release

345
Q

2 drugs that counter the hypoglycemic effect of insulin

A

Epinephrine
Glucagon

346
Q

Which type of pancreatic cells release glucagon

A

Alpha

347
Q

Which beta blocker inhibits conversion of T4 to T3

A

Propranolol

348
Q

Which agent primarily targets the chemoreceptor trigger zone?

A

Ondansetron

349
Q

What antiemetic is contraindicated with bowel obstruction

A

Metoclopramide

350
Q

What antiemetics are contraindicated for Parkinson’s

A

Butyrophenones
Phenothiazines
Metoclopramide

351
Q

How can IM ephedrine reduce PONV

A

Maintaining BP and cerebral perfusion

25mg IV

apex

352
Q

What receptor stimulated during motion induced nausea

A

M1 and H1 in the vestibular system of the inner ear

apex

353
Q

What are five patient risk factors for PONV

A

Female
Nonsmoker
Hx of motion sickness
Previous PONV
Youth > elderly

354
Q

What are 5 anesthetic risk factors for PONV

A

Halogenated gases
Nitrous oxide
Opioid
Etomidate
Neostigmine

355
Q

What drugs counter hypoglycemia

A

Epi
Glucagon
Estrogen

356
Q

What drugs enhance hypoglycemic effect

A

MAOIs
Tetracyclines
Salicylates

357
Q

Where is prothrombin produced

A

Liver

358
Q

What is the function of plasmin and anti-thrombin

A

Break down fibrin mesh

359
Q

What is needed for activation of prothrombin

A

Vitamin K

360
Q

What labs evaluate intrinsic pathway

A

aPTT and ACT

361
Q

What labs evaluate extrinsic pathway

A

PT

362
Q

What labs do we monitor for warfarin

A

PT INR

363
Q

What pathway does heparin work in

A

Intrinsic and common

364
Q

What pathway does warfarin work on

A

Extrinsic and intrinsic and common

365
Q

What clotting factors does PTTevaluate

A

12
11
9
8
10
5
2

366
Q

What factors does PT evaluate for

A

7
10
5
2
1

367
Q

Heparin MOA

A

Indirect thrombin inhibitor

Binds to anti thrombin 3 to prevent conversion of fibrinogen to fibrin

Inhibits common pathway at Xa and thrombin; inhibits factors Xa, XIIa, XIa, and IXa

368
Q

What site of coag cascade for UFH and LMWH work at

A

UFH: Xa and IIa

LMWH: Xa

369
Q

Protamine MOA

A

Irreversibly binds to heparin molecule creating an inactive salt which is eliminated through the liver or kidneys; makes heparin inactive

370
Q

Does HIT 1 or HIT 2 require treatment?

A

HIT2

The body immune system activated platelets in presence of heparin and causes platelets to clot which results in platelet level dropping; puts at risk for developing blood clots

371
Q

LMWH onset and doa

A

Onset: 20-30 min

DOA: 6-12hrs

372
Q

Examples of direct thrombin inhibitors

A

Bivalirudin
Argatroban
Lepirudin
Desirudin

373
Q

What is half-life of argatroban

A

40 min

374
Q

Lab monitor for argatroban

A

aPTT

If pt has HIT and AKI argatroban is med of choice

375
Q

Key points for lepirudin

A

-irreversibly inhibits thrombin
-pt can produce direct antibodies so frequent aPTT monitoring
-half life 80 min
-renal excreted; don’t use in renal fx patients
- NO REVERSAL AGENT

376
Q

Key points Desirudin

A

-reduces DVT/VTE better after total hip or knee
-only direct thrombin inhibitor approved for subQ use
-can have anaphylaxis response through hypersensitivity
-half life 60 min IV 120 min subQ
-only med in class that does not require lab monitoring of dose

377
Q

Warfarin MOA

A

Inhibits vitamin k synthesis

378
Q

What meds require antithrombin as cofactor

A

LMWH
Fondaparinux
UFH

379
Q

Most common use for Rivaroxaban

A

Reduce stroke and systemic embolism in afib

380
Q

How can rivaroxaban be reversed?

A

PCCs

381
Q

ASA class and MOA

A

Platelet inhibitor

Irreversibly inhibits COX-1 and prevents formation of thromboxane A2 which inhibits platelets for 7 days

382
Q

Platelet inhibitors

A

ASA
Clopidogrel
Prasugrel
Ticagrelor

MOA: irreversibly bind to P2Y12 receptors blocking ADP binding which inhibits ADP mediated platelet activation and aggregation

383
Q

TPA MOA and class

A

Class: thrombolytics; tissue plasminogen activator

MOA: coverts plasminogen into its active form plasmin to breakdown fibrin mesh to break up clot and restore circulation

384
Q

What factors do protein C and S work to inhibit

A

5a and 8a

385
Q

What factors does antithrombin inactivate

A

9
10
11
12

386
Q

Advantages of direct thrombin inhibitors

A

-lack of binding to other plasma proteins
- anti platelet effect
- absence of immune mediated thrombocytopenia
-can inhibit soluble thrombin and fibrin bound thrombin
-more predictable anti coag effect

387
Q

Pre op eval for cancer pts

A

-correct electrolytes, obtain ECG, chest X-ray, check cbc and coags, abg, glucose, LFTs, renal labs, platelet, H&H
-aggressive PONV prophylaxis (emend, Marinol, scope patch, Zofran, etc)
-aseptic techniques bc of immunosuppression

388
Q

What do you do if pt on chronic steroids and has suppression of HPA axis

A

Prednisone >20mg/day for >3 weeks then stress dose

100mg of hydrocortisone

389
Q

MOA of recombinant factor 7 (NovoSeven)

A

Bind to the surface of activated platelets directly activating factor X and leading to an improved generation of thrombin

390
Q

What is necessary for recombinant factor 7 to work

A

Normal fibrinogen levels
Normal pH

391
Q

Cryo anesthesia indications

A

-treat vWF and hemophilia when direct concentrates not available
-rapid transfusion protocols
-active bleed in OB patients
-hypofibrinogenemia

*Cryo preferred for fibrin levels <150 with no known clotting deficiency *

392
Q

Risk of Cryo

A

Exposure to multiple donors and no viral inactivation

393
Q

Which cancer drug has risk of skeletal muscle weakness and prolonged neuromuscular blockade

A

Alkylating agents

394
Q

Anesthesia consideration for methotrexate

A

NSAIDs and salicylates can increase drug levels and cause toxicity

Contraindicated in pregnancy bc it blocks folic acid

395
Q

Which mediator promotes vasoconstriction in response to vascular injury

A

Thromboxane 2

396
Q

How long do you stop ADP inhibitors for surgery

A

5-14 days

Apex

397
Q

How long do you stop GPIIb/IIIa receptor antagonists for surgery

A

1-3 days

398
Q

How long do you stop COX inhibitors before surgery?

A

ASA 7 days

NSAIDs 1-2 days

399
Q

Common lab results in DIC

A

Low platelets
Low fibrinogen
Increased PT/PTT
Increased D dimer

400
Q

Cryo contains what factors

A

Fibrinogen
vWF
Factor 8

401
Q

Warfarin + H2 =

A

Increased risk of hemorrhage

Ranitidine and cimetidine are H2 blockers

402
Q

Functions of cortisol

A

Maintenance of cardiac function
Systemic Bp
Normal response to Catecholamines
Regulate fat metabolism, carbs, and protein
Balances sodium, k and water levels

403
Q

What is stress dose for minor surgical stress

A

Usual corticosteroids steroid dose + 25 mg hydrocortisone

404
Q

What is the stress dose for moderate surgical stress

A

Usual corticosteroid dose + 50-75mg hydrocortisone for 24-48 hrs

405
Q

What is stress dose for major surgical stress

A

Usual corticosteroid dose + 100-150mg hydrocortisone IV Q8 hr for 48-72 hrs

406
Q

MOA of dexamethasone PONV

A

Inhibits prostaglandin synthesis

407
Q

MOA of dexamethasone as analgesic

A

Inhibition if phospholipase that is necessary for the inflammation chain reaction along both the cyclooxygenase and lipoxygenase pathways

408
Q

What 5 receptors mediate nausea and vomiting

A

M1
Dopamine D2
5HT3 serotonin
Neurokinin (NK1)
Substance P

409
Q

Which respiratory factor increases in elderly population

A

Dead space

apex

410
Q

Respiratory changes in geriatric patients

A

-Minute ventilation increases
-Lung compliance increases
-Lung elasticity decreases
-Chest wall compliance decreases
-Response to hypercarbia/hypoxia decreases
-airway reflexes decrease
-upper airway tone decreases

411
Q

Example of carbonic anhydrase inhibitor

A

Acetazolamide

412
Q

What are carbonic anhydrase inhibitors used for

A

-open angle glaucoma
-altitude sickness
-central sleep apnea

413
Q

Examples of osmotic diuretics

A

Mannitol, isosorbide, glycerin

414
Q

What are osmotic diuretics used for

A

-prevent AKI
-intracranial HTN
-acute oliguria

415
Q

anesthesia considerations for HYPOthyroid

A

-severe hypothyroid (myxedema) cancel surgery
-delayed gastric emptying-aspiration risk
-hypodynamic circulation= decreased HR, SVR, contractility, decreased baroreceptors
-mac is unchanged
-muscle weakness/sensitivity to NMB
- treat hemodynamics with sympathomimetics NOT PHENYLEPHRINE

416
Q

insulin is metabolized by

A

liver and kidneys

417
Q

therapy of choice for Graves’ disease

A

Radio iodine

418
Q

Hyperthyroid Anesthesia considerations

A

-euthyroid before surgery
-emergency surgery warrants admin of BB, potassium iodine, PTU
-titrate NMBs carefully; it increases myasthenia gravis and myopathy
-avoid sympathomimetics, anticholinergics, ketamine, and pancuronium

419
Q

oxytocin dose

A

10-20 units in 1000ml NS or LR

420
Q

ACTH stimulates

A

adrenal gland to produce cortisol

421
Q

TSH stimulates

A

thyroid to produce T3 and T4 for metabolism

422
Q

oxytocin anesthesia considerations

A

-rapid bolus cause hypotension; treat with phenylephrine
-reflex tachycardia
-un GA and spinal pt may not compensate with increased CO

423
Q

indications for vasopressin

A

-diabetic insipidus
-refractory hypotension (especially ACE and ARBs)
-uncontrolled hemorrhage in esophageal varices
- septic or hemorrhagic shock
-refractory cardiac arrest

424
Q

treatment for DI

A

DDAVP or vasopressin

425
Q

treatment for SIADH

A

fluid restriction
sodium correction

426
Q

what are the thyroid hormones

A

T3
T4
calcitonin

427
Q

what hormones regulate alpha and beta receptors

A

T3 T4

428
Q

in older adults and in pregnancy what changes are to thyroid medication dose

A

decreases in older adults
increases in pregnancy

429
Q

how long should a patient be euthyroid before surgery

A

6-8 weeks; check levels before surgery

430
Q

thyroid storm can mimic what under GA

A

MH
pheochromocytoma
neuroleptic malignant syndrome
light anesthesia

431
Q

what drugs do we use in perioperative thyroid storm

A

Methimazole (block synthesis)
PTU/ Propanolol (block t4 to t3 conversion)
propanolol/esmolol (beta blocker)

432
Q

dexamethasone key points

A

-rapid onset 1-2
-effects all proinflammatory mediators
-antiinflammatory properties
-PONV
-can cause burning perineal area
-give after pt is asleep
-long 6-12 hrs
-reduce post-op pain

433
Q

what is the most important stimulus for aldosterone secretion

A

accumulation of potassium in the plasma

434
Q

what do mineralcorticoids (aldosterone) do

A

Regulates salt and water

blood pressure on RAAS system

435
Q

how do we treat CONNs syndrome

A

excessive mineralcorticoids; treat with spironolactone ACE/ARBS

436
Q

anesthesia consideration for Conn’s syndrome

A

increased sensitivity to non-depolarizing NMBs
avoid hyperventilation
caution with volume overload

437
Q

what can cause addison disease crisis

A

illness
surgery
sepsis
stress on body

Chronic steroids– give stress dose steroids for patient with surgery 100mg then 100-200mg every 24hr

438
Q

What is required for GI tract to absorb vitamin K

A

Bile

439
Q

What is required for GI tract to absorb vitamin K

A

Bile salts

440
Q

In a negative feedback loop what does the hormone do

A

Reduces its own release

441
Q

In a positive feedback loop what does the hormone do

A

Increases its own release

442
Q

What can affect ACT results

A

Hypothermia
Thrombocytopenia
Deficiency in fibrinogen, factor 7 and 12

443
Q

what is in FFP

A

2
5
8
9
10
11
anti thrombin 3

Advanced Pharm (4 decks)

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