Exam 3 Material Flashcards
(443 cards)
1
Q
List the 4 steps of hemostasis
A
- Vascular spasm
- Formation of platelet plug (primary hemostasis)
- Coagulation and fibrin formation (secondary hemostasis)
- Fibrinolysis
2
Q
Platelets contain the following components
A
Actin
Adenosine diphosphate
Calcium
3
Q
Where and how are platelets produced
A
By megakaryocytes in the bone marrow
4
Q
Normal platelet levels
A
150,000-300,000mm3
5
Q
How long do platelets live
A
8-12 days (1-2weeks)
apex
6
Q
How are platelets cleared
A
Macrophages in the reticuloendothelial system and the spleen
7
Q
What’s the function of actin
A
Helps the platelet contract to form a platelet plug
8
Q
What is the function of glycoproteins
A
Adheres to injured endothelium, collagen and fibrinogen
9
Q
What is the function of ADP
A
Platelet activation and aggregation
10
Q
What is the function of serotonin in the platelet
A
Activates nearby platelets
11
Q
What is the function of growth factor in the platelet
A
Helps repair damaged vessel walls
12
Q
Which substance is responsible for adhering the platelet to the damaged vessel
A
Von Willebrand Factor
13
Q
What substance is responsible for platelet activation and aggregation
A
ADP
Thromboxane A2
apex
14
Q
list the 3 steps required to produce a platelet plug
A
adhesion
activation
aggregation
15
Q
Von Willebrand factor binds to the platelet during which step
A
adhesion (step 1)
16
Q
How does the injured blood vessel initially activate the platelet plug
A
endothelial injury exposes collagen which activates platelets
17
Q
what are the vitamin K dependent factors
A
2
7
9
10
18
Q
What is the first coagulation factor activated in the extrinsic pathway?
A
Tissue Factor (3)
19
Q
what factors are part of the extrinsic pathway
A
3 and 7
20
Q
how fast can a clot form via the extrinsic pathway
A
~ 15 seconds
21
Q
what is the first factor to be depleted in the patient with vit K deficiency
A
factor 7
22
Q
a deficiency of what factor causes hemophilia A
A
factor 8
23
Q
how long does it take to form a clot via the intrinsic pathway
A
up to 6 min
24
Q
what factors make up the intrinsic pathway
A
12
11
9
8
25
what is the role of thrombin
it converts fibrinogen to fibrinogen monomer
26
what must be present to convert fibrinogen monomer to fibrin fibers
calcium (factor 4)
27
2 true statements regarding fibrinolysis
- D dimer measures fibrin split products
-alpha 2 antiplasmin inhibits the action of plasmin on fibrin
28
what are 4 mechanisms that counterbalance clot formation
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
29
what are 2 enzymes that convert plasminogen to plasmin
1 tPa
2 Urokinase
30
what 2 enzyme inhibitors turn off the fibrinolytic process
1. tPa inhibitor (TPAI)
2. alpha 2 antiplasmin
31
how are plasmin activators used therapeutically
they help dissolve thrombi to restore blood flow
32
Identify the best predictor of bleeding during surgery
History and physical
33
What is a normal platelet count
150,000-300,000mm3
34
A platelet count less than 20,000mm3 increases the risk of?
Spontaneous bleeding
35
What lab test measures for fibrinolysis
D dimer
36
Heparin inhibits which pathway(s)
Intrinsic and common pathway
37
Where is endogenous heparin produced
Liver
Basophils
Mast cells
38
On what part of the coagulation cascade does heparin work
Intrinsic and common pathways
39
Where should the aPTT be maintained for active VTE
1.5-2.5 times normal
40
What is a normal ACT
90 seconds
Apex
41
What are 3 contraindications to heparin administration
1. Neurosurgical procedures
2. HIT
3. Regional anesthesia
42
Warfarin inhibits factors
2, 7, 9, 10
Proteins C and S
43
Where do we obtain inactive vitamin K?
Diet
Manufactured in the gut via bacteria
44
How does warfarin work
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
45
What are the antidotes for warfarin
Vitamin k
FFP
46
What is the therapeutic level for PT/INR for patient on warfarin
2-3 times normal
47
What is the dose for exogenous vitamin K
10-20mg PO, IM or IV
Apex
48
What risk is associated with IV phytonadione
Life threatening anaphylaxis
IV admin is best avoided, if have to give IV rate should not exceed 1mg/min
Apex
49
What is MOA for clopidogrel
ADP receptor antagonist
50
What is MOA of Abciximab
GpIIb/GpIIIa receptor antagonist
51
Warfarin MOA
Vitamin K antagonist
52
Enoxaparin MOA
Antithrombin cofactor
53
A patient scheduled for coronary revascularization is diagnosed with type 3 von willebrand disease. What is the best treatment for this patient?
vWF/ factor 8 concentrate
54
Which type of vWF disease responds best to desmopressin?
Type 1
55
What is the first line agent for patient with type 3 vWF disease?
Purified 8-vWF concentrate
56
What coagulation factors are in cryoprecipitate
8
13
Factor 1 (fibrinogen)
vWF
57
Cryo is useful in treating which type of vWB disease
Type 1,2,3
58
What coagulopathies present with prolonged PTT and normal PT
Hemophilia A and B
59
Hemophilia A and B affect what factors?
8 hemophilia A
9 hemophilia B
60
Which type of hemophilia is more severe
Hemophilia A
61
Which pathway in coag cascade is affected by hemophilia A and B?
Intrinsic pathway
PTT will be prolonged with severe disease, slightly prolonged with mild disease
62
What should always be performed before surgery with a severe hemophilia?
Type and cross
63
6 treatments for hemophilia A
Factor 8
FFP
Cryo
DDVAP
Antifibrinolytics
Recombinant factor 7
64
Recombinant factor 7 increases risk of
Arterial thrombosis (MI and stroke)
Venous thrombosis (DVT and PE)
65
Define DIC
Disordered clotting and fibrinolysis that leads to hemorrhaging and systemic thrombosis
66
Conditions with high risk of DIC
Sepsis
Ob
Cancer (adenocarcinoma, leukemia, lymphoma)
67
Signs of DIC
Ecchymisis
Petechiae
Mucosal bleeding
Bleeding at Iv site
Prolonged PT/PTT
Increased D dimer and fibrin split products
Decreased fibrinogen and antithrombin
68
Side effects of cisplatin
Acoustic nerve injury
Nephrotoxicity
69
Side effect of vincristine
Peripheral neuropathy
70
Side effect of bleomycin
Pulmonary fibrosis
71
Side effect of doxorubicin
Cardiotoxic
72
Side effects of methotrexate
Bone marrow suppression
73
What meds can increase risk of hyperkalemia when used with K sparing diuretics?
ACE
ARBs
NSAIDs
Beta blockers
Apex says beta blockers, his ppt said the others
74
Which potassium sparing diuretic antagonizes aldosterone at the mineral cortical is receptors
Spironolactone
75
Side effects of potassium sparing diuretics
Hyperkalemia
Metabolic acidosis
Gynecomastia
Libido changes
Nephrolithiasis
76
How can loop diuretics affect nondepolarizing neuromuscular blockade
Potentiates it
77
What cross sensitivity can happen with furosemide
Cross sensitivity with allergies to sulfunamides
78
Thiazide diuretics can ___ nondepolarizing neuromuscular blockade
Potentiate
79
NSAIDs and thiazide diuretics
NSAIDs decrease effectiveness of thiazide diuretics
80
Which hormones are released by the anterior pituitary gland
Prolactin
Luteinizing hormone
Melanin
Growth hormone
ACTH
Tsh
81
Anesthetic considerations for the patient with diabetes insipidus
DDAVP to treat
82
When compared to T4 which statements best describe T3
T 3 has:
Shorter half life
Higher potency
Less protein bound
Smaller conc in the blood
83
What are 2 CV side effects of hypocalcemia
-hypotension
-prolonged QT interval
84
What are the 4 Bs when treating the patient with thyroid storm?
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)
85
List 4 ways the body responds to hypocalcemia
-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
86
How does aldosterone affect renal function
-increases Na and water reabsorption
-increases K and H excretion
87
How much cortisol does the body produce each day
Average cortisol production is 15-30mg/day, dr p s says 10 to 20
with a normal serum level of 12 mcg/dL
88
How does cortisol production change in response to perioperative stress
Major perioperative stress can increase cortisol production upwards of 100mg/day, with serum level up to 30-50mcg/dL
89
what are the hemodynamic effects of cortisol
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
90
what are the 3 most relevant endogenous steroids
cortisol
cortisone
aldosterone
91
what steroid has the greatest mineralocorticoid effect
aldosterone
its 3000 times more potent than cortisol
92
which synthetic steroid is best suited to treat addisons disease
Prednisone
of all the synthetic steroids, it most closely resembles cortisol
93
what herbal supplement can cause a syndrome that resembles hyperaldosteronism
Licorice
94
4 signs of Cushing's syndrome
HTN
HYPOkalemia
metabolic alkalosis
hyperglycemia
95
a patient with adrenal insufficiency and sepsis requires an emergency intubation in the intensive care unit. which drug should be avoided
etomidate
by inhibiting 11BH a single induction dose of etomidate can cause adrenocortical suppression for >8hrs
this could cause acute adrenal crisis.
96
what is protamine typically used for
reversing heparin
97
what is the MOA for the antifibrinolytic agents TXA and EACA
Competitively inhibit activation of plasminogen to plasmin
98
low factor 13 puts patient at risk for?
bleeding
99
what is the preferred treatment for vitamin K antagonist reversal in emergent situations
PCC or FFP
100
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
Cryoprecipitate
101
what is a potential risk for giving TPA for an ischemic stroke
conversion from ischemic stroke to hemorrhagic stroke
102
true or false: protamine works to neutralize LMWH
False
103
what two sites do most anticoagulants work on
10a and 2a
104
which medication primarily targets the chemoreceptor trigger zone
ondansetron
105
when should ondansetron be given in surgical patients
30 min before emergence
106
true or false: H2 receptor antagonists have an influence on pH of gastric fluid that is already present in stomach
False
107
when should oral omeprazole be given before anticipated induction of anesthesia for chemoprophylaxis (PONV)
>3 hrs before
108
what is the site of action for loop diuretics
thick ascending loop of henle
109
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
False
110
rapid administration of metoclopramide can induce what
abdominal cramping
111
what is the MOA for carbonic anhydrase inhibitors
noncompetitive inhibitors of enzyme activity in the PROXIMAL CONVOLUTED TUBULE
112
what diuretic should you avoid in a patient with gout
thiazide diuretics
113
which pump do the aldosterone antagonists work on
sodium/potassium pump in collecting duct
114
what side effect would require d/c in statin medications
muscle weakness side effects
115
true or false: statin medications decrease LDL levels through alterations in cholesterol synthesis and uptake of LDL in the liver
true
116
which statin would increase the risk of muscle myopathy and rhabdo with use if fibrates
lovastatin
117
what is the half life and onset for regular insulin
half life: 5-10min
onset 30-60 min
118
what are side effects of systemic corticosteroids
HTN
HYPERglycemia
adrenal suppression
increased risk of infections
peptic ulcers
119
when would a systemic corticosteroid be given
copd/asthma exacerbation
120
what nerve is at risk of damage during parathyroid or thyroid surgery
recurrent laryngeal nerve (vocal cord closure)
121
what type of anesthesia technique is preferred during parathyroid/thyroid surgery
TIVA
allows nerves to still respond to make sure recurrent laryngeal nerve is working during surgery
122
what type of anesthesia would be avoided if trying to monitor nerve function
paralytic
123
what is the onset, peak and duration of regular insulin
onset: 30-60 min
peak: 2-4 hrs
duration: 5-8 hrs
124
what type of insulin is used preop and post op
regular insulin
easier to have tighter control without long term effects
125
what are risk factors for thyroid storm
surgery
pregnancy
trauma
acute illness
126
what are symptoms of thyroid storm
T3 and T4 elevated, TSH low
fever, tachycardia, confusion, sweating
127
how can thyroid storm affect anesthesia
increases metabolism of drugs- need to increase drug administration
128
how can you treat thyroid storm
propylthiouracil
beta blockers- propanolol/esmolol
plasmapheresis/dialysis to remove thyroid hormone
129
what can severe hypothyroidism lead to and what are the symptos
myxedema coma
hypothermia, loss of conciousness
give thyroxine
130
what is the most common acute complication of pituitary disorders
diabetes insipidus
give DDAVP
131
what is a disease for acute adrenal insufficiency
addisonian crisis
132
what are three recommended induction agents during thyroid surgeries/hyperthyroidism
fentanyl
propofol
dexmeditomodine
133
true or false: general anesthesia is recommended for thyroid surgeries
false
TIVA
134
what meds can be given for HPA suppression
hydrocortisone, dexamethasone
135
what drug class is good at preventing opioid induced nausea/vomitting
antipyschotics- perphenazine
136
what are the four extrapyramidal symptom groups
acute dystonic
drug induced akathisia
drug induced parkisonism
tardive dyskinesia
137
what electrolyte imbalances can diuretics cause that potentiate NMB drugs
HYPOkalemia
HYPOcalcemia
138
what can diuretics cause during operation with blood pressure
hypovolemia=hypotension
139
true or false; daily diuretics should not be taken the day of surgery?
TRUE
140
where does osmotic diuretics work
proximal convoluted tubule
141
where does loop diuretics work
thick ascending loop of henle
142
where do thiazide diuretics work
early distal tubule/distal convoluted tubule
143
where do sodium channel blocker diuretics work
collecting tubule
144
where do aldosterone antagonist diuretics work
collecting tubule
145
what can omega 3 fatty acid (fish oil) cause
increased risk of bleeding
146
what can vitamin B3 (niacin) in nondiabetic patients cause
HYPERglycemia
147
how long should fish oil be d/c'd for surgery
at least a week
148
true or false: pt can continue statins all the way up to surgery
true
149
what can happen if you touch scopolamine patch and dont wash your hands then touch eyes
dry eyes and dilate them
150
what anesthetics increase PONV
NO
opioids
volatiles
neostigmine
151
what surgical factors increase risk of PONV
length/type of surgery
152
what patients are more at risk for PONV
women
non-smoker
hx motion sickness
past episode of PONV
153
when should you not give metoclopramide
small bowel obstruction
major bowel surgery
intrabdominal surgery where high motility will cause problem
154
what patients may benefit from metoclopramide before a surgery
DM
obese
pregnant
trauma
any pt recently ingested food
155
what does activation of the HPA axis in response to surgical stimulus cause
increased secretion of catabolic hormones
156
what is the pathway for HPA axis to release more cortisol
1- hypothalamus- corticotrophin releasing hormone stimulates
2-anterior pituitary to release adrenocorticotropin releasing hormone (ACTH) which stimulates
3- adrenal cortex to release cortisol
157
cortisol has what effects?
mineralocorticoid and glucocorticoid effects
158
how does cortisol promote HYPERglycemia
promotes gluconeogenesis in liver
protein catabolism
reduces peripheral glucose utilization
159
what are four meds that can affect release of adrenocortical hormones
opioids
midazolam
dexmedetomidine
etomidate
160
what are two ways to suppress release of cortisol to prevent surgical stimulus
high dose opioids
extensive dermatological blockade during regional anesthesia
161
what disease causes excessive release of growth hormone from pituitary gland
acromegaly
162
what are anesthetic considerations during acromegaly surgery
difficult airway
blood sugar monitoring
hydrocortisone replacement post op
163
what is the drug of choice for preop optimization for thyroidectomy
carbimazole
optimize hormone levels
164
what are anesthetic considerations for thyroidectomy
carbimazole preop
difficult airway equipment
atropine/glyco to dry secretions
opioid/dex/propofol
monitor NMB for myasthenia gravis
multiple endocrine neoplasia syndrome
165
what are three keys in periop management of DM
normal glucose, electrolytes, and volume
166
what medication should be avoided in patients with HYPERkalemia
succs
use ROC
167
what med can decrease cortisol levels and suppress hyperglycemic response to surgery
midazolam
168
what opioid if preferred in DM pt with kidney disease
fentanyl
169
true or false: pain can lead to increased glucose levels in DM patient
TRUE
170
true or false: metformin and ace inhibitors should be avoided periop in DM patient
TRUE
171
what electrolyte imbalances may need treatment post op parathyroid surgery
HYPOcalcemia
HYPOmagnesemia
172
what patient population is more likely to have hypoglycemia during surgery
geriatric patients
173
who has an increased allergic reaction risk to protamine
fish allergy
vasectomy
DM
174
what are the indirect Xa inhibitors
LMWH
heparin
175
what are the direct IIa inhibitors
bivalirudin
argatroban
dabigatran
176
what are the direct Xa inhibitors
rivaroxaban
apixaban
177
what are the indirect IIa inhibitors
heparin
178
what lab should be monitored with heparin
PTT
ACT
179
how is LMWH different from heparin
binds to less proteins so more bioavailability
180
what med is used for risk of HIT
bivalirudin or argatroban
181
when should coumadin be stopped before surgery
1-3 days
182
what factors does warfarin inhibit
2
7
9
10
183
what test should be preformed pre-op for pt on xarelto
anti XA
184
what is reversal agent for dabigatran
idarucizumab
185
how do you treat bleeding while on TPA
cryo and platelets
186
what is an anticholinergic antiemetic
scopolamine
187
true or false: propofol has antiemetic properties
true
188
when should decadron vs ondansetron be given
decadron-after induction
ondansetron- prior to induction or 15-20 min before emergence
189
true or false: benadryl is a primary PONV agent
FALSE
190
how do NSAIDs effect platelets
increases inhibition of platelet aggregation
191
how long does aspirin inhibit platelet aggregation
7 days from last dose
192
what is the most powerful anti-inflammatory
glucocorticoid
193
what is a type of glucocorticoid
hydrocortisone, dexamethasone
194
what reduced inflammation and tissue damage
steroids
195
what is the prodrug for steroids
hydrocortisone
196
what are steroids derived from
cholesterol
197
where are steroids secreted from
gonads
placenta
adrenal cortex
198
what are the two types of steroids
mineralocorticoids
glucocorticoids
199
what steroid controls and influences metabolic processes such as BP, immunosuppression and temp
glucocorticoid
200
what steroids help balance water, Na and K
mineralocorticoids
201
what is the proposed MOA of steroids
phospholipase A2
202
what is the most commonly used steroid in OR
dexamethasone
203
why is dexamethasone commonly used in anesthesia
less fluid retention
long half life
more potent
204
what are steroid used for in anesthesia
regional
epidural
PONV
reduce airway swelling after intubation
205
what is steroid PONV dose
4-8mg before surgery or after induction (better before surgery)
206
how do steroids work
inhibit prostaglandin synthesis which leads to reduction in inflammation and vascular permeability to prevent edema
207
what is thought for using steroids in anesthesia
reduce tissue edema and nerve transmission created by inflammation
reduce PONV
208
how do steroids prevent PONV
reduce afferent stimulation from incision and reduce trigger response in brain for PONV- not totally sure why it works
209
what is risk with chronic steroid use
adrenal suppression
need stress dose of steroids even though they are on steroids
210
diuretics can increase risk of which arrhythmia
VTACH
211
how does phenytoin cause hyperglycemia
inhibits insulin secretion
212
how does hypothermia affect bleeding
increases bleeding
platelets cant work
213
in what ways do procoagulants help
prevent clot lysis
reduce bleeding
reduce blood transfusion requirements
214
what are the lysine analogs
TXA
epsilon aminocaproic acid (EACA)
215
what medication competitively inhibits activation of plasminogen to plasmin
epsilon aminoproic acid (EACA)
216
what is the enzyme that breaks down fibrin clots and fibrinogen
plasminogen
217
are lysine analogs prothrombic or clot stabilizers
clot stabilizers
prevents clot lysis
218
what are general risks for TXA and EACA
thrombosis
219
what is a risk of using TXA with general anesthesia
seizures
220
how does TXA help in orthopedic surgeries
bloodless surgical field for visualization
reduce blood loss
221
what is the heparin rebound effect
protamine iv 1/2life is 5 min, heparin 1/2 life is 1 hr
222
what procoagulant is typically used in cardiac cases
protamine
223
what is only agent that can reverse UF heparin
protamine
224
how does protamine work
decreases activated clotting time
225
what medication is a polypeptide that contains 70% arginine residues
protamine
226
what on protamine inactivates acidic heparin molecule
protein
227
what does excess protein do
increases clotting time, inhibits platelets and serine proteases
228
what are the side effects of protamine
anaphylaxis
RV failure
hypotension
pulm htn
229
what happens when pt receives too much protamine
coagulopathy
platelet inhibition, increased clotting time
230
what does desmopressin stimulate release of
von Willebrand Factor
231
what is the role of von Willebrand Factor
mediates platelet adherence to vascular endothelium
232
what med is used for hemophilia A and von Willebrand disease
Desmopressin
233
what are side effects of desmopressin
hypotension
MI
234
why is fibrinogen important
clot formation
235
how does fibrinogen work
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
what initates cross linking of fibrin polymers
factor 13a
237
what increases elasticity of clot and its resistance to fibrinolysis
factor 13a
238
what are normal fibrinogen levels
200-400mg/dL
239
what does hypofibrinogenemia raise the risk of
bleeding
240
how can you increase fibrinogen levels
cryo
fibrinogen concentrates
241
in the transfusion algorithm, what is the target increase of fibrinogen levels
150-200 mg/dL
242
what are some topical hemostatic agents
surgicel
oxycel
gelfoam
coseal
bioglue
243
when would you use topical hemostatic agents
intraoperatively to promote hemostasis
244
what factor provides stability to new clots
factor 13a
245
what is recombinant activated factor VIIa used for
hemophilia a and b
glanzmann thombasthenia
battlefield injuries
246
what are the factors included in the prothrombin complex concentrates
2
7
9
10
247
what are the prothrombin complex concentrates used for
vitamin K antagonist reversal
prevent/control bleeding
hemophilia
248
what is the actual standard of care in US to reverse acute bleeding on warfarin
FFP
249
what is the MOA for TXA and EACA
competitively inhibit activation of plasminogen to plasmin
250
what site does rivaroxaban, apixaban and edoxaban work
Xa
251
what sites does LMWH, heparin, and fondaparinux work
Xa
252
what site does argatraban, bivalrudin, dabigatran, lepirudine and heparin work
IIa
253
what does heparin bind to
anti thrombin III
254
is heparin acidic or basic
acidic
255
what is the IV 1/2 life of heparin
1 hour
256
what is the onset of subQ heparin
1-2 hrs
257
what lab do you use to monitor heparin
aPTT
258
what is a normal aPTT
25-35 seconds
259
what other labs can be used to monitor heparin besides aPTT
ACT
260
when is activated clotting time used
during Cardiopulmonary bypass
261
what is heparin used for
PE DVT
acute coronary syndromes
periop anticoag
HD
262
what is normal ACT and therapeutic ACT
normal 70-120
therapeutic 150-600
263
how is LMWH different from heparin
binds less to proteins, more bioavailability
264
what does renal failure do to LMWH
prolongs the effects
265
how long should surgery or epidural/spinal be delayed after last dose of lmwh?
12 hrs
longer with renal dysfunction
266
what surgery has unique risk of venous thrombosis
hip replacement
kinks femoral vein
267
how do direct thrombin inhibitors work
bind to two sites on thrombin
-catalytic site
-fibrinogen binding site
268
examples of direct thrombin inhibitors
bival, dabigatran, argatroban
269
what is the half life of warfarin
24-36 hrs
270
What medication do you use to correct central anticholinergic syndrome
Physostigmine
15-60mcg/kg IV q 1-2 hrs
271
what is the therapeutic anti xa range
0.6-1 units/ml
272
what is the preferred treatment for vitamin k antagonist reversal in emergent situations
FFP or PCCs
273
how does hypoalbuminea affect warfarin
increases amount of warfarin in circulation
274
why does lmwh have higher bioavailability than heparin
less protein bound
275
what are benefits of using decadron
less fluid retention
long half life
more potent
reduce inflammation
PONV
276
how do steroids reduce PONV
reduce inflammation triggered by the stimulation of the PNS
277
what stimulates platelet aggregation
thromboxane
278
what stabilizes clots that are already present
txa
279
what prevents plasminogen from forming plasmin so the clot isnt broken down
txa
280
what breaks down a clot
plasmin
281
what are normal fibrinogen levels
200-400 mg/dl
282
what can increase fibrinogen levels
cryo
283
what factors are in PCC
2, 7, 9, 10
284
what is the intrinsic pathway activated by
blood trauma/ surface contact (exposure to collagen)
285
what does tissue trauma activate
factor 3 and factor 7
286
what factors are in the intrinsic pathway
12
11
9
8
287
what factors are in the extrinsic pathway
3 (tissue factor "thromboplastin")
7
288
what factors are in the common pathway
10
5
2
1
289
what factors does thrombin activate
5
8
11
13
290
what turns fibrinogen (factor 1) into fibrin
thrombin
291
what is the onset of subQ heparin
1-2 hrs
292
what is therapeutic aPTT
60-100 sec
293
what pt factor can cause prolonged effects of lmwh
renal disease
294
how long should surgery be delayed after dose of lmwh
12 hrs
295
what are benefits of coumadin
predictable onset
duration of action
bioavailability
296
what is the half life of coumadin and how long to d/c before surgery
24-36 hrs
1-3 days before surgery
297
what lab do you check in preop for coumadin
INR
298
what does idarucizumab reverse
dabigatran
299
what lab do you check for rivaroxaban
anti xa
300
what can reverse warfarin beside ffp
PCC
301
what anticoagulant medication class is used for CAD and vascular patients
platelet inhibitors
302
what anesthesia technique should be avoided when pt has been on platelet inhibitors
regional anesthesia
need to be off meds for 5-7 days before regional anesthesia can be done
303
what clotting factor does lmwh work on
Xa
304
what has a decreased risk of inducing HIT
lmwh
305
what meds can be used in risk of HIT
bival, argatroban
306
what coag factors does heparin inactivate
Xa and IIa (thrombin)
307
what is factor 1
fibrinogen
308
what is factor 2
prothrombin
309
what is factor 3
tissue thromboplastin or tissue factor
310
what is factor 4
calcium
311
what is factor 5
labile factor
312
what is factor 7
stable factor
313
what is factor 8
anti hemophilic factor
314
what is factor 9
Christmas factor
plasma thromboplastin component
315
what is factor 10
stuart-prower factor
316
what is factor 11
plasma thromboplastin antecedent
317
what is factor 12
Hageman factor
318
what is factor 13
fibrin stabilizing factor
319
what is a high risk in PCCs vs ffp post reversal
clotting complications
320
why do we give protamine slow
to prevent hypotension; anaphylactoid rxn
321
what is a p2y platelet inhibitor
clopidogrel
322
what drugs make up dual antiplatelet therapy
ASA and clopidogrel
323
what medications work on Xa
rivaroxaban
apixaban
endoxaban
LMWH
fondaparinux
UFH
324
what medications work at IIa
argatroban
bivalirudin
dabigatran
lepirudin
UFH
325
side effects of heparin
hemorrhage
HIT
allergic rxn
hypotension
decreased antithrombin concentration
326
what are contraindications for heparin
neurosurgery procedures
hx HIT
regional anesthesia
327
what is dose of protamine
1mg for every 100 units of circulating heparin
0.75mg for every 100 units if at least 30 min after heparin dose
328
advantages of LMWH
-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
how long after being stopped does anticoag go back to normal on argatroban
4 hrs
330
what lab do we use to monitor argatroban
aPTT
331
what lab do you use to monitor Bivalirudin
ACT
332
true or false: warfarin crosses the placenta?
TRUE
dramatic effects on the fetus
333
what labs are used to monitor warfarin
INR and PT
334
what can effect vitamin K levels in a patient
antibiotics
IV fluids
liver disease
age
diet
335
where is vitamin K synthesized
in GI by bacterial synthesis, need good gut flora
336
when do you stop warfarin for surgery
1-3 days
337
what is exogenous vitamin k called
phytonadione
338
when can neuroaxial anethesia be used after rivaroxaban (Xarelto)
18 hrs after last dose to remove catheter
do not restart med until 6 hrs after catheter removed
339
what are side effects of chronic steroid use
-suppression of HPA axis
-electrolyte and metabolic changes
-osteoporosis
-PUD
-skeletal muscle myopathy
-CNS dysfunction
-peripheral blood changes
-inhibition of normal growth
340
anesthesia considerations for thiazide diuretics
-can increase effects of non depolarizing neuromuscular blockade
-NSAIDs decrease effectiveness of thiazides
-lithium increases reabsorption and risk for toxicity with thiazides
341
side effects of loop diuretics
hypokalemia
hyperglycemia
increase risk of digitalis toxicity
hypotension
"braking phenomenon"
ototoxicity
342
What effect does the PNS stimulation have on insulin release?
Increased insulin release
343
What effect does beta 2 stimulation have on insulin release
Increased insulin release
344
What effect does alpha 2 stimulation have on insulin release
Decreased insulin release
345
2 drugs that counter the hypoglycemic effect of insulin
Epinephrine
Glucagon
346
Which type of pancreatic cells release glucagon
Alpha
347
Which beta blocker inhibits conversion of T4 to T3
Propranolol
348
Which agent primarily targets the chemoreceptor trigger zone?
Ondansetron
349
What antiemetic is contraindicated with bowel obstruction
Metoclopramide
350
What antiemetics are contraindicated for Parkinson’s
Butyrophenones
Phenothiazines
Metoclopramide
351
How can IM ephedrine reduce PONV
Maintaining BP and cerebral perfusion
25mg IV
*apex*
352
What receptor stimulated during motion induced nausea
M1 and H1 in the vestibular system of the inner ear
*apex*
353
What are five patient risk factors for PONV
Female
Nonsmoker
Hx of motion sickness
Previous PONV
Youth > elderly
354
What are 5 anesthetic risk factors for PONV
Halogenated gases
Nitrous oxide
Opioid
Etomidate
Neostigmine
355
What drugs counter hypoglycemia
Epi
Glucagon
Estrogen
356
What drugs enhance hypoglycemic effect
MAOIs
Tetracyclines
Salicylates
357
Where is prothrombin produced
Liver
358
What is the function of plasmin and anti-thrombin
Break down fibrin mesh
359
What is needed for activation of prothrombin
Vitamin K
360
What labs evaluate intrinsic pathway
aPTT and ACT
361
What labs evaluate extrinsic pathway
PT
362
What labs do we monitor for warfarin
PT INR
363
What pathway does heparin work in
Intrinsic and common
364
What pathway does warfarin work on
Extrinsic and intrinsic and common
365
What clotting factors does PTTevaluate
12
11
9
8
10
5
2
366
What factors does PT evaluate for
7
10
5
2
1
367
Heparin MOA
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
What site of coag cascade for UFH and LMWH work at
UFH: Xa and IIa
LMWH: Xa
369
Protamine MOA
Irreversibly binds to heparin molecule creating an inactive salt which is eliminated through the liver or kidneys; makes heparin inactive
370
Does HIT 1 or HIT 2 require treatment?
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
LMWH onset and doa
Onset: 20-30 min
DOA: 6-12hrs
372
Examples of direct thrombin inhibitors
Bivalirudin
Argatroban
Lepirudin
Desirudin
373
What is half-life of argatroban
40 min
374
Lab monitor for argatroban
aPTT
If pt has HIT and AKI argatroban is med of choice
375
Key points for lepirudin
-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
Key points Desirudin
-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
Warfarin MOA
Inhibits vitamin k synthesis
378
What meds require antithrombin as cofactor
LMWH
Fondaparinux
UFH
379
Most common use for Rivaroxaban
Reduce stroke and systemic embolism in afib
380
How can rivaroxaban be reversed?
PCCs
381
ASA class and MOA
Platelet inhibitor
Irreversibly inhibits COX-1 and prevents formation of thromboxane A2 which inhibits platelets for 7 days
382
Platelet inhibitors
ASA
Clopidogrel
Prasugrel
Ticagrelor
MOA: irreversibly bind to P2Y12 receptors blocking ADP binding which inhibits ADP mediated platelet activation and aggregation
383
TPA MOA and class
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
What factors do protein C and S work to inhibit
5a and 8a
385
What factors does antithrombin inactivate
9
10
11
12
386
Advantages of direct thrombin inhibitors
-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
Pre op eval for cancer pts
-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
What do you do if pt on chronic steroids and has suppression of HPA axis
Prednisone >20mg/day for >3 weeks then stress dose
100mg of hydrocortisone
389
MOA of recombinant factor 7 (NovoSeven)
Bind to the surface of activated platelets directly activating factor X and leading to an improved generation of thrombin
390
What is necessary for recombinant factor 7 to work
Normal fibrinogen levels
Normal pH
391
Cryo anesthesia indications
-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
Risk of Cryo
Exposure to multiple donors and no viral inactivation
393
Which cancer drug has risk of skeletal muscle weakness and prolonged neuromuscular blockade
Alkylating agents
394
Anesthesia consideration for methotrexate
NSAIDs and salicylates can increase drug levels and cause toxicity
Contraindicated in pregnancy bc it blocks folic acid
395
Which mediator promotes vasoconstriction in response to vascular injury
Thromboxane 2
396
How long do you stop ADP inhibitors for surgery
5-14 days
Apex
397
How long do you stop GPIIb/IIIa receptor antagonists for surgery
1-3 days
398
How long do you stop COX inhibitors before surgery?
ASA 7 days
NSAIDs 1-2 days
399
Common lab results in DIC
Low platelets
Low fibrinogen
Increased PT/PTT
Increased D dimer
400
Cryo contains what factors
Fibrinogen
vWF
Factor 8
401
Warfarin + H2 =
Increased risk of hemorrhage
Ranitidine and cimetidine are H2 blockers
402
Functions of cortisol
Maintenance of cardiac function
Systemic Bp
Normal response to Catecholamines
Regulate fat metabolism, carbs, and protein
Balances sodium, k and water levels
403
What is stress dose for minor surgical stress
Usual corticosteroids steroid dose + 25 mg hydrocortisone
404
What is the stress dose for moderate surgical stress
Usual corticosteroid dose + 50-75mg hydrocortisone for 24-48 hrs
405
What is stress dose for major surgical stress
Usual corticosteroid dose + 100-150mg hydrocortisone IV Q8 hr for 48-72 hrs
406
MOA of dexamethasone PONV
Inhibits prostaglandin synthesis
407
MOA of dexamethasone as analgesic
Inhibition if phospholipase that is necessary for the inflammation chain reaction along both the cyclooxygenase and lipoxygenase pathways
408
What 5 receptors mediate nausea and vomiting
M1
Dopamine D2
5HT3 serotonin
Neurokinin (NK1)
Substance P
409
Which respiratory factor increases in elderly population
Dead space
*apex*
410
Respiratory changes in geriatric patients
-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
Example of carbonic anhydrase inhibitor
Acetazolamide
412
What are carbonic anhydrase inhibitors used for
-open angle glaucoma
-altitude sickness
-central sleep apnea
413
Examples of osmotic diuretics
Mannitol, isosorbide, glycerin
414
What are osmotic diuretics used for
-prevent AKI
-intracranial HTN
-acute oliguria
415
anesthesia considerations for HYPOthyroid
-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
insulin is metabolized by
liver and kidneys
417
therapy of choice for Graves' disease
Radio iodine
418
Hyperthyroid Anesthesia considerations
-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
oxytocin dose
10-20 units in 1000ml NS or LR
420
ACTH stimulates
adrenal gland to produce cortisol
421
TSH stimulates
thyroid to produce T3 and T4 for metabolism
422
oxytocin anesthesia considerations
-rapid bolus cause hypotension; treat with phenylephrine
-reflex tachycardia
-un GA and spinal pt may not compensate with increased CO
423
indications for vasopressin
-diabetic insipidus
-refractory hypotension (especially ACE and ARBs)
-uncontrolled hemorrhage in esophageal varices
- septic or hemorrhagic shock
-refractory cardiac arrest
424
treatment for DI
DDAVP or vasopressin
425
treatment for SIADH
fluid restriction
sodium correction
426
what are the thyroid hormones
T3
T4
calcitonin
427
what hormones regulate alpha and beta receptors
T3 T4
428
in older adults and in pregnancy what changes are to thyroid medication dose
decreases in older adults
increases in pregnancy
429
how long should a patient be euthyroid before surgery
6-8 weeks; check levels before surgery
430
thyroid storm can mimic what under GA
MH
pheochromocytoma
neuroleptic malignant syndrome
light anesthesia
431
what drugs do we use in perioperative thyroid storm
Methimazole (block synthesis)
PTU/ Propanolol (block t4 to t3 conversion)
propanolol/esmolol (beta blocker)
432
dexamethasone key points
-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
what is the most important stimulus for aldosterone secretion
accumulation of potassium in the plasma
434
what do mineralcorticoids (aldosterone) do
Regulates salt and water
blood pressure on RAAS system
435
how do we treat CONNs syndrome
excessive mineralcorticoids; treat with spironolactone ACE/ARBS
436
anesthesia consideration for Conn's syndrome
increased sensitivity to non-depolarizing NMBs
avoid hyperventilation
caution with volume overload
437
what can cause addison disease crisis
illness
surgery
sepsis
stress on body
Chronic steroids-- give stress dose steroids for patient with surgery 100mg then 100-200mg every 24hr
438
What is required for GI tract to absorb vitamin K
Bile
439
What is required for GI tract to absorb vitamin K
Bile salts
440
In a negative feedback loop what does the hormone do
Reduces its own release
441
In a positive feedback loop what does the hormone do
Increases its own release
442
What can affect ACT results
Hypothermia
Thrombocytopenia
Deficiency in fibrinogen, factor 7 and 12
443
what is in FFP
2
5
8
9
10
11
anti thrombin 3
