Hemo Pharm Test 3 Flashcards
(174 cards)
1
Q
Factor I
A
Fibrinogen ; Source Liver
2
Q
Factor II
A
Prothrombin ; Liver
3
Q
Factor III
A
Thromboplastin/Tissue Factor
Source: Platelet and Endothelium
4
Q
Factor IV
A
Calcium
Source: Bone and GI
5
Q
Factor V
A
Labile Factor aka Proccelerin
Source : Liver and Platelet
6
Q
Factor VII
A
Proconvertin/ Serum Prothrombin Conversion Accelerator
Source: Liver and Platelet
7
Q
Factor VIII
A
Anti-hemophillic Factor A
Source : endothelium
8
Q
Factor IX
A
Christmas Factor
Source: Liver
9
Q
Factor X
A
Stuart factor
Source; Liver
10
Q
Factor XI
A
Plasma Thrombosplasmin Antecedent (PTA)
Source: Liver
11
Q
Factor XII
A
Hageman Factor
Source: Liver
12
Q
Factor XIII
A
Fibrin Stabilizing Factor
Source: Liver
13
Q
Source Liver
A
Factors 1, 2, 7, 9 ,10, 11, 12, 13
14
Q
Intrinsic Patheway
A
Factors : 9, 11, 12, (8)
15
Q
Extrinsic Primarily Factor
A
7
16
Q
Common Pathway
A
Primarily Factor 10 but also Factor 2 & 13
17
Q
2 frequent test in peri -op other than blood
A
PT: Extrensic Pathway
APTT: Intrinsic Pathway
18
Q
Initially for Critical Bleeding what do we use ?
A
Crystalloids, Colloids, PRBC
They do not improve coagulation because they have no coagulation factors
19
Q
Severe Bleeding with require what treatment ?
A
1) FFP
2) PLT
3) Cryo
4) Factor concentrations : Fibrinogen and Prothrombin complex concentrates. PCC
20
Q
What is the single minimal acceptable level of Hgb used to determine if we need PRBC
A
There is no single minimal acceptable level
21
Q
Which is tolerated better ? Chronic or Acute
A
Chronic
22
Q
In acute anemia, compensatory mechanism such as increased CO and improved oxygenation depends on
A
The patient’s cardiac reserve
23
Q
What could limit compensation during acute anemia ?
A
Heart Failure and or Flow restrictions lesions.
24
Q
Factors to consider for a transfusion
A
1) Intravascular Volume
2) Patient actively bleeding
3) Need to Improve O2 transport
25
ASA task force recommends for a blood transfusion of a young health patient
Hgb <6g/dL
26
Usually unecessary to transfuse with a PRBC when the Hbg is
>10g/dL
27
When should the ASA task force parameters change ?
In the presence of 1) anticipated blood loss 2) active critical Ischemia 3) Target organ Ischemia
28
What are 5 factors that should be considered to determine the need for transfusion of Hbg 6 to Hbg 10 g/dL
1) Target Organ Ischemia
2) Potential and Actual bleeding including rate and magnitude
3) intravascular volume status
4) Risk factors for complication of inadequate Oxygen
5) Low cardiopulmonary reserve + high Oxygen consumption ( Low SaO2)
29
Transfusion parameters are absolute. True or False
False
30
Patient with inadequate myocardial oxygenation should be transfused. True or False
True
31
How long is PRBC stored?
1) For up to 42 days
| For more than 14- 21 days stored PRBC may lead to adverse effects.
32
Storage Lesions is defines as
Changes in older PRBC
1) Depletion of ATP and 2,3,DPG
2) Membrane phospholipid vesiculation, blistering and shedding
3) Protein Oxidation and Lipid peroxidation of cell membrane
4) shape changes, increase in fragility, = impaired microcirculatory flow
5) Increased red cell endothelial cell interaction, bioactive lipids, may initiate inflamotory TRALI
33
TRALI aka Transfusion Related Acute Lung Injury
Any Acute Lung Injury that occurs minutes to 6 hours of transfusion of ANY blood products
***Rule out other ALI issues L Sepsis, Pneumonia, Aspiration
TRALI is under diagnosed
34
TRALI treatment
Supportive
35
If TRALI is suspected
1. Stop the infusion
2. Obtain WBC and CXR
3. Quanrantine blood from the donor from other bloods
4. Request other units to be given if needed
36
TRALI has ——-incidence with plasma from ______ who have not been ______
Decreased; male or female ; who have not need pregnant
37
What characterized TRALI
1) Onset : Minutes to 6 hours
2) Hypoxia w/o HF
3) Bil Pumonary Infiltrates
38
How to replace Coag during Massive Transfusion
Plasma/ FFP
39
Plasma FFP
1) used for Warfarin reversal
2) used for coagulation in massive transfusion
3) FFP is Frozen within 8 hours - cryo from that
4) FFP24 in US : within 24 hours- cannot collect Cryo from that
5) to treat and prevent further bleeding
40
FFP is
Plasma that remains that after RBC and platelets are removed
41
FFP contains
Blood Coagulation
Fibrinogen
Plasma proteins
42
What is volume of FFP. Can be stored up to
170- 250 ml
| Stored up to 1 year
43
Most Plasma given in the Peri Op is actually
FP24
44
FFP should be administered
With a 170 micronfilter
45
After thawed can be transfused within ____Hrs; once relabeled thawed plasma can be stored for another ______
24 hrs; 4 days
46
Thawed Plasma maintains normal levels of all factors except?
Factor V: Labile/Proccerelin: falls to 80% of normal
| Factor VIII : Antihemophilia A: falls to 60% of normal during storage
47
TXA complications
Seizure by blocking GABA in frontal cortex
48
In the USA TXA PO is used for
Heavy menstrual bleeding
49
Dose of TXA
Initial :1gm/10minutes then and 1gm q 8hrs
50
TXA inhibits ____at higher doses
Plasmin
51
TXA inhibits
Plasminogen
52
EACA, AProtinin and TXA are effective at reducing the need for
RBC Transfusion
53
Protamine is a
Polypeptide containing 70% arginine residues and only available reversal fir UFH
54
Excess protamine can contribute to coagulopathy . True or False
True
55
Protamine . How does it work?
Inhibits platelets and serine proteases
56
Lowest ACT values produced when given
Exact amount needed to reverse circulation heparin
57
Heparin rebound can occur after
Initial reversal, and is observed within 2 to 3 hours when pt in the ICU
58
Initial dose of protamine causes what to ACT
Large drop in ACT time
59
A repeat dose may well be less than the
50 mg commonly administered
60
Most pats may not need additional protamine doses within
30 minutes of initial administration
61
Protamine adverse reaction
Anaphylaxis
RVF
Hypotension
Pulmonary vasoconstriction = Pumonary HTN
62
Patients at an increased risk for adverse reaction are sensistized how
Neutral protamine in NPH -
63
Other protamine risk patients
Vasectomy
Multiple Drugs allergies
Protamine exposure
64
Desmopressin
Is a V2 analog arginine vasopressin that stimulates release of vWf multimers from endothelial cell , specific surgical patient that might benefit from DDAVP is not clear
65
Heparin Induced Thrombocytopenia . What happens
Decreased platelet caused by heparin
Hyper-coagulation
Antibodies against heparin in the form of IgG
66
Heparin and Antithrombin relationship
Antithrombin inactivates factors
Heparin makes Antithrombin on steroids and makes it work really well.
This will inactivate Factor II and X= block coagulation of common pathway
67
LMWH is a
```
Short chained Polysaccharide
Doesn’t need PTT
Decreased risk of HIT
Lasts longer and works better because of increased half-time
Does bing to plasma protein as much -
```
68
Unfractioned Heparin contains
Long, medium, small chain polysaccharides
Need to monitor PTT
Can be blocked with protamine sulfate
69
Hemophilia A
Factor VII deficiency
Factor can’t activate = fibrin polymer meshwork does not form *
* Normal BT and Normal platelet level
BUT increased PTT ( PTT measures Intrinsic pathway )
70
Treatment for Hemophilia A
Give Factor VIII
71
Hemophilia B
Factor IX deficiency
| Christmas tree disease
72
Protein C inactivates
Factor Va and VIIIa
73
Coumadin binds to
Vitamin K
| Protein S makes Protein C and requires Vitamin K to work
74
Vitamin K deficiency lab
Increase PT Extrensic pathway
Protein S makes protein C
Coumadin binds to Vitamin K
75
PT PTT does not measure factor
13
76
Intrinsic Factor : PTT
12 11 9 and 8
| 12 inactive converted to 12 a by Kallikrein
77
Factor X is the ist factor in the
Common pathway
78
Extrinsic Factor is
Factor XII , and is measured buy PT
| 7 to 7a buy Factor III aka tissue factor as a result of Trauma *
79
Common pathway way is
Factor X , II, XIII
10a acts as a protease and converts factor 2(prothrombin ) to 2a ( Thrombin )
8 converted to 8a to form a fibrin polymer meshwork
80
Fibrin Clot is broken down by
Fibrinolytics - Plasminogen to Plasmin is the ultimate breakdown of fibrinogen to fibrin clot
81
DIC labs
Platelets and Fibrinogen = low
| PT PTT D-Dimer = high
82
Dose of DDAVP
0.3mg/kg over 15-20 minutes to avoid hypotension
| Hypotension because it releases other vasoactive drugs in addition to vWF
83
DDVAP treats which type of vWF
```
Type 1 ( mild form)
and maybe 2 a as well
```
84
DDAVP is not effective in which type
Type 3 and serve type 1 and 2
85
Fibrinogen is synthesized in the___; substrate of 3 enzymes
Liver; TFP Thrombin (2a) , XIIa and Plasmin
86
1/2 life of Fibrinogen
3.7 days = 4 days
87
Cross linking of fibrin polymers induced by
Factor XIIIa is fundamental to the coagulation increasing elasticity of the clot and its resistance to fibrinolyis
88
Fibrinogen also acts as the binding site for
Glycoproteins IIb/IIIa found on platelet surface which are responsible for platelet aggregation
89
Fibrinogen forms fibrin monomers which are_____ to form a
Polymerized ; loose
90
Platelet enmeshed
Withing the fibrin strands, stabilizing the growing clot
91
Fibrinogen supplementation is key in Massive hemorrhage to restore
Plasma fibrinogen = normalizing clotting factor
Fibrinogen is under recognized coagulation factor critical for producing effective clot
Treating fibrinogen deficiency is critical for survival and has positive correlation ***
92
Fibrinogen increases _____ in pregnancy
> 400mg/dL
Bleeding increased for each 100 mg drop
Consider transfusion BEFORE it fibrinogen level drops below 100...may not be fixed my FFP
93
For adequate replacement of Fibrinogen give
Cryo or Fibrinogen concentrate not FFP
| Cryo 1 unit/ 10 kg = increased Fibrinogen 50-70 mg/dL
94
RFVIIa approved for
Hemophilia but off label for massive hemorrhage
95
Important Final step in clot formation in
Factor XIII
96
Prothrombin Platelets Concentrates
10 9 7 2
2 PCC for Vitamin K antagonist -induced Warfarin reversal are :
Kcentra
Octaplex
97
3 other PCC approved in US for the use of hemophilia and contain mainly Factor 9*
FPB-9 VH or SD
FEIBA VH
ProfilnineSD
Bebulin VH
98
In US warfarin reversal typically with
FFP
99
Other countries reverse warfarin with
PCC
Guidelines recommende PCC in warfarin reversal when
1) life threatening bleeding
2) Increased INR when urgent reversal is required
100
Gelfoam
Purified Pork skin gelatin
Increase contact activation
Help create topical clot
101
Surgicel or Oxycel
Oxidized regenerated cellulose
| Work like Gelfoam
102
Gelatin Foam should be used near
1) near Nerves
| 2) in confined spaces
103
UF heparin extracted from
```
Porcine intestines ( majority ) or from
Cow’s lungs where heparin is stored on mast cells
```
104
Heparin anticogulant effects are produced by binding to
Antithrombin (AT)
AT is a circulation serine protease
Heparin binds to Antithrombin enhancing the rate of Thrombin- AT complex formation by 1,000 to 10,000 times
105
What is inhibited by AT
10a , 9, 11, 12
106
When swelling and expansion are not a concern what topical hemostatic used ?
Coseal
107
Heparin potency is based on
in Vitro comparison with a known standard
108
A unit of heparin is defined as
The volume of heparin containing solution that will prevent 1 ml of citrates sheep blood from clotting for 1 hour after the addition of 0.2 ml of 1:100 calcium chloride .
109
Heparin 1 ml with 0.2 ml Ca chloride 1:100 will not clot in citrated sheep blood for
1 hour
110
Heparin must contain
120 United States pharmacopeia USP per millimiter 120 units/ml
111
uses for Heparin
Prevention and tx
1) DVT
2) PE
3) ACS
4) peri op anti coag for ECMO -bypass
112
IV heparin onset
Immediate
| SuQ is 1-2 hrs
113
Labs on Heparin
APTT ( 30-35) 1 to 1.5 times
| Therapeutic APTT : 45 sec to 87.5 seconds
114
What is prolonged APTT
Greater and 120 seconds
| Can be shortened by omitting the dose bc heparin has short 1/2 time
115
Low dose heparin can be monitored using anti Xa -assay
True
116
Activated CLotting time
Used for high heparin concentration
| By Mixing whole blood with an activated substance with large surface such as Celite or Kaolin .
117
Which ACT to use for AProtinin therapy
Kaolin ACT bc Kaolin binds to Aprotinin to minimize its effects .
118
Most coagulation factors circulate in the body as inactive enzymatic precursors called
Zymogens
119
What is the function of GP Ib
Receptor for vWF
120
What is the function of GPIIb/IIIa
Receptor for fibrinogen that links platelet
121
What is the function of fibrinogen (Factor I)
Acts like a bridge between platelet to platelet to GPIIb/IIIa
122
ACT is reliable for
High heparin concentrations > 1 unit/ml
123
Activator speeds up the clotting time of ACT to normal values of
100 - 150 seconds
| 1.5 to 2.5 minutes depending on the device
124
ACT is based on detecting
The onset of clot formation
125
Target ACT in CABG is
350 to 400 seconds
126
ACT values are misleading in CABG because
1) Hypothermia
| 2) Dilution effects
127
HIT develops
4-5 days of heparin therapy . Can begin within hours , caused by heparin defendant antibodies to platelet .
128
If an immediate reaction to heparin is noted :
HIT should be suspected
129
Reversal of HIT
```
Protamine :
Strong alkaline
Polycationic
Low molecular weight protein
In Salmon Sperm
```
130
Protamine is
Positively charged alkaline combines with negatively charged acidic heparin tip form a stable complex that is devoid of anticoagulant activity
131
Protamine heparin complex is removed by
Reticuloendilthelial system within 20 minutes
132
Protamine Dose
1 mg for every 100 units of circulating heparin .
| Protamine does not neutralize LMWH
133
Heparin 1/2 time is
```
1 hour.
Protamine dosing 1 hour after heparin 10,000 given
5,000 left after 1 hour
Protamine 1 mg for 100 units
500/100= 50 mg protamine
```
134
2 LMW heparin
Enoxaparin and Dalteparin
By depolymerization of heparin
They bind less to protein than heparin does
Anti Xa 4:1 Anti IIa 2:1
135
Prevention of Thromboembolism in high risk medical and surgical pts . Better treated with ?
Better treated with LWH than heparin
136
Disadvantage of LWH
Prolonged in Renal failure
137
Kidney Failure , which do you use?
UFH
138
Surgery delayed _____after last dose of LWH if normal function
And delayed_______if renal dysfunction
12 hrs
| >12 hrs
139
Fondaparinux - Arixtra inhibits
Xa- Stuart factor
Synthetic anticoagulant LMWH
Used for HIT
140
Fondaparinux - Arixtra dose
```
Once daily *
15 hours 1/2 life *
Hold 2 days prior to surgery
Given to HIT positive
No metabolism
Do not use in renal failure patient*
```
141
Should not be used in patients with renal pts
Fondaparinux
LWH
Danaparoid
142
Danaparoid -Orgaran
From porcine intestinal mucosa
LMW heparinoid
Binds to AT and attenuates Fibrin formation
Elimination primarily in the kidneys
143
Surgery increases VTE risk by
20 fold
144
DVT incidence is ______% in general surgery patients
10- 40 %
145
DVT risk is higher than 10 -20% in
```
High risk surgery patients :
Ortho
Thoracic
Cardiac
Vascular
```
146
In renal failure patients Only _____and _____ are minimally affected because of non renal clearance
Heparin and Warfarin
147
Which greater DVT risk HIP vs General
Hip > general
| Surgical technique for hip surgery kinks the femoral vein
148
Which is more likely to develop in either leg
Calf vein thrombosis.
149
PE occurs in _____ %of pts with major trauma
2- 22%
150
3rd MCC death in patients who survive the first 24 hours of trauma
Pulmonary Embolism
151
Bivalirudin . Renal dose adjustment . 1/2 time / stop when/ who?
20 % dose adjustment for renal impairment
1/2 time is 25 minutes
STOP 4-6 Hrs before surgery ****
For unstable angina undergoing PCTA ,
Heparin replacement for HIT + cardiac surgery on or off pump ****
152
Bivilirudin 1/2 time
25 minutes
153
Bilvilirudin
For HIT and Cardiac Sx on or off pump
154
Argatroban . SYnthetic
Stop 4-6 hours before surgery
For prophylaxis or treatment of thrombosis in pt with high risk for HIT
No need to adjust dose in renal impairment
Elimination by liver
155
Lepirudin
Irreversibly inhibit thrombin
Stop 24 hrs before surgery
From leeches
Use in HIT
156
Reopro Abciximab
Stop 72 hours pre op
| 12-24 hrs 1/2 time
157
ASA
Stop 7 - 10 days before surgery
158
Pradaxa
First 2 hours after catheter is removed
159
Xarelto epidural Catheter
Wait 18 hours after last xarelto dose to remove it
| Once catheter removed wait 6 hours to give Xarelto again
160
Warfarin
Predictable Onset and Duration . But delayed onset
161
Warfarin dose
starts at 5 - 10 mg average maintenance is 5 mg
162
Warfarin delay of onset of anticoagulant
Oral or IV delayed 8 - 12 hrs
163
Warfarin pharmacokinetics
97% bound to albumin , long elimination time 24-36 hrs
Very little Renal excretion
Crosses the placenta with exaggerated effects in fetus
164
Oral anticoagulant before elective surgery
Major surgery : stop 1-3 days pre op to give prothrombin time to return to within 20% of normal range
Restart post op 1- 7 days
165
Direct factor Xa inhibitor - Xarelto and Eliquis
Wait 18 hrs after xarelto to remove it
166
Direct thrombin inhibitor - Pradaxa
First dose 2 hours after catheter is removed.
167
Desirudin - SubQ administration for Hip and Knee prevent DVT
Close monitor with APTT
| Plavix, Prasugrel ( Effient) argatroban .are prodrug
168
Oral anticoagulants are derivatives of
4- hydroxycoumarin (Coumadin )
169
Volume of FFP
170 - 250 ml
| Stored up to 1 year
170
Thawed Plasma maintains factor V and III
Factor V falls to 80% normal
Factor VII. Falls to 60% normal
Thawed can be stored for additional 4 days
171
Cryo
```
Fibrinogen
Factor VIII
Factor XIII
VWF
Formed form FFP thaw at 1 C to 10C
```
172
Apherisis
Sufficient Number from a single donor
173
Significant risk of infection with platelet bc
Stored at 22C instead of 4C
174
Platelet is only crossmatched to
RBC antigen
