Protamine
The fixed dose protocol for protamine dosing uses this ratio when reversing heparin.
What is 1:1 or 1.3:1?
mg protamine : units of heparin.
1mg protamine neutralizes 100 units of heparin
Endothelial cells carry this charge.
What is a negative charge?
Repels platelets
Cardioplegia solution delivered at 4 degreesC will reduce myocardial demand by this percentage.
What is 97%?
This medical student discoverd heparin while working in a lab at Johns Hopkins.
JAY McLean
When referring to the French size of an arterial cannula, you are referring to this part of the cannula.
What is the external diameter of an arterial cannula?
Lab tests that a good at predicting disease, fewer false negatives.
What are sensitive tests?
A hemoconcentrator can typically remove solutes of this size.
What is < 20,000 Daltons?
1 atmosphere = ?? mmHg.
What is 760 mmHg?
List 3 risk factors that could contribute to a protamine reaction.
What are previous exposure (reop), fish allergies, vasectomy, rapid administration and site of administration, DM with NPH insulin use, PHTN?
The most abundant glycoprotein.
What is GPIIb-IIIa (integrin)?
The mismatch between 02 supply and 02 demand.
What is ischemia?
The half-life of heparin.
What is 1-6 hours, average 90 minutes.
Heat transfer in an oxygenator occurs due to these 2 principles.
What is conduction and convection?
In a TEG interpretation a decreased maximum amplitude indicates this.
What is a decreased platelet count and/or function?
Increased R value? Heparin or decreased coag factors
Increased K value? Decreased fibrinogen
Increased Ly-30? Increased clot lysis
When using a hemoconcentrator, the ultrafiltration rate is directly proportional to this.
What is transmembrane pressure?
J= (D xA x ^P) /x.
What is Fick's First Law of Diffusion
D= Diffusion Coefficient (depends on gas and the membrane material)
A= Area available for diffusion
^P/x= 02 partial pressure gradient (between gas phase and blood phase)/ membrane thickness
This type of reaction is mediated by an antibody-antigen reaction and produces IgE.
What is an anaphylactic reaction?
This factor is found in blood and bridges platelet surface receptors to collagen at the site of vascular injury. Is essential in platelet activation and adhesion.
What is von Willebrand factor?
The normal resting membrane potential of a cardiac myocyte.
What is -85 mV?
Heparin inhibits coagulation by inactivation of clotting factors of which clotting cascade pathways.
What are the intrinsic and common pathways?
Volume of fluid in one ft of 1/4", 3/8", and 1/2" tubing.
What is approximately 10cc, 22cc, 39cc?
3/16" 6ml
5/8" 44ml
The expected normal range for SvO2.
What is 65-75%?
When Z-buffing to reduce hyperkalemia level while on bypass, this cystalloid solution must be used.
What is normal saline?
While on CPB, you can increase oxygen delivery by increasing these 3 things.
What are:
Cardiac output: increase flow
Oxygen Saturation: increase Fi02 (to a limit)
Oxygen Carrying Capacity: increase Hgb level
In the protamine reaction classifications by Utely, this type is mediated by thromboxane release and causes rapid severe RV failure.
What is Type III?
How do we treat this?
CPB effects platelet count and function via:
List 5
What are the large surface area of the circuit (plts stick)
Trauma/destruction (roller pumps, air/blood interface, duration of CPB)
Hemodilution
Drugs effects: heparin, nitro, protamine, halothane
Hypothermia
Sequestration by liver
Decreased plt response due to damaged membranes and granules
Increasing the concentration of this acts to depolarize the normal resting membrane potential of a myocyte.
What is extracellular potassium?
It creates a less negative resting potential
The average molecular weight if a heparin molecule.
What is 15,000 Daltons?
The typical pore size of an arterial filter.
What is 20-40 microns?
When interpreting causes of acid/base imbalances, the definition of ROME.
What is:
Respiratory: Opposite pH and CO2
Metabolic: Equal (Same) pH and HCO3
Reducing hemodilution by displacing prime volume with patient's blood is known as this.
What is RAP and/or VAP?
The Oxyhemoglobin Curve..shift left means? Shift right means?
Shift left: hgb holds onto 02, less available for tissues
Shift right: hgb releases 02 more readily
Factors aiding in shift to right: high pCO2 (Bohr Effect), increased temp, 2,3-DPG, decreasing pH at tissues
This inhalational gas can be used as treatment during a protamine reaction.
What is nitric oxide?
Why?
Platelets play an important role is this segment of hemostasis.
What is primary hemostasis?
Coagulation cascade is secondary hemostasis.
Fill in the blanks:
____________ is the hallmark of ____________ cardioplegia and acts as a sodium channel blocker that reduces intracellular sodium and calcium.
Lidocaine, del Nido
Fill in the blanks:
1 USP unit of heparin is the minimum amount of heparin, which when added to ____________________ will prevent coagulation of ____________ for ____________.
citrated, re-calcified sheep plasma
1ml of that plasma
1 hour
This protein is highly concentrated in cardiac muscle and released during even small infarcts.
What are Troponin-T and Troponin -I?
When ZBUF is not successful, this alternative measure can be taken to reduce hyperkalemia
What is treating with insulin to drive the K from extracellular (in the blood) to intracellular space? Glucose must be given to offset the impact of the insulin on blood glucose levels.
This gas diffuses 20 times faster than oxygen through a membrane.
What is CO2?
Oxygenator failure...what will you see first?
Protamine is a weak/strong acid/base and has a positive/negative charge.
What is a strong base, with positive charge?
Name 2 antagonistic prostaglandins and their roles in coagulation.
What are Thromboxane and Prostacyclin?
TXA2: Increases ADP, stimulates plt aggregation, causes vasoconstriction
Prostacyclin: Decreases ADP, inhibits plt aggregation, causes vasodilatation
3 ways to deliver cardioplegia and the pressures expected with each type of delivery.
Antegrade, pressure ~ 180-220 mmHg
Retrograde, pressure ~ 40 mmHg
Coronary ostia, pressure ~ 100- 150 mmHg
Calculate your patient's HDR.
Total heparin: 28,000u
Total volume: 5100 ml
Baseline ACT: 122
1st ACT on CPB: 430
Is this within normal range
Heparin concentration 28,000/5100 = 5.4 u/ml
(430 sec- 122 sec) / 5.4 u/ml = 57 sec/u/ml
NO (90-110 sec/u/ml)
What is 25%?
This body system provides compensation for metabolic acid/base imbalances______________ while this one compensates for respiratory imbalances___________.
The internal diameter of the hemoconcentrator hollow fiber is approximately this.
What is approximately 200 micrometers?
State 4 levels of hypothermia and corresponding temperature ranges.
What are:
Mild: 32-35 degrees C
Moderate: 26-31
Deep: 18-25
Profound: <18
This equation is used to calculate your patient's protamine dose.
What is:
(Last ACT- baseline ACT) / HDR= u/ml
u/ml x PATIENT BV (ml)= units
units/100= mg Protamine
The R value from a TEG or ROTEM device respresents this and if abnormal, can be treated with this.
What is the clotting time (ACT)? Depending on where you are in your case, treat with FFP (ATIII) to extend the R value, or treat with protamine to decrease the R value.
The goal of delivering of cold, blood cardioplegia is to reduces myocardial ischemic injury by......list 4.
Producing an immediate arrest
Creating profound myocardial hypothermia, decreasing 02 demands
Reducing 02 debt, wash out metabolites
Substrate enhancement (glucose, aspartate, glutamate) for anaerobic metabolism
Buffering of acidosis
Prevention of calcium accumulation
Fill in the blanks:
Heparin combines with _____________ to prevent formation of ____________. Heparin causes a ___________-fold increase in the activity of__________.
What is ATIII, Fibrin, 1000-fold increase, ATIII?
Compared to concurrent flow, countercurrent flow in an oxygenator requires this with regards to sweep gas.
What is LESS sweep than concurrent flow?
What is
( 0.3 x kg weight) x (desired K - actual K) / 2
= mEq dose
HC's can typically remove solutes of this size.
What is <20,000 Daltons?
Equation used for calculating the oxygen content of blood (CaO2).
What is (Hgb x 1.34 x SaO2) + (0.0031 x Pa02)