Circuit Surfers

The Currents, Eddys & Riptides- of Open-Heart Surgery

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Dabigatran (Pradaxa)

Dabigatran (Pradaxa) (Boehringer Ingelheim) It should be noted up front that while Dabigatran is indicated as an anticoagulation Rx for atrial fibrillation, it is not recommended for patient’s with concomitant valvular disease, and not indicated for anticoagulation therapy in patient’s receiving valve replacements or experiencing valve dysfunction. Mechanism of Action Dabigatran and its acyl glucuronides…

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Bicarb Alternatives: Sodium Acetate & Balanced Crystalloids

Editor’s Note: Authorization for the contributions below were obtained from each contributor via email.  Please see comments section… Balanced Crystalloids “For those who are still using bicarb in your prime. There is some literature that states the occurrence of acidosis at the start of bypass is an iatrogenic event, that is due to the choices…

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Welcome to the New World : THAM

Click Image to View Source Article… Tham Dosage and Administration (ADULT Calculation) Tham Solution (mL of 0.3 M) Required = Kg x Base deficit x 1.1* Thus, a 70 kg patient with a buffer base deficit (“negative base excess”) of 5 mEq/liter would require 70 x 5 x 1.1 = 385 mL of Tham Solution…

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2016: Sodium Bicarbonate Shortage

UPDATE:  2/22/2016 From:  Bryan Lich, CCP Please be advised that you will soon be experiencing a Biarb shortage at your hospital, so please use it sparingly. https://www.ashp.org/menu/DrugShortages/ResolvedShortages/bulletin.aspx?id=788 Thanks, News Release Sodium Bicarbonate Injection [29 January 2016] Products Affected – Description Sodium Bicarbonate injection, Amphastar 8.4%, 50 mL syringe, 10 count (NDC 76329-3352-01) 8.4%, 50 mL…

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THAM As an Alternative Buffer

Tham Description Tham Solution (tromeThamine injection) is a sterile, non-pyrogenic 0.3 M solution of tromeThamine, adjusted to a pH of approximately 8.6 with glacial acetic acid. It is administered by intravenous injection, by addition to ACD blood for priming cardiac bypass equipment and by injection into the ventricular cavity during cardiac arrest. Each 100 mL…

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Heparin Alternatives [Reprint]

Authored by Steve Sutton, LP, CCP Editor’s Note: Steve Sutton is well known and highly regarded into today’s Perfusion community.  He is a strong proponent for advancing Perfusion education and in pursuing that goal,  he has given numerous presentations at some of the most  premier Perfusion meetings held each year. Along with his dedication to…

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How Much Mannitol & Why ?

I got a few comments recently regarding using Mannitol in the prime- and how much people are using per case. Here is a summary of some casual positions colleagues over the years have laid out for the use of Mannitol: Don’t give it for renal failure / insufficiency patients Causes skeletal muscle dilation- thus a…

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Blood Volume Expanders: Voluven™

(Arnold: The Ultimate Total Body Volume Expander…) Editor’s Note: I got an email today asking me if I knew anything about using Voluven™ as a replacement for Albumin as a prime constituent for the ECC. When looking it up, the obvious similarities to Hespan (Hetastarch), is that they both are synthetic BVE’s. The primary difference…

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Tranexamic Acid Protocols ?

Editor’s Note:   This is in answer to a previous question posted regarding Tranexamic Dosing Protocols: Dosing Implications: (see last article below for source) A 10 mg/kg initial dose of tranexamic acid Followed by an infusion of 1 mg.kg(-1).h(-1) produced plasma concentrations throughout the cardiopulmonary bypass period sufficient to inhibit fibrinolysis in vitro. QUESTION: Does…

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And Now… Amicar ?

Another Questionable Availability Issue… (Click Image to View Source) I would get on top of this as soon as possible.  Amicar is a generic yet essential part of life if conducting Cardiopulmonary Bypass. 1st Protamine Then Magnesium Sulfate Now Epsilon Aminocaproic Acid (EACA  aka Amicar) Is there a common denominator?  Hospira Inc ….Click Image to…

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Protamine Shortage: Update

Update …  You can add MgSO4 to that list … “Labor & Delivery would be a good ancillary source for MgSO4 if you use it in your cardioplegia or otherwise.“ Steve Sutton, LP, CCP Some updates on why some Hospitals are running short on Protamine supplies. Heads up and thanks to Mr. Steve Sutton, LP,…

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Protamine Shortage?

Is There a Problem? I just saw read a sign on “The Board” in our O.R. saying that the next shipment of Protamine for us wasn’t due until September 21 or something like that. Here in West Texas we are hearing of a protamine shortage in the area?  Is this a local  issue or a…

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Heparin v. Protamine

Calculating Heparin Dosing and Protamine Reversal: Well it was one of those days when we had a TEG representative running TEGS on all of our patient’s for a few days, and I was having a discussion with our Lab manager regarding standards for heparin reversal.  We use the HepCon system, but had been dealing with…

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Colloid v. Crystalloid ?

Selecting  Your Perfusate Authored By:  Gerard J Myers Did you ever consider why we use one type of perfusate over the other?  Thousands of cases are done with crystalloids only and thousands are done with colloid/crystalloid primes. Each program has equal results and I would imagine each program would argue that there outcome stats are…

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STS: Meds: Beta Blockers

Pre & Postop Beta Blockade A series of STS Definitions: To Visit the Circuit Surfer STS Page  Click Here For a list of STS posts Click here Sniffing through the patient’s chart to establish beta blocker (BB) therapy seems simple but can be tricky.  I usually find the immediate source in one of the many…

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STS: Meds: Anti-Lipids

Pre & Postop Lipid Lowering Agents A series of STS Definitions: To Visit the Circuit Surfer STS Page  Click Here For a list of all STS posts Click Here If they are here for a heart operation, it’s hard to find a patient who doesn’t have cholesterol and weight issues, has a BMI of less…

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Dabigatran (Pradaxa)

Dabigatran (Pradaxa) (Boehringer Ingelheim) It should be noted up front that while Dabigatran is indicated as an anticoagulation Rx for atrial fibrillation, it is not recommended for patient’s with concomitant valvular disease, and not indicated for anticoagulation therapy in patient’s receiving valve replacements or experiencing valve dysfunction. Mechanism of Action Dabigatran and its acyl glucuronides…

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Heparin Alternatives

Authored by Steve Sutton, LP, CCP Steve Sutton is well known and highly regarded into today’s Perfusion community.  He is a strong proponent for advancing Perfusion education and in pursuing that goal,  he has given numerous presentations at some of the most  premier Perfusion meetings held each year. Along with his dedication to Perfusion as…

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Protamine v1

Protamine   A polycationic protein derived from salmon milt, possess strong alkalinity because of an amino acid composition consisting of 67% arginine.  In its natural state, the numerous positive charges on the protamine molecule bind with the negatively charged phosphate groups of the nucleoprotein material of salmon sperm.  Heparin, a polyanion, binds ionically to protamine…

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Protamine Reaction v1

I.    DESCRIPTION: Following cardiopulmonary bypass with heparin anticoagulation, protamine sulfate is used to neutralize the effects of heparin and reverse anticoagulation.  Currently protamine is the only drug available in the United States that can be used for this purpose. Hexadimethrine bromide (Polybrene) and toluidine blue are for laboratory use only. II.    ADMINISTRATION: The method of…

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Right Ventricular Function v. 1

Right Ventricular Function Patients with right coronary artery disease may be susceptible to right ventricular ischemia and infarction when right ventricular distension or increased afterload occurs resulting in diminished cardiac performance and reduced right coronary perfusion pressure.  The interrelationships of aortic end-diastolic pressure, afterload volume, coronary perfusion pressure, and pulmonary vascular resistance, play a significant…

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Desmopressin v.1

Desmopressin Desmopressin acetate (DDAVP) is a synthetic analog of vasopressin and like ADH, epinephrine, and insulin, releases a variety of hemostatically active substances from vascular endothelium.  It is administered in doses of 0.3 µg/kg by intravenous, intranasal, or subcutaneous routes.  It has a half life of 55 minutes, (with clinical effects lasting from 5 to…

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Cardioplegia

Cardioplegia Vinten-Johansen J, Nakanishi K. Postcardioplegia acute cardiac dysfunction and     reperfusion injury. Journal of Cardiothoracic and Vascular Anesthesia.     1993;7(Suppl 2):6-18.

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Angiomax

Angiomax Perfusion Issues Reconstitute Angiomax in OR- 250 mg in powder with 5 cc NSS=  50 mg per ml. No heparin coated surfaces (circuit, CDI, Swann Ganz– etc) Angiomax ½ life = 25 minutes Will precipitate if blood is allowed to pool Observed clot in the pericardium (after Angiomax is bolused)  is Normal- remove with…