Podcast
Questions and Answers
What factor primarily influences Charlotte's reduced snowfall compared to areas slightly to its west?
What factor primarily influences Charlotte's reduced snowfall compared to areas slightly to its west?
- A heat dome effect consistently deflects snowstorms away from Charlotte.
- Charlotte's higher elevation prevents snow accumulation.
- Charlotte is shielded by the foothills of mountains, blocking snowfall. (correct)
- The proximity to the ocean moderates Charlotte's winter temperatures.
How does the speaker describe the local reaction in Charlotte when there is even a small amount of snow?
How does the speaker describe the local reaction in Charlotte when there is even a small amount of snow?
- People in Charlotte generally ignore minor snowfalls.
- A small amount of snow is considered a pleasant change.
- The residents of Charlotte are well-prepared for heavy snow.
- Even a little snow in Charlotte is seen as a major event. (correct)
What type of precipitation does the speaker prefer driving on, and why?
What type of precipitation does the speaker prefer driving on, and why?
- The speaker prefers driving on snow rather than a wintry mix. (correct)
- The speaker prefers driving on ice for the challenge it presents.
- The speaker prefers driving in wintry mix due to better traction.
- The speaker avoids driving in any winter precipitation for safety reasons.
What is implied about the speaker's potential consideration of a 'bearded lady' look?
What is implied about the speaker's potential consideration of a 'bearded lady' look?
What observation is made about the boy filter and its resemblance to someone familiar?
What observation is made about the boy filter and its resemblance to someone familiar?
Based on the conversation, what weather event occurred in Charlotte shortly before the discussion?
Based on the conversation, what weather event occurred in Charlotte shortly before the discussion?
What does the speaker mean when they say '10 years can go ham'?
What does the speaker mean when they say '10 years can go ham'?
What are the speakers doing while discussing the weather and filters?
What are the speakers doing while discussing the weather and filters?
A patient with a known allergy to sulfonamides requires a diuretic. Which diuretic class should be used with caution due to potential cross-reactivity?
A patient with a known allergy to sulfonamides requires a diuretic. Which diuretic class should be used with caution due to potential cross-reactivity?
A patient is prescribed a loop diuretic for heart failure. What electrolyte imbalance is most likely to occur as a direct result of this medication?
A patient is prescribed a loop diuretic for heart failure. What electrolyte imbalance is most likely to occur as a direct result of this medication?
Which mechanism of action is most characteristic of loop diuretics?
Which mechanism of action is most characteristic of loop diuretics?
A patient presents with pulmonary edema and requires rapid diuresis. Which diuretic would be the MOST appropriate choice?
A patient presents with pulmonary edema and requires rapid diuresis. Which diuretic would be the MOST appropriate choice?
A patient with hypertension is prescribed hydrochlorothiazide. What is the primary mechanism by which this drug lowers blood pressure?
A patient with hypertension is prescribed hydrochlorothiazide. What is the primary mechanism by which this drug lowers blood pressure?
A patient with cirrhosis and ascites is being treated with spironolactone. What is the primary mechanism by which spironolactone reduces ascites?
A patient with cirrhosis and ascites is being treated with spironolactone. What is the primary mechanism by which spironolactone reduces ascites?
Which diuretic is most likely to cause hyperkalemia as a significant adverse effect?
Which diuretic is most likely to cause hyperkalemia as a significant adverse effect?
A patient taking a loop diuretic is also prescribed digoxin for heart failure. Which electrolyte imbalance caused by the diuretic could increase the risk of digoxin toxicity?
A patient taking a loop diuretic is also prescribed digoxin for heart failure. Which electrolyte imbalance caused by the diuretic could increase the risk of digoxin toxicity?
A patient with increased intracranial pressure is given mannitol. What mechanism underlies the use of mannitol in this situation?
A patient with increased intracranial pressure is given mannitol. What mechanism underlies the use of mannitol in this situation?
Which of the following is a common side effect associated with the use of acetazolamide?
Which of the following is a common side effect associated with the use of acetazolamide?
A patient with angle-closure glaucoma requires medication to rapidly reduce intraocular pressure. Which diuretic is most appropriate?
A patient with angle-closure glaucoma requires medication to rapidly reduce intraocular pressure. Which diuretic is most appropriate?
A patient is started on a thiazide diuretic for hypertension. What effect would this medication have on serum calcium levels?
A patient is started on a thiazide diuretic for hypertension. What effect would this medication have on serum calcium levels?
Which of the following diuretics is an aldosterone antagonist?
Which of the following diuretics is an aldosterone antagonist?
A patient with heart failure is prescribed both a loop diuretic and an ACE inhibitor. What is the primary reason for using this combination?
A patient with heart failure is prescribed both a loop diuretic and an ACE inhibitor. What is the primary reason for using this combination?
A patient taking a diuretic develops muscle cramps and weakness. Which electrolyte imbalance is MOST likely to be the cause?
A patient taking a diuretic develops muscle cramps and weakness. Which electrolyte imbalance is MOST likely to be the cause?
Why is vasoconstriction important in the area of a damaged blood vessel during the initial stages of hemostasis?
Why is vasoconstriction important in the area of a damaged blood vessel during the initial stages of hemostasis?
What is the role of nitric oxide (NO) released by endothelial cells in normal blood vessels?
What is the role of nitric oxide (NO) released by endothelial cells in normal blood vessels?
How does prostacyclin contribute to maintaining normal blood vessel function?
How does prostacyclin contribute to maintaining normal blood vessel function?
What is the initial response when the endothelial layer of a blood vessel is damaged, exposing the collagen beneath?
What is the initial response when the endothelial layer of a blood vessel is damaged, exposing the collagen beneath?
What is the primary function of von Willebrand factor (vWF) in primary hemostasis?
What is the primary function of von Willebrand factor (vWF) in primary hemostasis?
In a patient with von Willebrand disease, what would be the expected change in bleeding time and why?
In a patient with von Willebrand disease, what would be the expected change in bleeding time and why?
Why might DDAVP (desmopressin) be administered to a patient with von Willebrand disease?
Why might DDAVP (desmopressin) be administered to a patient with von Willebrand disease?
If a patient with a bleeding disorder has a normal platelet count but prolonged bleeding time, which of the following deficiencies is most likely the cause?
If a patient with a bleeding disorder has a normal platelet count but prolonged bleeding time, which of the following deficiencies is most likely the cause?
Which of the following best describes the sequence of events in primary hemostasis after a blood vessel injury?
Which of the following best describes the sequence of events in primary hemostasis after a blood vessel injury?
A patient has a condition that impairs their ability to produce serotonin at the site of a vascular injury. What immediate effect would this most likely have on primary hemostasis?
A patient has a condition that impairs their ability to produce serotonin at the site of a vascular injury. What immediate effect would this most likely have on primary hemostasis?
Why is it important for the body to maintain a balance between procoagulation and anticoagulation?
Why is it important for the body to maintain a balance between procoagulation and anticoagulation?
How does the exposure of collagen during blood vessel injury initiate the process of hemostasis?
How does the exposure of collagen during blood vessel injury initiate the process of hemostasis?
A researcher is investigating a new drug that aims to improve primary hemostasis. Which of the following mechanisms would be the MOST promising target for this drug?
A researcher is investigating a new drug that aims to improve primary hemostasis. Which of the following mechanisms would be the MOST promising target for this drug?
A patient's lab results show normal levels of all coagulation factors, but their bleeding time is prolonged. Which of the following tests would be most useful in determining the cause of the prolonged bleeding?
A patient's lab results show normal levels of all coagulation factors, but their bleeding time is prolonged. Which of the following tests would be most useful in determining the cause of the prolonged bleeding?
A cardiologist is deciding whether to prescribe a medication that affects components of hemostasis. What information about the patient is MOST important when making this decision?
A cardiologist is deciding whether to prescribe a medication that affects components of hemostasis. What information about the patient is MOST important when making this decision?
In the extrinsic pathway of coagulation, which factor directly activates Factor 7?
In the extrinsic pathway of coagulation, which factor directly activates Factor 7?
Which factor is NOT typically explicitly listed in coagulation pathways despite its essential role?
Which factor is NOT typically explicitly listed in coagulation pathways despite its essential role?
What is the correct sequence of activation in the intrinsic pathway?
What is the correct sequence of activation in the intrinsic pathway?
A deficiency in which factor leads to Hemophilia B?
A deficiency in which factor leads to Hemophilia B?
Which of the following best describes the role of the intrinsic pathway in coagulation?
Which of the following best describes the role of the intrinsic pathway in coagulation?
In the context of blood coagulation, what does the term 'propagation' refer to?
In the context of blood coagulation, what does the term 'propagation' refer to?
Why might a patient with issues in the intrinsic or extrinsic pathways still form clots that are unstable?
Why might a patient with issues in the intrinsic or extrinsic pathways still form clots that are unstable?
What is the primary function of Factor 13 in the final common pathway?
What is the primary function of Factor 13 in the final common pathway?
In the final common pathway, what complex is responsible for converting prothrombin into thrombin?
In the final common pathway, what complex is responsible for converting prothrombin into thrombin?
What role does thrombin play in the final common pathway?
What role does thrombin play in the final common pathway?
Which of the following coagulation factors is also known as Christmas factor?
Which of the following coagulation factors is also known as Christmas factor?
During the amplification stage, which factor is bypassed in the intrinsic pathway countdown?
During the amplification stage, which factor is bypassed in the intrinsic pathway countdown?
In which phase of coagulation is thrombin primarily formed?
In which phase of coagulation is thrombin primarily formed?
How do the clots formed in patients with intrinsic and extrinsic pathway issues typically differ from normal clots?
How do the clots formed in patients with intrinsic and extrinsic pathway issues typically differ from normal clots?
Which of the following sequences accurately represents the final common pathway?
Which of the following sequences accurately represents the final common pathway?
Which of the following is the primary role of thromboxane A2 in primary hemostasis?
Which of the following is the primary role of thromboxane A2 in primary hemostasis?
How does prostacyclin contribute to the regulation of primary hemostasis?
How does prostacyclin contribute to the regulation of primary hemostasis?
What distinguishes secondary hemostasis from primary hemostasis?
What distinguishes secondary hemostasis from primary hemostasis?
Which event characterizes the initiation phase of secondary hemostasis, particularly within the extrinsic pathway?
Which event characterizes the initiation phase of secondary hemostasis, particularly within the extrinsic pathway?
How do activated platelets change their morphology during primary hemostasis, and what is the functional significance of this change?
How do activated platelets change their morphology during primary hemostasis, and what is the functional significance of this change?
What is the role of von Willebrand factor (vWF) in the initial stages of primary hemostasis?
What is the role of von Willebrand factor (vWF) in the initial stages of primary hemostasis?
Which of the following factors are known to be vitamin K-dependent in the coagulation cascade?
Which of the following factors are known to be vitamin K-dependent in the coagulation cascade?
During primary hemostasis, what is the combined role of ADP and thromboxane A2?
During primary hemostasis, what is the combined role of ADP and thromboxane A2?
What is the significance of fibrinogen in the context of platelet aggregation?
What is the significance of fibrinogen in the context of platelet aggregation?
Why is the initial platelet plug formed during primary hemostasis considered 'temporary'?
Why is the initial platelet plug formed during primary hemostasis considered 'temporary'?
Which factor does the term 'thromboplastin' refer to, and from where is it derived?
Which factor does the term 'thromboplastin' refer to, and from where is it derived?
A patient has a deficiency in Factor VIII. Based on the information, during which phase of hemostasis would this deficiency have the most impact?
A patient has a deficiency in Factor VIII. Based on the information, during which phase of hemostasis would this deficiency have the most impact?
A researcher is investigating new drugs to prevent thrombosis. Which of the following mechanisms would be most effective in preventing the initial formation of a platelet plug?
A researcher is investigating new drugs to prevent thrombosis. Which of the following mechanisms would be most effective in preventing the initial formation of a platelet plug?
In a patient with liver disease, synthesis of several clotting factors is impaired. Which stage of hemostasis will be most directly affected?
In a patient with liver disease, synthesis of several clotting factors is impaired. Which stage of hemostasis will be most directly affected?
If a patient has a genetic defect that prevents platelets from changing shape upon activation, which aspect of primary hemostasis would be most directly impaired?
If a patient has a genetic defect that prevents platelets from changing shape upon activation, which aspect of primary hemostasis would be most directly impaired?
Which factor directly contributes to stabilizing a blood clot?
Which factor directly contributes to stabilizing a blood clot?
A patient is taking a Gp 2b 3a inhibitor. What is the primary target of this medication?
A patient is taking a Gp 2b 3a inhibitor. What is the primary target of this medication?
What does the Prothrombin Time (PT) primarily assess?
What does the Prothrombin Time (PT) primarily assess?
What condition would MOST likely cause a prolonged PT value?
What condition would MOST likely cause a prolonged PT value?
The International Normalized Ratio (INR) is used to standardize which coagulation test across different laboratories?
The International Normalized Ratio (INR) is used to standardize which coagulation test across different laboratories?
A patient with liver dysfunction is likely to have a prolonged PT due to:
A patient with liver dysfunction is likely to have a prolonged PT due to:
What coagulation pathway does the Activated Partial Thromboplastin Time (aPTT) primarily assess?
What coagulation pathway does the Activated Partial Thromboplastin Time (aPTT) primarily assess?
A patient with hemophilia is MOST likely to have a prolonged:
A patient with hemophilia is MOST likely to have a prolonged:
Heparin exerts its anticoagulant effect primarily by affecting the:
Heparin exerts its anticoagulant effect primarily by affecting the:
Which condition is LEAST likely to prolong the aPTT?
Which condition is LEAST likely to prolong the aPTT?
The Activated Clotting Time (ACT) is primarily used to monitor:
The Activated Clotting Time (ACT) is primarily used to monitor:
Which factor can falsely prolong Activated Clotting Time (ACT)?
Which factor can falsely prolong Activated Clotting Time (ACT)?
In preparation for a major surgery, a fibrinogen level of at least what value (mg/dL) is generally desired?
In preparation for a major surgery, a fibrinogen level of at least what value (mg/dL) is generally desired?
A patient is scheduled for surgery and their INR is 1.8. What is the MOST appropriate action?
A patient is scheduled for surgery and their INR is 1.8. What is the MOST appropriate action?
A patient with a history of cardiovascular disease is on an anticoagulant. In the context of the perioperative period, what is the MOST important consideration regarding the drug?
A patient with a history of cardiovascular disease is on an anticoagulant. In the context of the perioperative period, what is the MOST important consideration regarding the drug?
When determining whether to continue or discontinue an anticoagulant before surgery, what factors are considered in the risk-benefit analysis?
When determining whether to continue or discontinue an anticoagulant before surgery, what factors are considered in the risk-benefit analysis?
Why might a patient undergoing a liver resection have different anticoagulant considerations compared to someone undergoing carpal tunnel surgery?
Why might a patient undergoing a liver resection have different anticoagulant considerations compared to someone undergoing carpal tunnel surgery?
For which of the following patients would bridge therapy with low molecular weight heparin most likely be considered during the perioperative period?
For which of the following patients would bridge therapy with low molecular weight heparin most likely be considered during the perioperative period?
What is the primary reason for anesthesiologists to assess a patient’s anticoagulant status during pre-operative assessment?
What is the primary reason for anesthesiologists to assess a patient’s anticoagulant status during pre-operative assessment?
Why might the administration of Toradol (ketorolac) be reconsidered in a patient undergoing surgery?
Why might the administration of Toradol (ketorolac) be reconsidered in a patient undergoing surgery?
What distinguishes unfractionated heparin from low molecular weight heparin?
What distinguishes unfractionated heparin from low molecular weight heparin?
If a medication is labeled as 'low molecular weight heparin', what can be definitively inferred about its composition?
If a medication is labeled as 'low molecular weight heparin', what can be definitively inferred about its composition?
What is the immediate effect of heparin binding to antithrombin III (AT-III)?
What is the immediate effect of heparin binding to antithrombin III (AT-III)?
Which coagulation pathway is most directly affected by antithrombin III (AT-III) once it's activated by heparin?
Which coagulation pathway is most directly affected by antithrombin III (AT-III) once it's activated by heparin?
How does antithrombin III (AT-III) function as a regulator of coagulation?
How does antithrombin III (AT-III) function as a regulator of coagulation?
In what specific way does heparin influence platelet activation?
In what specific way does heparin influence platelet activation?
If a patient is on unfractionated heparin, what types of heparin molecules are present in their system?
If a patient is on unfractionated heparin, what types of heparin molecules are present in their system?
Why is it important to understand whether a patient received bridge therapy with heparin before surgery?
Why is it important to understand whether a patient received bridge therapy with heparin before surgery?
What is a key difference in how unfractionated heparin and low molecular weight heparin are typically referred to in clinical settings?
What is a key difference in how unfractionated heparin and low molecular weight heparin are typically referred to in clinical settings?
What is the origin of unfractionated heparin?
What is the origin of unfractionated heparin?
Why is it recommended to use a preservative-free form of heparin in pediatric patients, especially infants?
Why is it recommended to use a preservative-free form of heparin in pediatric patients, especially infants?
A patient with a known antithrombin III deficiency is prescribed heparin. What is a likely consequence?
A patient with a known antithrombin III deficiency is prescribed heparin. What is a likely consequence?
In a pregnant patient requiring anticoagulation, why is monitoring factor Xa levels preferred over aPTT when using heparin?
In a pregnant patient requiring anticoagulation, why is monitoring factor Xa levels preferred over aPTT when using heparin?
What is the primary concern regarding neuroaxial anesthesia (spinal or epidural) in a patient receiving anticoagulation therapy?
What is the primary concern regarding neuroaxial anesthesia (spinal or epidural) in a patient receiving anticoagulation therapy?
Which of the following statements is correct regarding heparin and the placenta?
Which of the following statements is correct regarding heparin and the placenta?
A patient on a therapeutic dose of heparin requires an urgent surgical procedure under neuroaxial anesthesia. According to the guidelines, what is the most appropriate course of action?
A patient on a therapeutic dose of heparin requires an urgent surgical procedure under neuroaxial anesthesia. According to the guidelines, what is the most appropriate course of action?
What is the primary reason heparin is often administered subcutaneously as a prophylactic measure?
What is the primary reason heparin is often administered subcutaneously as a prophylactic measure?
Which factors directly influence the effectiveness of heparin?
Which factors directly influence the effectiveness of heparin?
How long should subcutaneous heparin be held before neuroaxial anesthesia
How long should subcutaneous heparin be held before neuroaxial anesthesia
You have a patient that cannot tolerate general anesthesia. What course of action could you explore in a hypercoagulable patient?
You have a patient that cannot tolerate general anesthesia. What course of action could you explore in a hypercoagulable patient?
If a patient is heparin resistant, what deficiency is the initial thought?
If a patient is heparin resistant, what deficiency is the initial thought?
If a patient is receiving heparin intravenously to reach a therapeutic PTT, what kind of dose are they most likely receiving?
If a patient is receiving heparin intravenously to reach a therapeutic PTT, what kind of dose are they most likely receiving?
What pathway(s) does heparin primarily affect?
What pathway(s) does heparin primarily affect?
What is a major site of action for heparin?
What is a major site of action for heparin?
How long does subcutaneous heparin take to take effect?
How long does subcutaneous heparin take to take effect?
Why might a healthcare provider's practice sometimes deviate slightly from textbook guidelines?
Why might a healthcare provider's practice sometimes deviate slightly from textbook guidelines?
What is a key consideration regarding regional anesthesia for patients on low-dose anticoagulants?
What is a key consideration regarding regional anesthesia for patients on low-dose anticoagulants?
What is the target range for Activated Clotting Time (ACT) during heparin therapy, according to the information?
What is the target range for Activated Clotting Time (ACT) during heparin therapy, according to the information?
What role does platelet factor 4 (PF4) play in Heparin-Induced Thrombocytopenia (HIT)?
What role does platelet factor 4 (PF4) play in Heparin-Induced Thrombocytopenia (HIT)?
What is a characteristic sign of a severe reaction to heparin, potentially indicating HIT?
What is a characteristic sign of a severe reaction to heparin, potentially indicating HIT?
How does low molecular weight heparin (LMWH) primarily inhibit the coagulation cascade?
How does low molecular weight heparin (LMWH) primarily inhibit the coagulation cascade?
What is an advantage of low molecular weight heparin (LMWH) compared to unfractionated heparin regarding its pharmacological properties?
What is an advantage of low molecular weight heparin (LMWH) compared to unfractionated heparin regarding its pharmacological properties?
Why is low molecular weight heparin (LMWH) generally avoided or adjusted in patients with renal dysfunction?
Why is low molecular weight heparin (LMWH) generally avoided or adjusted in patients with renal dysfunction?
Why is protamine not typically used to fully reverse the effects of low molecular weight heparin (LMWH)?
Why is protamine not typically used to fully reverse the effects of low molecular weight heparin (LMWH)?
How long should low molecular weight heparin be held before surgery, according to the information provided?
How long should low molecular weight heparin be held before surgery, according to the information provided?
What risk is heightened when a patient on low molecular weight heparin (LMWH) undergoes spinal or epidural anesthesia?
What risk is heightened when a patient on low molecular weight heparin (LMWH) undergoes spinal or epidural anesthesia?
For a patient on a prophylactic dose of low molecular weight heparin (LMWH) needing a peripheral nerve block, what is the recommended delay?
For a patient on a prophylactic dose of low molecular weight heparin (LMWH) needing a peripheral nerve block, what is the recommended delay?
If a patient is receiving a therapeutic dose of low molecular weight heparin, how long should it be held before neuroaxial anesthesia?
If a patient is receiving a therapeutic dose of low molecular weight heparin, how long should it be held before neuroaxial anesthesia?
Why does the instruction emphasize looking up specific guidelines for anticoagulant management on a case-by-case basis?
Why does the instruction emphasize looking up specific guidelines for anticoagulant management on a case-by-case basis?
What is a crucial step to consider when creating a care plan involving surgery and a patient on anticoagulants?
What is a crucial step to consider when creating a care plan involving surgery and a patient on anticoagulants?
Which of the following best describes the mechanism of action of warfarin?
Which of the following best describes the mechanism of action of warfarin?
Which vitamin K-dependent clotting factors are affected by warfarin?
Which vitamin K-dependent clotting factors are affected by warfarin?
What is the typical target INR range for a patient on warfarin therapy?
What is the typical target INR range for a patient on warfarin therapy?
A patient on warfarin is scheduled for an elective surgery. Current recommendations suggest discontinuing warfarin how many days prior to the procedure?
A patient on warfarin is scheduled for an elective surgery. Current recommendations suggest discontinuing warfarin how many days prior to the procedure?
Which of the following is the MOST appropriate initial treatment for a patient with an elevated INR due to warfarin, who requires emergent surgery?
Which of the following is the MOST appropriate initial treatment for a patient with an elevated INR due to warfarin, who requires emergent surgery?
Why is intravenous vitamin K administered slowly when reversing warfarin?
Why is intravenous vitamin K administered slowly when reversing warfarin?
Which of the following factors can affect the effectiveness and dosing of warfarin?
Which of the following factors can affect the effectiveness and dosing of warfarin?
What is a major disadvantage of using vitamin K to reverse warfarin's effects in a patient needing urgent surgery?
What is a major disadvantage of using vitamin K to reverse warfarin's effects in a patient needing urgent surgery?
Which of the following is a common indication for warfarin therapy?
Which of the following is a common indication for warfarin therapy?
What is the primary reason warfarin is avoided during pregnancy?
What is the primary reason warfarin is avoided during pregnancy?
A patient with a history of Vitamin K deficiency is started on Warfarin. How might this impact the Warfarin's onset of action and required dosage adjustments?
A patient with a history of Vitamin K deficiency is started on Warfarin. How might this impact the Warfarin's onset of action and required dosage adjustments?
What factor contributes to warfarin's delayed onset of action?
What factor contributes to warfarin's delayed onset of action?
A patient with liver disease is prescribed warfarin. What adjustments, if any, are typically required?
A patient with liver disease is prescribed warfarin. What adjustments, if any, are typically required?
Which of the following best explains why Prothrombin Complex Concentrate (PCC) provides faster reversal of warfarin compared to Fresh Frozen Plasma (FFP)?
Which of the following best explains why Prothrombin Complex Concentrate (PCC) provides faster reversal of warfarin compared to Fresh Frozen Plasma (FFP)?
Which statement accurately describes the oral bioavailability of warfarin?
Which statement accurately describes the oral bioavailability of warfarin?
What is the mechanism of action of fondaparinux (Arixtra)?
What is the mechanism of action of fondaparinux (Arixtra)?
Which of the following is a key consideration for fondaparinux (Arixtra) administration prior to surgery?
Which of the following is a key consideration for fondaparinux (Arixtra) administration prior to surgery?
How do argatroban and bivalirudin exert their anticoagulant effects?
How do argatroban and bivalirudin exert their anticoagulant effects?
What monitoring is appropriate for argatroban and bivalirudin?
What monitoring is appropriate for argatroban and bivalirudin?
What is the manufacturer's recommendation regarding regional anesthesia in patients taking dabigatran (Pradaxa)?
What is the manufacturer's recommendation regarding regional anesthesia in patients taking dabigatran (Pradaxa)?
What is the primary mechanism by which aspirin inhibits platelet aggregation?
What is the primary mechanism by which aspirin inhibits platelet aggregation?
Why is aspirin typically held 7-10 days prior to surgery, especially at higher doses?
Why is aspirin typically held 7-10 days prior to surgery, especially at higher doses?
Clopidogrel (Plavix) inhibits platelet aggregation by which mechanism?
Clopidogrel (Plavix) inhibits platelet aggregation by which mechanism?
What type of receptor is the P2Y12 receptor, which is targeted by clopidogrel (Plavix)?
What type of receptor is the P2Y12 receptor, which is targeted by clopidogrel (Plavix)?
What dictates the duration of aspirin's effect on platelet function?
What dictates the duration of aspirin's effect on platelet function?
A patient is scheduled for surgery and is currently taking clopidogrel (Plavix). Which test would be most useful in assessing the patient's coagulation status prior to the procedure?
A patient is scheduled for surgery and is currently taking clopidogrel (Plavix). Which test would be most useful in assessing the patient's coagulation status prior to the procedure?
A patient with a history of HIT (Heparin-Induced Thrombocytopenia) requires anticoagulation. Which of the following would be the MOST appropriate alternative?
A patient with a history of HIT (Heparin-Induced Thrombocytopenia) requires anticoagulation. Which of the following would be the MOST appropriate alternative?
A patient is taking both aspirin and clopidogrel following a recent cardiac stent placement. What is the MOST significant risk associated with this dual antiplatelet therapy?
A patient is taking both aspirin and clopidogrel following a recent cardiac stent placement. What is the MOST significant risk associated with this dual antiplatelet therapy?
How does aspirin's inhibition of cyclooxygenase (COX) lead to its antiplatelet effect?
How does aspirin's inhibition of cyclooxygenase (COX) lead to its antiplatelet effect?
Which statement accurately differentiates between the mechanisms of action of aspirin and clopidogrel?
Which statement accurately differentiates between the mechanisms of action of aspirin and clopidogrel?
In trauma patients, what is the primary concern regarding fibrinolytic shutdown?
In trauma patients, what is the primary concern regarding fibrinolytic shutdown?
Why might administering TXA too late in a trauma patient potentially worsen their condition?
Why might administering TXA too late in a trauma patient potentially worsen their condition?
Which of the following is a potential effect of a deficiency in Protein C or Protein S?
Which of the following is a potential effect of a deficiency in Protein C or Protein S?
How do antifibrinolytic medications like Amicar and tranexamic acid (TXA) reduce bleeding?
How do antifibrinolytic medications like Amicar and tranexamic acid (TXA) reduce bleeding?
What is the primary reason for administering antifibrinolytic agents like aprotinin during surgery?
What is the primary reason for administering antifibrinolytic agents like aprotinin during surgery?
Why might tranexamic acid (TXA) be preferred over aminocaproic acid (Amicar) in some clinical settings, particularly in Europe?
Why might tranexamic acid (TXA) be preferred over aminocaproic acid (Amicar) in some clinical settings, particularly in Europe?
Why is aprotinin rarely used in the US currently?
Why is aprotinin rarely used in the US currently?
What is the primary route of administration for tranexamic acid (TXA) when used by anesthesia providers?
What is the primary route of administration for tranexamic acid (TXA) when used by anesthesia providers?
What is the primary adverse effect associated with antifibrinolytic medications?
What is the primary adverse effect associated with antifibrinolytic medications?
In what scenario might a surgeon choose to administer tranexamic acid (TXA) topically rather than intravenously?
In what scenario might a surgeon choose to administer tranexamic acid (TXA) topically rather than intravenously?
Which patient factor requires an individualized risk assessment prior to administration of TXA?
Which patient factor requires an individualized risk assessment prior to administration of TXA?
What is a primary concern when considering the parenteral administration of tranexamic acid (TXA) in a patient with a history of thromboembolism?
What is a primary concern when considering the parenteral administration of tranexamic acid (TXA) in a patient with a history of thromboembolism?
In which of the following scenarios would topical TXA administration be considered over intravenous administration?
In which of the following scenarios would topical TXA administration be considered over intravenous administration?
What is the rationale behind using topical tranexamic acid (TXA) in orthopedic surgeries?
What is the rationale behind using topical tranexamic acid (TXA) in orthopedic surgeries?
What is a general contraindication for using TXA?
What is a general contraindication for using TXA?
Why is it important to discuss a patient's pre-operative medication and medical history with the surgeon when considering the use of TXA?
Why is it important to discuss a patient's pre-operative medication and medical history with the surgeon when considering the use of TXA?
Why is the potential for GABA blockade in the frontal cortex a safety concern with tranexamic acid (TXA)?
Why is the potential for GABA blockade in the frontal cortex a safety concern with tranexamic acid (TXA)?
A patient presents with an uncontrolled seizure history and is scheduled for surgery. Which of the following considerations is most important when deciding whether to administer TXA?
A patient presents with an uncontrolled seizure history and is scheduled for surgery. Which of the following considerations is most important when deciding whether to administer TXA?
What is the recommended dose and timing of tranexamic acid (TXA) administration for postpartum hemorrhage (PPH)?
What is the recommended dose and timing of tranexamic acid (TXA) administration for postpartum hemorrhage (PPH)?
Besides postpartum hemorrhage, what is another common surgical scenario where tranexamic acid (TXA) is typically administered?
Besides postpartum hemorrhage, what is another common surgical scenario where tranexamic acid (TXA) is typically administered?
What is the typical dose of TXA administered during a surgical case?
What is the typical dose of TXA administered during a surgical case?
Why is renal dysfunction a concern when considering the use of aminocaproic acid?
Why is renal dysfunction a concern when considering the use of aminocaproic acid?
In trauma cases, when should tranexamic acid (TXA) be administered to maximize its benefit?
In trauma cases, when should tranexamic acid (TXA) be administered to maximize its benefit?
What serious adverse event has been reported due to wrong-site administration of TXA?
What serious adverse event has been reported due to wrong-site administration of TXA?
A surgeon asks for a repeat dose of tranexamic acid (TXA) at the end of a high-risk surgery. What is the primary rationale for this?
A surgeon asks for a repeat dose of tranexamic acid (TXA) at the end of a high-risk surgery. What is the primary rationale for this?
Why is there a risk of administering TXA into the spinal canal?
Why is there a risk of administering TXA into the spinal canal?
How does tranexamic acid (TXA) exert its antifibrinolytic effect at the molecular level?
How does tranexamic acid (TXA) exert its antifibrinolytic effect at the molecular level?
What is the primary reason a clinician might hesitate to administer tranexamic acid (TXA) to a patient with a recent history of deep vein thrombosis (DVT)?
What is the primary reason a clinician might hesitate to administer tranexamic acid (TXA) to a patient with a recent history of deep vein thrombosis (DVT)?
What patient population is at higher risk for wrong-site administration of TXA?
What patient population is at higher risk for wrong-site administration of TXA?
While all forms of TXA (oral, topical, IV) have similar efficacy, when might the oral form be particularly useful?
While all forms of TXA (oral, topical, IV) have similar efficacy, when might the oral form be particularly useful?
Why is it important to communicate with the medical team before administering DDAVP to a patient?
Why is it important to communicate with the medical team before administering DDAVP to a patient?
Why should DDAVP be infused slowly?
Why should DDAVP be infused slowly?
What is the primary role of fibrinogen (Factor I) in clot formation?
What is the primary role of fibrinogen (Factor I) in clot formation?
When might a clinician consider administering fibrinogen to a patient?
When might a clinician consider administering fibrinogen to a patient?
What is the typical target range for fibrinogen levels in most surgical patients?
What is the typical target range for fibrinogen levels in most surgical patients?
How does cryoprecipitate (cryo) administration impact fibrinogen levels?
How does cryoprecipitate (cryo) administration impact fibrinogen levels?
What is the primary mechanism of action of recombinant activated factor VIIa (rFVIIa)?
What is the primary mechanism of action of recombinant activated factor VIIa (rFVIIa)?
Through which pathway does recombinant factor VIIa exert its effect?
Through which pathway does recombinant factor VIIa exert its effect?
Why might facilities opt for transfusion over recombinant factors to improve clotting ability?
Why might facilities opt for transfusion over recombinant factors to improve clotting ability?
What role does Factor XIII play in the coagulation cascade?
What role does Factor XIII play in the coagulation cascade?
Why is it challenging to accurately dose protamine based on the initial heparin dose?
Why is it challenging to accurately dose protamine based on the initial heparin dose?
What is the most likely mechanism behind protamine-induced hypotension?
What is the most likely mechanism behind protamine-induced hypotension?
What is the most significant risk associated with rapid administration of protamine?
What is the most significant risk associated with rapid administration of protamine?
From where is von Willebrand factor released?
From where is von Willebrand factor released?
Why might a patient experience 'heparin rebound' after protamine administration?
Why might a patient experience 'heparin rebound' after protamine administration?
How do absorbable hemostatic agents like Gelfoam and Surgicel work?
How do absorbable hemostatic agents like Gelfoam and Surgicel work?
In what situation might a surgeon request topical hemostatic agents during a procedure?
In what situation might a surgeon request topical hemostatic agents during a procedure?
What is the primary mechanism by which protamine reverses the effects of heparin?
What is the primary mechanism by which protamine reverses the effects of heparin?
Which of the following is a potential adverse effect associated with high doses of protamine?
Which of the following is a potential adverse effect associated with high doses of protamine?
A patient is undergoing a surgical procedure, and the surgical team requests Gelfoam. What does this likely indicate?
A patient is undergoing a surgical procedure, and the surgical team requests Gelfoam. What does this likely indicate?
What is the physiological effect of desmopressin (DDAVP) related to hemostasis?
What is the physiological effect of desmopressin (DDAVP) related to hemostasis?
Why is the timing of DDAVP administration important in relation to surgery for patients with von Willebrand disease?
Why is the timing of DDAVP administration important in relation to surgery for patients with von Willebrand disease?
Besides DDAVP, what other treatment options are available for a patient with von Willebrand disease?
Besides DDAVP, what other treatment options are available for a patient with von Willebrand disease?
What is the typical dosage and route of administration for DDAVP in patients with von Willebrand disease undergoing surgery?
What is the typical dosage and route of administration for DDAVP in patients with von Willebrand disease undergoing surgery?
Which of the following drug interactions should be considered when administering protamine?
Which of the following drug interactions should be considered when administering protamine?
What is the role of the pre-operative nurse in managing a patient with von Willebrand disease who is scheduled for surgery and requires DDAVP?
What is the role of the pre-operative nurse in managing a patient with von Willebrand disease who is scheduled for surgery and requires DDAVP?
Which mechanism describes how antithrombin III (ATIII) reduces coagulation?
Which mechanism describes how antithrombin III (ATIII) reduces coagulation?
Why might it be important for anesthesia staff to be aware of a patient's medication list including NPH insulin when administering protamine?
Why might it be important for anesthesia staff to be aware of a patient's medication list including NPH insulin when administering protamine?
Why might a patient with nephrotic syndrome be at risk for heparin resistance?
Why might a patient with nephrotic syndrome be at risk for heparin resistance?
In a patient receiving therapeutic heparin, which laboratory finding would suggest a potential antithrombin III deficiency?
In a patient receiving therapeutic heparin, which laboratory finding would suggest a potential antithrombin III deficiency?
In the case of an inadvertent intrathecal injection of medication, what immediate intervention was used in the case described?
In the case of an inadvertent intrathecal injection of medication, what immediate intervention was used in the case described?
How does tissue plasminogen activator (tPA) contribute to fibrinolysis?
How does tissue plasminogen activator (tPA) contribute to fibrinolysis?
Following the removal of medication via CSF drainage after an inadvertent injection, what potential long-term outcome was observed in the patient?
Following the removal of medication via CSF drainage after an inadvertent injection, what potential long-term outcome was observed in the patient?
What should a healthcare provider do to prevent inadvertent intrathecal injections of medication?
What should a healthcare provider do to prevent inadvertent intrathecal injections of medication?
How do endothelial cells contribute to the regulation of the coagulation process?
How do endothelial cells contribute to the regulation of the coagulation process?
What is the role of plasmin in the fibrinolytic system?
What is the role of plasmin in the fibrinolytic system?
A patient has a genetic mutation that impairs the production of tissue plasminogen activator (tPA). What condition could this mutation predispose them to?
A patient has a genetic mutation that impairs the production of tissue plasminogen activator (tPA). What condition could this mutation predispose them to?
How does activated protein C exert its anticoagulant effects?
How does activated protein C exert its anticoagulant effects?
A patient with a history of recurrent thrombotic events is found to have a protein S deficiency. How does this deficiency contribute to the patient's thrombotic tendency?
A patient with a history of recurrent thrombotic events is found to have a protein S deficiency. How does this deficiency contribute to the patient's thrombotic tendency?
What is the primary difference between unfractionated heparin and low molecular weight heparin regarding their mechanism of action?
What is the primary difference between unfractionated heparin and low molecular weight heparin regarding their mechanism of action?
How does endogenous heparin, produced by mast cells and basophils, contribute to anticoagulation?
How does endogenous heparin, produced by mast cells and basophils, contribute to anticoagulation?
Why is it essential for endothelial cells to regulate the coagulation process and reverse it when necessary?
Why is it essential for endothelial cells to regulate the coagulation process and reverse it when necessary?
What is the mechanism of action of clopidogrel (Plavix) in preventing platelet activation?
What is the mechanism of action of clopidogrel (Plavix) in preventing platelet activation?
A researcher is developing a drug to enhance fibrinolysis. Which of the following mechanisms would be the MOST promising target for this drug?
A researcher is developing a drug to enhance fibrinolysis. Which of the following mechanisms would be the MOST promising target for this drug?
A patient with liver cirrhosis is started on heparin for a thromboembolic condition. Which factor should be closely monitored due to the liver's role in its production?
A patient with liver cirrhosis is started on heparin for a thromboembolic condition. Which factor should be closely monitored due to the liver's role in its production?
Why is it typically recommended to discontinue clopidogrel (Plavix) before elective high-risk surgery?
Why is it typically recommended to discontinue clopidogrel (Plavix) before elective high-risk surgery?
How does the thrombin-thrombomodulin complex contribute to anticoagulation?
How does the thrombin-thrombomodulin complex contribute to anticoagulation?
What is the general recommendation regarding elective high-risk surgery for a patient who has recently undergone percutaneous coronary intervention (PCI) with a drug-eluting stent?
What is the general recommendation regarding elective high-risk surgery for a patient who has recently undergone percutaneous coronary intervention (PCI) with a drug-eluting stent?
What is a key difference between cangrelor and clopidogrel in terms of their administration and onset of action?
What is a key difference between cangrelor and clopidogrel in terms of their administration and onset of action?
What is the approximate half-life of cangrelor, and how quickly do platelets recover function after its discontinuation?
What is the approximate half-life of cangrelor, and how quickly do platelets recover function after its discontinuation?
How do Glycoprotein IIb/IIIa antagonists like eptifibatide work to prevent clot formation?
How do Glycoprotein IIb/IIIa antagonists like eptifibatide work to prevent clot formation?
A patient on clopidogrel needs emergency surgery. Which of the following strategies might be used to provide continued antiplatelet effect while minimizing bleeding risk?
A patient on clopidogrel needs emergency surgery. Which of the following strategies might be used to provide continued antiplatelet effect while minimizing bleeding risk?
What is the primary mechanism by which thrombolytic drugs like tissue plasminogen activator (tPA) restore circulation in occluded vessels?
What is the primary mechanism by which thrombolytic drugs like tissue plasminogen activator (tPA) restore circulation in occluded vessels?
Why is there a contraindication for regional anesthesia or surgery within 48 hours (2 days) of thrombolytic administration?
Why is there a contraindication for regional anesthesia or surgery within 48 hours (2 days) of thrombolytic administration?
Following thrombolytic administration and prior to a neuroaxial anesthetic, how frequently should a patient be assessed for neurological deficits, and why?
Following thrombolytic administration and prior to a neuroaxial anesthetic, how frequently should a patient be assessed for neurological deficits, and why?
A patient who has recently received thrombolytic therapy requires an emergent surgical procedure. Besides the increased risk of bleeding, what other potential side effect should be closely monitored?
A patient who has recently received thrombolytic therapy requires an emergent surgical procedure. Besides the increased risk of bleeding, what other potential side effect should be closely monitored?
A patient with a bare metal stent is scheduled for elective surgery. What is the minimum recommended duration to wait after stent placement before proceeding with surgery, assuming dual antiplatelet therapy is a concern?
A patient with a bare metal stent is scheduled for elective surgery. What is the minimum recommended duration to wait after stent placement before proceeding with surgery, assuming dual antiplatelet therapy is a concern?
A patient with a history of PCI on dual antiplatelet therapy is undergoing a high-risk surgery that cannot be delayed. Which strategy is LEAST appropriate for managing their antiplatelet therapy?
A patient with a history of PCI on dual antiplatelet therapy is undergoing a high-risk surgery that cannot be delayed. Which strategy is LEAST appropriate for managing their antiplatelet therapy?
In the context of bridging antiplatelet therapy, what advantage does eptifibatide offer compared to clopidogrel when a patient requires urgent surgery?
In the context of bridging antiplatelet therapy, what advantage does eptifibatide offer compared to clopidogrel when a patient requires urgent surgery?
What is the primary reason for the recommendation to assess a patient every 2 hours for neurological deficits after thrombolytic administration, particularly if a neuroaxial anesthetic has been performed?
What is the primary reason for the recommendation to assess a patient every 2 hours for neurological deficits after thrombolytic administration, particularly if a neuroaxial anesthetic has been performed?
Flashcards
Temperature Plunge
Temperature Plunge
A sudden and significant drop in temperature after a period of warmth.
Wintry Mix
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Precipitation that is a mix of rain and snow.
Snowfall (Excessive)
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Protamine Side Effects
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DDAVP Mechanism
DDAVP Mechanism
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DDAVP Purpose
DDAVP Purpose
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DDAVP Infusion
DDAVP Infusion
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Timing of DDAVP
Timing of DDAVP
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DDAVP Duration
DDAVP Duration
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DDAVP's Speed
DDAVP's Speed
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Fibrinolytic Shutdown
Fibrinolytic Shutdown
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Late TXA Risks
Late TXA Risks
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Aprotinin Action
Aprotinin Action
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Aprotinin in the US
Aprotinin in the US
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Antifibrinolytics Adverse Effect
Antifibrinolytics Adverse Effect
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TXA and Recent VTE
TXA and Recent VTE
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TXA Risk Assessment
TXA Risk Assessment
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TXA Contraindications
TXA Contraindications
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Pre-op Assessment for TXA
Pre-op Assessment for TXA
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Other TXA Contraindications
Other TXA Contraindications
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TXA Dose and Seizure Risk
TXA Dose and Seizure Risk
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Aminocaproic Acid Risks
Aminocaproic Acid Risks
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Wrong-Route TXA
Wrong-Route TXA
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Wrong-Route TXA Consequences
Wrong-Route TXA Consequences
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Why Wrong-Route TXA Happens
Why Wrong-Route TXA Happens
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Hypercoagulable State (Protein C or S Deficiency)
Hypercoagulable State (Protein C or S Deficiency)
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Protein S and Protein C Function
Protein S and Protein C Function
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Antifibrinolytics
Antifibrinolytics
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Aminocaproic Acid (Amicar/Epsilon-aminocaproic acid)
Aminocaproic Acid (Amicar/Epsilon-aminocaproic acid)
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Tranexamic Acid (TXA)
Tranexamic Acid (TXA)
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Tranexamic Acid high dose effect
Tranexamic Acid high dose effect
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Tranexamic Acid (TXA) Routes of Administration
Tranexamic Acid (TXA) Routes of Administration
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Common Uses of Tranexamic Acid (TXA)
Common Uses of Tranexamic Acid (TXA)
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Surgeon Preference: Topical vs. IV TXA
Surgeon Preference: Topical vs. IV TXA
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Safety Concern of TXA
Safety Concern of TXA
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Postpartum Hemorrhage (PPH)
Postpartum Hemorrhage (PPH)
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TXA for Postpartum Hemorrhage
TXA for Postpartum Hemorrhage
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TXA Dose During Surgery
TXA Dose During Surgery
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TXA for trauma patients.
TXA for trauma patients.
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DDAVP Function
DDAVP Function
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DDAVP Risks
DDAVP Risks
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Fibrinogen (Factor 1) Function
Fibrinogen (Factor 1) Function
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Fibrinogen Use
Fibrinogen Use
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Low Fibrinogen Effects
Low Fibrinogen Effects
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Cryo Dosing
Cryo Dosing
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Recombinant Factor 7a
Recombinant Factor 7a
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Factor 7a Pathway
Factor 7a Pathway
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Recombinant Factor Use
Recombinant Factor Use
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Protamine-Induced Hypotension Cause
Protamine-Induced Hypotension Cause
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Topical Hemostatic Agents
Topical Hemostatic Agents
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Absorbable Agents
Absorbable Agents
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Topical Agents Hint
Topical Agents Hint
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Topical Thrombin
Topical Thrombin
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TXA and Topical
TXA and Topical
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Study Notes
Facial Hair Filter
- Some people experimented with a facial hair filter
Weather
- Charlotte went from nearly 80 degrees on Sunday to around 39 degrees.
- There was no snow in Charlotte.
- New Hampshire got 2 feet of snow.
- Charlotte is somewhat shielded from snowfall.
- The speaker has been living in Charlotte for 3 years.
- Charlotte can be considered to be in a heat dome.
Exam and ADC Meeting
- The educator will be flying to Tucson for an anesthesia educators meeting.
- Availability for meetings will be limited, especially before Sunday morning.
- Availability will be open Monday.
- Questions can be sent via email.
- There will the normal class meeting.
Test Details
- The upcoming test will focus on drug classes and will feel different from the first test.
- Plan for approximately 60 questions.
- There will be a group activity will take place at 11AM
- Focus study efforts on essential information.
- Understanding the mechanism of action for each drug class down to the cellular level is critical.
- Knowledge of the physiology is related to the mechanism of the drug class.
- There needs to be recognition the names of drugs within each class.
- The clinical and side effects of each drug class is an area of focus.
- The impact on lab values and the possible treatment options must be evaluated.
- Focus study efforts on the main adverse effects associated with different drug classes.
- Pay special attention to specific drugs the instructor emphasizes.
- Knowledge anesthetic considerations for drugs is necessary.
- There is a need to draw out mechanisms and understanding receptors to know how ions flow.
- Memorization of unique facts that differentiate the drugs from one another.
- You should know drug doses and routes with the information that has been provided.
- Each question simulates board exams so that you get used to them.
- The upcoming tests will progressively get longer to build up the stamina to be able to sit to complete them.
- A cumulative exam is expected at the end
Hemostasis Review
- A review of hemostasis and coagulation
- The topic will cover both procoagulation and anticoagulation
Normal Blood Vessels
- Endothelial cells line blood vessels and release nitric oxide.
- Nitric oxide promotes vasodilation to increase blood flow
- Prostacyclin has beneficial effects.
- Prostacyclin, combined with platelet receptors to prevent the activation and aggregation of platelets.
- The body is designed to respond to injury without over-responding.
Injury to a Blood Vessel
- Extrinsic or intrinsic damage can occur to your blood vessels.
- Collagen and connective tissue provides structural support to the blood vessel.
- Disruption causes the activation of platelets.
- Release mediators, such as serotonin, to cause vasoconstriction.
- Vasoconstriction decreases blood flow in the area.
- Platelets adhere to the vessel surface and form a platelet plug.
- Vasoconstriction in this area helps to slow down the blood flow in the area.
Three Phases of Primary Hemostasis
- Adhesion, activation, and aggregation.
Adhesion
- Endothelial cells break, and collagen is exposed.
- Platelet adhesion occurs to the subendothelial collagen layer.
- Endothelial cells create and release factor 8 (von Willebrand).
- Von Willebrand tethers a platelet to a collagen receptor.
- Issues with von Willebrand production (von Willebrand disease) impairs primary hemostasis.
- Bleeding time increases in the setting of Von Willebrand disease.
- Platelet count and other lab values can be normal, except bleeding time.
- DDAVP releases endogenous stores of von Willebrand
- Cryo can also be given because it contains factor 8.
- Cryo is rich in 1, 8, 13.
Adherence
- The platelets are activated.
- Round platelets mean they are unactivated.
- Activated platelets take on this sort of starfish shape.
Activation
- Thrombin (activated factor 2) binds the thrombin receptor on the platelet.
- Platelets change into the starfish shape.
- Thromboxane A2 and adenosine diphosphate (ADP) are released.
- Thromboxane A2 and ADP are responsible for platelet activation and aggregation.
- Appendages on platelet help hook onto another platelet.
Thromboxane A2
- Induces vasoconstriction
- Encourages platelets to activate and aggregate.
Aggregation
- Thromboxane A2 uncovers a fibrinogen receptor.
- Fibrinogen binds and helps to link the platelets.
- A water-soluble clot can form.
- The clot isn't stable and can break off easily. This is sometimes called temporary hemostasis.
- Primary hemostasis is just a platelet plug
Prostacyclin
- Inhibits platelet aggregation.
- This prevents the plug from growing too large and occluding the vessel.
Primary Hemostasis
- Resting platelet adheres with the help of Von Willebrand
- ADP and thromboxane A2 uncover the fibrinogen receptor.
- Fibrinogen provides links to bring in other activated platelets.
Secondary Hemostasis
- A more stable clot forms and the building of fibrin occurs.
- Coagulation cascades and clotting factors get involved.
- Clot becomes thicker, cross-linked, water-insoluble, and stable.
Clotting Factors
- Clotting factor one = fibrinogen made by the liver.
- Factors 2, 7, 9 and 10 are vitamin K dependent
- Thromboplastin comes from the vascular wall.
- Von Willebrand factor comes from vascular endothelial cells.
- Get familiar with all the clotting factors.
Secondary Hemostasis Model
- Initiation, amplification, and propagation.
Extrinsic Pathway
- Represents initiation.
- Triggered by damage exterior to the vascular compartment.
- Baseline level to prepare the body for potential damage.
- Tissue factor pathway is known as factor 3 or thromboplastin.
- Primary initiator.
- Extrinsic damage triggers the release of thromboplastin (factor 3).
- Factor 3 activates factor 7.
- 3 and 7a form a complex with calcium (factor 4).
- The complex activates factor 10, resulting in 10a.
- Small amounts of thrombin are formed.
Initiation vs Amplification
- To help with remembering, 3 + 7 = 10.
Intrinsic Pathway
- Represents amplification.
- Damage to a blood vessel increases activity.
- A different pathway gets involved.
The Intrinsic Pathway gets involved
- 12 becomes 12a that activates 11.
- Activates 9.
- 9 forms a complex with 8c and calcium on the platelet surface
- Factor 10 is activated.
- Results in amplification of thrombin (factor 2).
Hemophilia
- Hemophilia A- deficiency in 8c.
- Hemophilia B - deficiency in 9.
Amplification Phase
- Continual thrombin formation by both pathways.
Final Common Pathway
- Propagation phase
- Factor 9a generated from extrinsic and intrinsic pathways.
- 9a combines with 8a on a surface of a platelet where they are responsible for activating factor 10.
Problems Getting to Propagation
- Patients may still be able to form clots, but clots won't be as stable.
- Seepage through the vessel and damage around the clot can occur, so bleeding into other tissues, muscles, joints, etc.
Final Common Pathway
- Activated factor 10 forms a complex with activated 5 and calcium.
- Prothrombin is converted into thrombin.
- Activation of thrombin is the primary goal of this pathway
- Thrombin (2a) converts fibrinogen to fibrin.
- Factor 13 is added to get covalent bonding.
- Results in a stable clot
Final Common Pathway
- Factor 10 to 5; prothrombin to thrombin.
- Fibrinogen to fibrin.
- Factor 13 provides stabilization for final clot.
Fibrinogen
- Increased fibrinogen = more activity from platelet plug resulting in helping them to link together.
- Gp2b3a receptor helps link pieces together.
- Gp2b3a inhibitors target where therapy is being targeted on a cardiac floor.
Coag Testing Review
- APTT looks at the intrinsic pathway and PT looks at the extrinsic pathway.
- Both the intrinsic and extrinsic pathway look at different pathways on the way to a stable clot.
Prothrombin Time (PT)
- Looks at extrinsic and final common pathway.
- For detecting bleeding and monitor anticoagulant therapy, like warfarin.
- Normal PT is about 11-14.
- Labs use reagents to measure prothrombin time which results in use of the international normalized ratio (INR).
- Normal INR is usually what we use in anesthesia, and if they’re on warfarin for an indication we look for it.
- Usually a 1.5 - 2 INR is required to have surgery or anesthesia.
- Prolonged value if decreased amounts of 7 and 5.
APTT
- Intrinsic and final common pathway.
- Same indications for this test as a PT.
- Normal is 25-35 (values can vary by the lab).
- Prolonged with hepatic dysfunction, leukemia, intrinsic factor or vitamin K deficiencies, and use of heparin or a related anticoagulant.
Chart
- Serves to look at different conditions that can be associated with abnormalities in PT and PTT.
Activated Clotting Time (ACT)
- Intrinsic and final pathway.
- Monitors heparinization or protamine antagonism
- ACT is typically measured by procedure nurses, not typically by CRNAs.
- Prolongation: hypothermia, thrombocytopenia, drugs, and factor deficiencies
Other Coag Tests
- Bleeding time, platelet count, fibrinogen.
- We want fibrinogen a little higher and sometimes a surgical goal of 180 - 200, minimum greater than 150
- Tag and Tim are labs related to hemostasis and clot strength.
Anticoagulants
- Used for cardiovascular procedures, preventing clots, cardiovascular disease, arrhythmias.
- The question: should the patient hold the drug, get the drug, or continue it during the perioperative period.
- Bleeding risk vs. risk for clot needs to be considered
- Different classes have different recommendations for how long to hold them
- Comorbidities and indication for giving anticoagulant is important.
- Type of surgery is an important factor.
- A patient may need bridge therapy if stoping an anticoagulant where they can be bridged to some low weight like Enoxaparin.
- Assess anticoagulant status in the pre‐op assessment.
- Know all the drugs from their regimen.
Heparin
- Unfractionated (not separated into small vs. large molecules) or fractionated.
- Naturally occurring, it is released by mast cells during inflammation.
- Unfractionated form is derived from pig or cow
- Indications: clots, cardiac disease, or perioperatively for anticoagulation.
- Low molecular weight heparin can be unfractionated or fractionated.
- Unfractionated heparin is made up of both high and low forms.
- When referring to low molecular weight heparin, you are specifically saying the high weight was fractionated out so that the result would be the low.
- Low molecular weight heparin can only be fractionated, unlike heparin just referring to the high/low molecular weight.
Heparin Mechanism
- Reversibly binds antithrombin 3.
- Increases antithrombin 3 activity by about 1-10,000 times
- Factors Inhibited: thrombin, factor 10a, 12a, 11a, and 9a
- Inhibits platelet activation by fibrin.
- Antithrombin 3 is a protein that regulates and is the counterpoint for thrombin formation.
- Counterpoint to formation 9a and 10a.
- Increasing antithrombin to increase effectiveness thousands of times to inhibit effects.
Heparin Pharmacokinetics
- IV has immediate onset
- SubQ has onset in 1-2 hours
- Giving IV doses in boluses with usually an infusion to get to the therapeutic level
- Giving SubQ in order to lower chance of Thromboembolism
- Effectiveness depends on different factors, and antithrombin is one of them. Low anithrombin presence means the Heparin is working against the body.
- Effectiveness related to several factors relating to antithrombin 3
- First thought with Heparin resistance is Low anithrombin 3.
- Protein binding, or Genetic differences can contribute to low effective levels of heparin
- Low plasma levels tend to occur during pregnancy so best monitor 10a factor
- Heparin doesn’t cross placenta so pregnancy safe drug to use in the event it’s indicated however not a wealth of pregnancy data out there.
- With pediatrics, use preservative free due to adverse effects of mortality so you can avoid morbidity.
Heparin - Sites of Action
- Intrinsic primarily working on 12, 11, 9, 10, and thrombin.
- Little bit of work in the final site of action but primarily works on intrinsic.
Anesthetic Considerations
- Review Medications/Labs/Last time when heparin was given.
- Need to consider dose, route, renal function, patient comorbidities, and the surgical procedure itself.
- There are a couple slides with small differences so check slide on canvas.
- Regional Anesthesia consideration has varying amounts of time dependent on dose like whether or not they’re therapeutic wise, and depends on how long they're scheduled to be on the medication.
- If the risks can be reduced in using a neuroaxial or regional anasthetic technique, discuss with surgeon and specialist on if a reversal technique is indicated to reduce the risks with anesthetic plans.
Heparin
- Avoid any coagulopathy as poking around the area with a needle can be unsafe.
- Risks of nerve damage that could lead to paralysis as well in neurological deficits.
- Monitor deficits and recheck on functions coming back once anticoagulants wear off.
- The recommendation of low dose regional might be slightly altered without the need for interruption, due to practice differences of providers.
- Get in the practice of trying to learn the guidelines and look up on what type of drugs when approaching a type of plan for surgery.
Contraindications
- Monitor ACT or APTT the Goal whether Act reaches 3,400 or with APTT is 1 ½ or 2 ½ is normal
Hit - Heparin
- Antibodies that make to a formed protein called platelet four (that is not a clotting factor).
- End up with platelet activation causing aggregation thrombosis, and allergic reaction
- Cause severe thrombocytopenia so 50 percent drop count or 100,000.
- Hours Reaction, very bad reaction happening with 4-5 days.
Molecular Weight, Heparin - Low
- 10a> 2a
- Is more predictable due to less protien binding
- Give SubQ with 100 Percent avaliability
- Effectiveness decreases with reduced renal function.
- Monitoring of 10a may be necessary if trying to achieve therapeutics
- Protamine does not have effectiveness, do not use. Protamine response is ineffective.
- Subq is still only a low molecular factor.
Anesthesia Considerations (Heparin - Low Molecular Weight Heparin)
- Surgery: Held for 12 hours before surgery
- Spinal and Epidural: At risk for spinal hematoma
- Prophylactic Dosing. Hold dose 12 HR
- High Dosing Hold dose 24 HR
- You might get an anticoagulant guideline based on dose or other factors.
- Refer to SRA for more specifics.
Warfarin
- Vitamin K antagonist
- Vitamin K, Epoxide Reductase converts Vitamin K dependent enzymes to active forms.
- Inhibits that particular enzyme.
- Oral drug absorbed well
- Delayed onset of 8 hours, and peak of a few days.
- Variable Dosing with a risk of mortality if you have with a pregnant pt
- Monitor Pt and INR With about 2 to 3 therapy
- Liver disease can change affectivness. Other factors, such as no diet, can play a factor.
- The recommendation of stopping is about three to five days if needing discontinue pt needs continue day of surgery.
- A couple of other options. FFP to a total of three to four units of therapeutic in emergency.
- Vitamin k helps but 3 to 4 to 24 to help regulate.
- Prothrombin helps but is less readily available.
Extra drugs that affect pathway
- Eryxatra: blocks active levels from binding.
- Direct of action : inhibits pathways monitoring APTT ,4 to 6 hours.
- Pradaxa : No data around it. Just skip the patient. Contraindicated
Antiplatelet Drugs
- Try not getting too picky on these drugs that we that will give because you aren’t the ones that give them
Asprin
- Blocks pro inflammatory responses, like for platelets/Thromboxane a which activates platelets.
- Has higher irreversible effect on blocking platelets. Irreversibly blocks platelets from doing what is necessary, so we prefer you not to take asprin but not a high major thing with baby asprin
Non Competitve Drugs
- irreversibly blocks that they can’t be activated, let it wear off so new platelet forms
Plavix
- Needs to metabolized to its active version
- Also prevents activation in primary hemostasis.
- Irreversible binding from this drug blocks chain activation of primary
- Has resistance.
- Used to prevent patients from forming a stent to help keep coronary artery open, best recommendation.
Cardio Meds
- Avoid high risk surgery for 1 year that can cause you to bleed out.
- Bare metal stent, 1 month.
- Can be patient and condition dependent with what they need, such as some taking asprin and others taking this one.
- Kangaroo is short acting for helping and blocking. With a rate for 3-6 minutes.
Antagonists
- Block platelets from bonding. Reduce risk like Kanaroo
- Give all the way out close to operation, so good because still have benefit need by platelets
- Discontinue for almost 2 hours to have 50% recovery
Thrombolytics
- break clot, so can restore circulation to areas blocked. TPA, Stroke, but if this goes wrong can have hemorrhage
- Angioedema as well, that blocks breathing.
- Avoid 2 days of anesthetic techniques and assess every two hours for neurological damage
- Assess every 2 hours if given Thrombolytics
Physiology Of Anticoagulation
- Blocks and binds so it has limited function with what its doing
- And requires heparin as a cofactor so it works with heparin
- Therefore liver and cirrhosis helps help in the activation and regulation pathways
- Patients that have nephrotic syndrome can also have their vessels damaged due to having extra protein in the urine
Tissue Plasmin
- helps clot from growing, made in our body the
- helps release into circulation, go into that clot, and help break that clot apart.
- To help keep the vessels open to provide normal access blood that is important.
What Clots Do
- A little yellow substance to help help separate things during function.
- Proteins C and S are to helping the body
- Thrombin Helps binds to help no effectiveness.
Anti Fibrinolytics
- Reduce risk of Bleeding and reduce for transfusion.
- Cardiac to Ortho to Trauma
- Amicar stops activating plasma from functioning.
- Tranexamic acid TXA reduces blood loss of plasma
Cardiac Ortho Trauma uses TXA
- Potent over Amicar so parenteral route is usually indicated over a topical.
- Menstruating women benefit taking taking over other ones
- Surgeron Preference
- Safe concerns are limited.
- Does blockade GABA in the body
PPH
- Postpartum hemorrage. Approved indication for it.
- Recommendation
- Gram of PPH ASAP
- Surgeon want it at Incision and at End.
- Trauma you have a risk, trauma already hard time, so it also causes problems
- So the risks can inhibit activation
Aprontinin
- Inhibits body to help not cause damage to organs to help get it where you need those functions necessary
With AntiFibriniolic are issues such as
- High likely Hood of Trombus
- We don’t what parameters should indicated for the patients.
- If history of DVT PE, but not enough data what levels are problematic for certain people.
- Contra such as that one if know hypercoagulable so assess during pre op
- Dvt within 6 months or hold in general.
- Check pre-conditions when necessary for assessment to help know what you have to watch out for
- And can have vascular such as Dice disorder that can lead to damage
- Have pt also that has siezure history also can increase risks.
Med Neg Consequences with giving antifibrinolytics
- If the ampoule and and needle cause same symptoms such stroke, it would for the patient with the loss function of pain.
- It had report recently of antiallergicanitcs in spinal by reports that would not use spinal with it, or be careful with spinal and that anti cancer
- Patient would feel back pain to legs seizure to Fib and mortality rates around 50% rate
- A way to see effects in a neurological patient with a coma for many weeks
- They drain Csf fluid and that is dangerous.
- If giving near spine, can cause issues as the solution could have issues.
Polypeptide
- Acid base solution and what is negative neutralizes each reaction.
- Not effective with many medications
- Has more risk for rebound
- So clearance of heptrin with higher side effects causes too much effects
- Slow in administering, rapid can causes side effects
- Interactions.
Vasopressin (desmopressin Ddavid)
- Help increase and stimulates release by factor one for the patient.
- So von brand and fact eight helps plate plug
Patient needs infusion there needs some certain conditions
- .003 mics per kilo over 20 30 minutes is average rate
- Primary usually gets infusion started
- Is necessary to ask and communicate , usually ordered before you get there as well, what to look for to see if it needs already has started
Fibrinogen
- 1 factor that you want to have
Has to do with stable clot
- Binds platelets
- Can give it if lot of loss
- Get about 150 goal
- Normal about 200
- Lows can increase pt,ptt
Cryogen
- Unit over 10 factor you can increase about 50 -500
- Recombinant
- Factor helps bleeding hemophilia with a complex tissue and what it is combined
- But Doesn’t correct underline or effect.
Extrinsic PathWays
- Form of way to assess. Transfusion is quicker
- Stabilizes common pathway
- Can cause a few problems
- Protamine , help know that these can causes hypotension
Hemostatic and topical
- Helps cause veslels to emboliation
- Gel form- surgicel,seal what usually asked for if bleeding usually
- Toxin or other things like blood you may use .
- Can you toxin the topical.
- Can you toxin the top. If its the opposite how come if needs to be used .
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