Factor X Inhibition? Cardiac Health Supplements / Polyphenol Compounds & Considerations Regarding Hemostasis…

Editor’s Note:   Had an unusual presentation of unexpected post op bleeding the other day with a patient that had no concomitant coagulation issues nor other co-existing disease states that would possibly contribute or amplify post CPB hemostasis. Normally I would write this off as the “the less-than-extraordinary transcendence of damage to general hemostasis” that […]

Perfusion Policies 101: Anticoagulation Reversal

Renee Toth, BS, CCP   Editor’s Note: Renee is a colleague I work with quite often.  She is an amazing perfusionist as well as administrator, mom, and just a decent all around human being. She has a pretty scathing wit- so beware.  She offered to share a policy she has worked on for a quite […]

Perfusion Policies 101: Cold Agglutinins

Editor’s Note: PERFUSION POLICIES 101 Welcome to PERFUSION POLICIES 101.  This will be a continuing series provided to assist your programs with that one puzzle piece we all run into now and then- that one time that an unexpected patient condition may give you pause… The intention here is to disseminate some basic recipes that […]

Why is my Patient Bleeding? A Snapshot of Hemostasis, Part II

Click on image to view source article Editor’s Note: We have all revisted this pathway intensively throughout our careers, and of course, we have all been clinically challenged by open-heart cases that test our fundamental understanding of coagulation theory in real time, at a level that certainly reflects a fairly deep dive into esoteric hematology. So i am keeping it simple, and found […]

Perfusion Policies 101: Angiomax

Editor’s Note: The use of alternatives to heparin in terms of managing anicoagulation doesn’t come up often.  It’s easy to get a bit rusty when it comes to using exotic agents such as Ancrod (Hirudin), Angiomax and similar agents. So here is a brief refresher, and as always- a disclaimer here:  Use this information with […]

Desmospressin: A Primer on DDAVP

<img class="alignnone size-full wp-image-32561" src="https://i2.wp.com/circuit.perfusion.com/wp-content/uploads/2016/07/1 20 mg prednisone.jpg?resize=529%2C167″ alt=”1″ srcset=”https://i2.wp.com/circuit.perfusion.com/wp-content/uploads/2016/07/1.jpg?w=787 787w, https://i2.wp.com/circuit.perfusion.com/wp-content/uploads/2016/07/1.jpg?resize=300%2C95 300w, https://i2.wp.com/circuit.perfusion.com/wp-content/uploads/2016/07/1.jpg?resize=768%2C243 768w” sizes=”(max-width: 529px) 100vw, 529px” data-recalc-dims=”1″ /> Click on image to view source article = 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.  […]

TEG vs ROTEM? A Brief Comparison AND a Survey?

Click image above to take ROTEM Survey 🙂 Editor’s Note: I was asked by a reader to do an article on thromboelastograms.  Wasn’t sure what approach to take in this regards so decided to do a brief intro and switch the focus in particular to a comparison and differentiation between the two prevalent systems, the TEG and the […]

Angiomax: Use and Dosing Regimen

Editor’s Note: The use of alternatives to heparin in terms of managing anicoagulation doesn’t come up often.  So many of us get a bit rusty when it comes to using exotic agents such as Ancrod (Hirudin), Angiomax and similar agents. So here is a brief refresher, and as always- a disclaimer here:  Use this information […]

Cairo, Egypt: Case Study: AVR with Antiphospholipid Syndrome

Editor’s Note: I saw this post of Ramy’s FB page (or maybe one of the perfusion groups on FB) and reached out to Ramy to submit this as a case study.  He has graciously forwarded the case study and I thank you Ramy. Feel free to leave comments in the comments section- Happy Saturday 🙂 […]

Protamine

Protamine 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 […]

The TEG (Thromboelastogram)

Editor’s Note: Recently we began employing the TEG routinely for all of our open-heart procedures.  Now I am relatively familiar with the concept, having discussed and written about it before.  However there is an array of numbers and categories that come with the TEG analysis that I wasn’t certain about, so to clear it up […]

AT3 Deficiency

Antithrombin III (AT III) is a plasma glycoprotein with a molecular weight of 58,000 daltons.  AT III deficiency may be noticed when the patient’s activated clotting time (ACT) does not respond to heparin administration as would be expected when given a standard dosage.  Also can be confirmed by a laboratory value of the patient’s AT […]

Cold Agglutinins

Literature: Click image to view source article Cold Agglutinins in Cardiac Surgery: Management of Myocardial Protection and Cardiopulmonary Bypass CAs are autoantibodies to RBC antigens [3], which can causesystemic thrombosis and hemolysis. The cause of these CAs maybe primary/idiopathic, or more commonly, secondary to an infectiveprocess (eg, mycoplasma, human immunodeficiency virus) or alymphoproliferative disorder [2]. […]

On CPB- Heparin Protocol Survey

Editor’s Note: I received a note from a perfusionist the other day regarding heparin administration, and how it has become regulated at their institution.  It was significant enough- in terms of it’s implications of our ability to manage patients on bypass for me to pass on the concern, and as well- develop a survey to […]

Heparin: Factors Affecting & it’s Effects [Reprint]

HEPARIN ONSET: Maximal at 1 minute past atrial delivery: Measured at radial artery.  Note:  10-20% reduction in svr without affecting c.o. and or h.r. LUNG VS MUCOSAL: Mucosal requires larger doses- but can be reversed with 25-30% less protamine:  greater postoperative blood loss associated with mucosal heparin- speculated to result from lower molecular weight & […]

Coagulation Issues: Fibrinolysis & HIT: Helpful Graphics

Fibrinolysis Fibrinolysis is the dissolution of the clot formation process involving the plasma protein plasminogen.  This system of enzymes dissolves blood clots by the lysis of fibrin.  Fibrinolysis plays a role as well in other biological processes such as tissue repair, macrophage activation and function, ovulation, and embryo implantation.  Fibrinolysis is mediated by plasmin and […]

Heparin: Factors Affecting & it’s Effects

HEPARIN ONSET: Maximal at 1 minute past atrial delivery: Measured at radial artery.  Note:  10-20% reduction in svr without affecting c.o. and or h.r. LUNG VS MUCOSAL: Mucosal requires larger doses- but can be reversed with 25-30% less protamine:  greater postoperative blood loss associated with mucosal heparin- speculated to result from lower molecular weight & […]

Hemostasis Assays

Tests Available Screening Tests:     Prothrombin Time (PT)     activated Partial Thromboplastin Time (aPTT)     Thrombin Clotting Time (TCT)     Kaolin Clotting Time (KCT) Assessment of the Fibrinolytic Pathway:     Alpha-2-antiplasmin – functional assay     Euglobulin Lysis Time     Fibrinogen/fibrin degradation products (FDP)     Plasmin alpha-2-antiplasmin complex (PAP)     Plasminogen Activator Inhibitor – antigen (PAI-1) […]

Coagulation Cascade

Intrinsic Pathway The coagulation cascade is initiated when blood becomes traumatized by exposure to a foreign surface.  An example of this is the initiation of cardiopulmonary bypass.  Blood contact with the polyvinyl chloride tubing utilized in the extracorporeal circuit, the squeezing mechanism of the roller head pump, and various applications of blood filtering devices, all […]

Blood Components

Separating Components from Whole Blood Fibrinogen Fibrinogen is a high molecular weight protein occurring in the plasma in quantities of 100 to 700 mg/dl.  In the presence of calcium ions it becomes the precursor for fibrin threads the foundation of the blood clot.  In terms of replacement therapy, a target value of 150 mg/dl may […]

Heparin Metabolization or AT3 Deficiency ?

There has been a drive lately to reduce the amount of heparin administration during bypass at a couple of institutions I have been at. I’m all for that, although some of the parameters placed before us are clearly unrealistic and forwarded by people that know nothing about perfusion except what they have read in a […]

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 […]

A Day In The Life… [3] Reprint

24 Hours… of ECMO To view the entire “Day In The Life” series Click Here Part III:  Getting Past Midnight :   ACT’s & Clots … 11:00 pm Somehow during the initial debriefing from the previous ECMO coordinator that I had taken over for, the question of reliability regarding our ACT  (Activated Clotting Time) came […]

HELP ! Lupus Anticoagulant & Measuring Heparinization for CPB

– We are anticipating placing a patient on CPB for an AVR. The patient has tested positive for Lupus Anticoagulant, so I looked up some things to assist in preparing for the case. From what I have read, it seems the following points are salient regarding proper anticoagulant management during bypass. ptt is going to […]

Hemostasis Assays

Tests Available Screening Tests:     Prothrombin Time (PT)     activated Partial Thromboplastin Time (aPTT)     Thrombin Clotting Time (TCT)     Kaolin Clotting Time (KCT) Assessment of the Fibrinolytic Pathway:     Alpha-2-antiplasmin – functional assay     Euglobulin Lysis Time     Fibrinogen/fibrin degradation products (FDP)     Plasmin alpha-2-antiplasmin complex (PAP)     Plasminogen Activator Inhibitor – antigen (PAI-1) […]

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 […]

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 […]

ABTC Conference: Live Blog

Live Blogging The Autologous Blood Therapy Course (ABTC): (Click on Image to visit ABTC website) Heading down to Jackson, Mississippi… I’ve heard some great things about this course being offered up by Mr.Pat H. Courtney, Jr. LP, RABT (Licensed Perfusionist, Registered Autologous Blood Therapist.) . First of all, Pat’s a nice guy (as well as […]

Mr. Sid Yarrow: Perfusion Pioneer

Perfusion Profiles Mr. Sid Yarrow:  New Zealander :  Perfusion Pioneer  To View All the Profile Series…  Click Here. A Pioneer Passes… Editors Note:  The first part of this story was posted by Tim Willcox, CCP (Australia) on Perflist. I felt it such an inspiring story, that I tried to dig up a little bit more […]

HeartMate & HIT

HeartMate XVE :  Explantation in the Setting of Heparin Induced Thrombocytopenia (HIT) Utilizing ACT and TEG Analysis Authored by:   Scott M. Noesges LP, CCP  BAYLOR UNIVERSITY MEDICAL CENTER  DALLAS, TEXAS Scott M. Noesges LP, CCP, offers the community an amazing case study of a case already highly complex in nature, complicated even more so by […]

Rx for Hemolytic Reaction

Rx  FOR HEMOLYTIC REACTION As a result of gross exposure to a hypotonic environment. Hemolysis of blood samples. Red blood cells without (left and middle) and with (right) hemolysis. If as little as 0.5% of the red blood cells are hemolyzed, the released hemoglobin will cause the serum or plasma to appear pale red or […]

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 […]

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 […]

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 […]

AT3 Deficiency v.1

Antithrombin III (AT III) is a plasma glycoprotein with a molecular weight of 58,000 daltons.  AT III deficiency may be noticed when the patient’s activated clotting time (ACT) does not respond to heparin administration as would be expected when given a standard dosage.  Also can be confirmed by a laboratory value of the patient’s AT […]

Cold Agglutinins v.1

I.    BACKGROUND: Hypothermic cardiopulmonary bypass with the use of cold blood cardioplegia carries with it the risk of red cell agglutination caused by unsuspected cold agglutinin disease.  Patients with this condition possess serum antibodies which become reactive at temperatures usually less than 30°C and are directed against an antigen of the human erythrocyte causing agglutination […]

HIT

Heparin Induced Thrombocytopenia I.    DESCRIPTION: Heparin induced thrombocytopenia (HIT) and heparin induced thrombocytopenia thrombosis syndrome (HITTS) are immune mediated complications of heparin therapy.  An antibody, produced by the body upon initial exposure to     heparin, reacts with an antigen upon re-exposure or continuous exposure to heparin. HIT is characterized by a dramatic decrease in platelet […]

Common Pathway (Coagulation)

The endpoint of activity for both the extrinsic and intrinsic pathways for coagulation is the activation of factor X.  Reactions beyond this point are common to both pathways, and involves the combining of activated factor X with procoagulants (factor II, factor V, calcium ions, and platelet phospholipids) to form a prothrombinase complex.  This complex catalyzes […]

Coagulopathies

Coagulopathies The most common cause of intraoperative coagulopathy is thrombocytopenia secondary to hemodilution.  Thrombocytopenia is a condition where the circulating platelet count falls below 50,000 platelets per microliter.  As a result of such low circulating platelet levels, people have bleeding tendencies similar to those experienced by hemophiliacs (deficiency of Factor VIII), except that bleeding occurs […]

Protamine

Protamine 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 […]

Fibrinolysisv.1.0

Fibrinolysis Fibrinolysis is the dissolution of the clot formation process involving the plasma protein plasminogen.  This system of enzymes dissolves blood clots by the lysis of fibrin.  Fibrinolysis plays a role as well in other biological processes such as tissue repair, macrophage activation and function, ovulation, and embryo implantation.  Fibrinolysis is mediated by plasmin and […]

Heparin (v.1)

HEPARIN   ONSET:   Maximal at 1 minute past atrial delivery: Measured at radial artery.  Note:  10-20% reduction in svr without affecting c.o. and or h.r.   LUNG VS MUCOSAL:   Mucosal requires larger doses- but can be reversed with 25-30% less protamine:  greater postoperative blood loss associated with mucosal heparin- speculated to result from […]

Hemostasis Assays [v.1]

Partial Thromboplastin Time (Activated) The activated partial thromboplastin time (aPTT) is test that overlaps the prothrombin time (both evaluate the common pathway), and is designed to isolate the intrinsic pathway.  While these tests are similar, the aPTT utilizes kaolin or cellite and cephaloplastin to stimulate the intrinsic pathway.  This pathway is the longer of the […]

Activated Clotting Time (ACT)

Activated Clotting Time (ACT) The ACT is a standardized measurement of the patients procoagulation or anticoagulation level.  The unit of measurement is the time (in seconds) that is required for an ACT counter to detect the formation of blood clot in a 2-3 milliliter sample of whole blood.  Normal ACT levels range from 100-130 seconds, […]

Coagulopathies & Treatment

Coagulopathies & Treatment The most common cause of intraoperative coagulopathy is thrombocytopenia (decrease in platelet count) secondary to hemodilution.  Blood loss that is replaced by crystalloid volume will progressively dilute platelet numbers as well as platelet entrapment on the surfaces of the extracorporeal circuit.  Associated with bypass is platelet migration to the spleen and reticuloendothelial […]