Bicarb Alternatives: Sodium Acetate & Balanced Crystalloids

Editor’s Note:   Authorization for the contributions below were obtained from each contributor via email.  Please see comments section… THAM A a Buffer Tham Description Tham Solution (tromeThamine injection) is a sterile, non-pyrogenic 0.3 M solution of tromeThamine, adjusted to a pH of approximately 8.6 with glacial acetic acid. It is administered by intravenous injection, by […]

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.  […]

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 […]

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 […]

Adequacy of Perfusion:

Adequacy of Perfusion:  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 […]

Right Ventricular Function

Right Ventricle The right ventricle is one of four chambers (two atria and two ventricles) in the human heart. It receives deoxygenated blood from the right atrium via the tricuspid valve, and pumps it into the pulmonary artery via the pulmonary valve and pulmonary trunk. It is triangular in form, and extends from the right […]

Letters To ‘Surfers: From China: Pediatric Priming Solutions ?

(Click Image to Enlarge) Editor’s Note: I got this question regarding pediatric priming protocols from a perfusionist in China. My pediatric experience is limited to ECMO- so I defer to the more experienced pediatric perfusionists out there to help formulate an informed response 🙂 Leave your answers or suggestions in the “Comments” section plz? Frank […]

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 & […]

Protamine Reaction

“It binds to heparin to form a stable ion pair which does not have anticoagulant activity; on its own, protamine has a weak anticoagulant effect.”   Protamine sulfate is a drug that reverses the anticoagulant effects of heparin by binding to it. Protamine was originally isolated from the sperm of salmon and other species of […]

Malignant Hyperthermia

Editor’s Note: Just a brief primer on Malignant Hyperthermia, should the need ever arise to place a patient on CPB who has been diagnosed with this condition. It is an unusual co-morbidity and should be approached and treated with an abundance of clinical respect and caution.  Any insight or recommendations from readers would be greatly […]

The MgSO4 Shortage: Now We Know Why …

Click Image to View Drug Shortages Listed on the Site … Was it Real ? UPDATE ! Yeah …  It was. Click image to view source article … Nurse spotted mold-tainted drugs right away, hospital says By JoNel Aleccia, Senior Writer, NBC News A sharp-eyed nurse at Yale-New Haven Hospital in Connecticut is being credited […]

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 & […]

The “Hot Shot” : A Layman’s Approach to Myocardial Protection

A Salient Point from a Perfusionist: “I will give one good example of how a warm/hot shot worked for us. We finished up a normal 4 banger and before doing the proximals with the cross clamp on we routinely give a short hot shot, actually its room temperature shot, but I digress. The clamp was […]

HELP ! Potassium Acetate as a work-around for KCL Shortage ?

Editors Note: Have any of you out there ever used or considered using Potassium Acetate as a work around for KCL Shortage? I personally have zero experience with it- but the thought had crossed my mind in light of the current situation.  I saw this post from Jim Patterson, CCP on Perflist and asked him […]

KCL Shortage UPDATE

Most Recent Resupply Dates 2 mEq/mL; 20 mL vial (NDC 0409-6653-05) (Standard) Next delivery June 10 mEq/100 mL (NDC 00409-7074-26) Ample supplies available to meet market demand. 10 mEq/50 mL (NDC 00409-7075-14) Ample supplies available to meet market demand. 20 mEq/100 mL, (NDC00409-7075-26) Ample supplies available to meet market demand. 20 mEq/50 mL (NDC 00409-7077-14) […]

KCL Shortage ? FYI ( Yeah There Is … )

Is it Real ? UPDATE ! Yeah …  It is. I was just informed we have enough at one of our hospitals for 16 cases… Any suggestions on resources ??? More Recent Resupply Dates 2 mEq/mL; 20 mL vial (NDC 0409-6653-05) (Standard) Next delivery June 10 mEq/100 mL (NDC 00409-7074-26) Ample supplies available to meet […]

Are Drug Shortages the New Status Quo ?

Click above to view source article Editors Note: A List of articles on Perfusion related Med Shortages Below: Protamine MgSO4 Amicar NaHCO3 KCl WASHINGTON — At the Henry Ford Hospital in Detroit, pharmacists are using old-fashioned paper spreadsheets to track their stock of drugs in short supply – a task that takes several hours each day. […]

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 […]

Dabigatran (Pradaxa)

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

Bicarb Alternatives: Sodium Acetate & Balanced Crystalloids

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

Welcome to the New World : THAM

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

2016: Sodium Bicarbonate Shortage

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

THAM As an Alternative Buffer

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

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 […]

How Much Mannitol & Why ?

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

Blood Volume Expanders: Voluven™

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

Tranexamic Acid Protocols ?

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

And Now… Amicar ?

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

Protamine Shortage: Update

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

Protamine Shortage?

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

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 […]

STS: Meds: Beta Blockers

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

Dabigatran (Pradaxa)

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

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 […]

Desmopressin v.1

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

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 […]

Right Ventricular Function v. 1

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

Protamine Reaction v1

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