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Pharmacology

TXA and Amicar

amicar

PDE Inhibitors

  • Milrinone (PDEIII)

milrinone

Protamine

Effect:

  • Inactivates heparin via a heparin:protamine complex.
  • Decreases thrombin
  • Decrease in factor V, VIII activation via thrombin/Xa and tissue factor respectively
  • Decrease in factor VIII activity
  • Increased fibrinolysis
  • Decreased platelet function via increased activation, decreased thrombin, and decreased GPIb-vwF activity

These anticoagulant effects are mitigated by administering the correct dose of protamine and not "overdosing"

See this pdf for some interesting persecptives on protamine administration such as the rate of reactions if the patient takes aspirin or does it make sense to give it through a PIV...

View PDF

Cyanokit (Hydroxocobalamin)

Dose

  • 5g over 15min (full vial) mixed in 200cc NS

Mechanism

  • Nitric oxide scavenger

General Administration Guide

  1. Increase pressers
  2. Give dose
  3. Watch for large increase in BP and then slowly back off pressors
  4. Generally you have one shot to give a single dose...DO Not Waste It!!!

Side Effects

Info

Increased Blood Pressure

  • Allergic Reaction
  • Acute renal failure with ATN
  • Calcium oxylate urine cyrstals
  • Chromaturia (bright red urine)
  • Interference with Hgb, Creatine, Glucose levels on lab draws
  • Pulse ox changes
  • Red colored skin

Methylene Blue

  • Along with being quite helpful in hypotension methylene blue is also used to treat methemoglobinemia. This condition is the result of Fe2+ of hemoglobin getting oxidized to Fe3+. This significantly reduces the oxygen carrying capacity of hemoglobin.
  • Finally it also has been shown to help in malaria treatment by stopping the immunologically active byproduct production from the Plasmodium species.

Dose

  • 1mg/kg over 5-30min for methemoglobinemia

  • 2mg/kg over 20min of refractory vasoplegia

  • 36-72mg/kg over 3 days for Plasmodium treatment

Mechanism

  • Guanylate cyclase inhibitor
  • Endothelial nitric oxide synthase enzyme inhibitor
  • Inducible nitric oxide synthase inhibitor

Side Effects

Danger

Serotonin Syndrome

Info

Increased Blood Pressure

  • Decreased pulse ox to approx 85%
  • Dark blue/green urine
  • Pale skin

Physiology Overview

Link to a great paper: Vasoplegia after CPB

Comparison Between Methylene Blue and Hydroxocobalamin

Mechanism Review

A small sample size study showed no difference between the two treatment options when faced with vasoplegia status post cardiac bypass.

Link to Article