Common Medications and Laboratory test for Post-op Open Heart Patients Always remember….

Objectives Understand use of specific class of medications and their impact upon the cardiac system. Identify one indication and one contraindication for medications based upon patient needs. Identify laboratory testing and one corrective measure for specific abnormality. Understand the variants between POCT versus direct laboratory values and the impact upon the bedside treatment

Dilators, Constrictors, et al in between Medications Dilators, Constrictors, et al in between

Inotropes Used to alter force of energy creation Can be either ‘negative’ or ‘positive’ in nature Tend to like the ‘positive’ effects seen Always deliver centrally due to adverse effects to tissue May alter laboratory levels, i.e. Calcium Glucose diabetics

Inotropes - Drugs Dopamine Dobutamine Epinepherine Norepinepherine Milrinone Calcium Prostaglandins

Inotropes – effects (good) Increase cardiac output Increase systolic blood pressure Increase urinary output Improvement in contractility will augment cardiac output Rates calculated in microgram/kilogram/minute or micrograms/minute (usually first one is done)

Side effects of inotropic support Tachyarrhythmias Elevated glucose levels Anxiety Small vessel ischemia Kidney insufficiency

Phosphodiesterase inhibitors Isolated in rats brain in 1972 Further studies into 1977 brought them to light for use in humans Non-selective and selective PDE-3 or Milrinone places effect upon cAMP and calcium activation increase in CO decrease in SVR/PVR half-life longer than straight inotropic cousins

PDE inhibitor S/E Kidney dysfunction Considered proarrhythmic Bronchospasms Metabolic derangements potassium

Vasopressors Help with augmenting SVR and supporting blood pressure Majority are considered alpha-agonist with neosynepherine considered a pure alpha Some medications that are inotropes are used in the vasopressor avenue also, Levophed which has both properties Caution with use, may impact small vessel ischemia so patient assessment and evaluation key points

Hormone peptide - Vasopressin Increase vascular resistance, hence increasing arterial blood pressure Compensatory mechanism in shock states Does not increase myocardial oxygen demand as do the other inotropic agents Usually last line drug

Prostoglandins - Flolan Help to control vascular tone Influence sodium excretion Influence upon RAAS system Usually given in nebulized therapy In the presentation of right sided dysfunction 2/2 to pulmonary resistance issues (pulmonary HTN, ARDS, etc) costly

Antiarrhythmics Amiodarone Primarily seen for control and alleviation of atrial fibrillation Very long half life, to some extent indeterminate Can act as ‘chemical’ defibrillation agent so must be used cautiously Long term side effects – lungs, eyes, thyroid, GI

Antiarrhythmics - continued Digoxin Atrial fib impact Rate control predominantly Does have inotropic effects, positive to LV Requires loading dosage Levels should be monitored to avoid side effects

Antiarrhythmics - continued Cardizem Atrial fib rate control Will have some degree impact upon blood pressure Titrated to attainable heart rate, usually <110 Can quickly cause bradycardia

Antiarrhythmic medication side effects Proarrhythmic potential Bradycardia Hypotension Mentation alterations n/v Visual disturbances

Factor VIIa (recombinant) Used in face of coagulopathy not responsive to other means Direct action on reducing fibrinolysis Usually given in conjunction with cryoprecipitate factors Costly

Protamine sulfate Reversal for heparin Primarily given after completion of cardiopulmonary bypass Due to potential rebound heparin effects, can be given at bedside Allergy to fish contraindication, effects can be very dramatic 1 mg for every 100 units normal dosage regimen

Blood Products Platelets Fresh frozen plasma Cryoprecipitate Bleeding issues Low counts Fresh frozen plasma volume Cryoprecipitate Factor deficiencies

Labs commonly seen Hemoglobin/hematocrit Platelet count Basic metabolic profile Arterial blood gas Ionized calcium level Magnesium Lactic acid level Heparin antibody

Common labs – continued Coagulation profile Blood glucose ACT