Evaluating the effects on bypass in the presence of new medications
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This document discusses how complementary and alternative medicines (CAMs) are increasingly being used by patients and can impact cardiopulmonary bypass. It presents two case studies of patients taking specific CAMs (Sovaldi/Ribavirin and Saw Palmetto) who experienced bleeding issues during bypass surgery. The document advocates for perfusionists to be aware of CAMs patients are taking and create discontinuation plans in advance to improve outcomes and decrease blood product usage and costs.
![Karounka Keita-CCP; Justin Savagae-CCP; Bill Nicotra-CCP Chief; Melissa Harben-CCP
MedStar Union Memorial Hospital Perfusion Team.
Contention has always existed between Naturopathic and
Conventional medicine. Conversely, both append to the overall
health of the patient. As healthcare continues to go through a
paradigm shift, we have seen an exponential growth in patients
participating in “pioneer” drug studies and taking alternatives
medical therapy drugs. In the United States, approximately thirty-
eight percent of adults (about 4 in 10) and approximately 12
percent of children (about 1 in 9) are using some form of
Complementary and Alternative Medicine (CAM)1. These
medicines have a wide range of effects in the body, some of
which include a direct affect on the circulatory system. In
addition, as these medical therapies continue to become more
prevalent in the patient population; it is even more imperative that
the Perfusionist be conscious to how this will impact their ability
to conduct cardiopulmonary support.
Introduction
References
Evaluating the Effects on Cardiopulmonary Bypass, in the Presence of New Pharmacological Medications.
Mechanism of Action
Goal
*Improvement of Clinical Decisions.
*Better Patient Care on Cardiopulmonary Support.
*Increased Awareness when weaning from CPB.
* Anticipate events before they occur.
Conclusion
Chemical Compound
The field of perfusion is constantly adapting to new
challenges in a robust and ever changing patient population.
With the influx of newer and popular drug regiments,
coupled with an increase in personal wellness, a
Perfusionist’s clinical decision making abilities will not
always be indicated by normal biomarkers in the patients
chart (ie: platelet function, HCT and Hb). The two drugs
discussed are medicines that not only improve a patient’s
quality of life, but have lasting effects on the circulatory
systems. Careful management of these drugs; in
combination with surgical procedures, can help to improve
patient outcomes, decrease blood product usage and
increase hospital savings. With proper assessment of the
patient’s medical history, we can preemptively plan and
address issues that if otherwise were unnoticed, could cause
difficulty in stabilizing the patient.
.
Patient 1 [A] (CABGx5):
63 y/o male patient with five vessel coronary artery
disease was seen at UMH for elective Coronary Bypass
surgery. He has a H/O DM and Hep C. Diabetes is
controlled with medication and patient is currently
taking Sovaldi for Hep C treatment,. Bypass time 88
min, X-clamp time 61 min. ACT plateaud at 490 despite
AT3 administration a 50KU heparin bolus and 22KU
additionally. Patient had minor bleeding that was fully
resolved after increase in Protamine administration.
Patient 2 [B] (CABGx3):
70 y/o male patient with multi-vessel disease was seen at
UMH for elective Coronary Artery Bypass Grafting. H/O
HTN and DM for which symptoms are medically
controlled. Patient is taking Saw Palmetto and a One day
vitamin, no other OTC taken. Baseline Act 121. Bypass
time 64 min, X-clamp time 41 min. Full reversal of
heparin achieved. Post Protamine ACT 117, patient
remained in OR until bleeding was controlled with the
addition of products. FFP 330ml, Platelets 200ml.
Patient bleeding corrected.
Hospital Experience
Managing the effects of these drugs can have a great affect
on improving patient outcomes. The focal point would be at
starting with the creation of a personal plan for each patient
on the discontinuation of these drugs prior to surgery.
Articles show evidence that stopping the use of these drugs
1-2 weeks prior to surgery can decrease the amount of
surgical bleeding and blood product usage in addition to the
patient’s time in the operating room (3) . The decision to
discontinue these drugs prior to surgery must be evaluated
on an individual level in each patient depending on their
need and use of the drug (2) but will ultimately lead to
increased awareness and better patient care.
MANGEMENT
(A)-Pancytopenia, Hemolytic Anemia.
(B)-Slow Blood Clotting, Cross Rxn
(A) Ribavirin-inhibition of intracellular energy
metabolism and oxidative membrane damage,
leading to an accelerated extravascular hemolysis by
the reticulo-endothelial system (6) .
(B) Interferes with fibroblast proliferation, anti-
inflammatory effects, specifically the inhibition of
cyclooxygenase and subsequent platelet dysfunction
(5).
Cox- > Prostanoids- > ( prostaglandins,
prostacyclins, and thromboxanes)
Cost Savings
1 RBC-(203.00)
1-Platelet- (565.00)
1-Cryoprecipitate-
(700.00)
1-Fresh Frozen Plasma-
(49.00)
(A)SOVALDI [Sofosbuvir /Ribavirin]
-New Treatment for Hep C
SAW PALMETTO (B)
-Treatment for BPH symptoms
-Decreases Alopecia
Medications Discussed
Medications Used
1. National Center for Complementary and Integrative Health (2015 June 09) Retrieved from:
https://nccih.nih.gov/research/statistics/2007/camsurvey_fs1.html
2.Therapeutic Research Center (2015 June 09) Retrieved from: http://www.nlm.nih.gov/medlineplus/druginfo/natural/971.html
3.Medline Plus (2015 February 02) Retrieved from: http://www.nlm.nih.gov/medlineplus/druginfo/natural/971.html
4. Soldavi Drug Fact Sheet (2015 Feb 02) Retrieved from: http://www.gilead.com/~/media/Files/pdfs/medicines/liver-
disease/sovaldi/sovaldi_pi.pdf.
5.Open Anesthesia (2015 July 13) Retrieved from: https://www.openanesthesia.org/herbal_medicines_anticoagulation_effects/.
6. Russmann S, Grattagliano et al. Ribavirin-induced anemia: mechanisms,risk factors and related targets for future research.PubMed
2006;13(27):3351-7
Adverse Reactions](https://image.slidesharecdn.com/amsect18-190401164902/85/Evaluating-the-effects-on-bypass-in-the-presence-of-new-medications-1-320.jpg)
Evaluating the effects on bypass in the presence of new medications
- 1. Karounka Keita-CCP; Justin Savagae-CCP; Bill Nicotra-CCP Chief; Melissa Harben-CCP MedStar Union Memorial Hospital Perfusion Team. Contention has always existed between Naturopathic and Conventional medicine. Conversely, both append to the overall health of the patient. As healthcare continues to go through a paradigm shift, we have seen an exponential growth in patients participating in “pioneer” drug studies and taking alternatives medical therapy drugs. In the United States, approximately thirty- eight percent of adults (about 4 in 10) and approximately 12 percent of children (about 1 in 9) are using some form of Complementary and Alternative Medicine (CAM)1. These medicines have a wide range of effects in the body, some of which include a direct affect on the circulatory system. In addition, as these medical therapies continue to become more prevalent in the patient population; it is even more imperative that the Perfusionist be conscious to how this will impact their ability to conduct cardiopulmonary support. Introduction References Evaluating the Effects on Cardiopulmonary Bypass, in the Presence of New Pharmacological Medications. Mechanism of Action Goal *Improvement of Clinical Decisions. *Better Patient Care on Cardiopulmonary Support. *Increased Awareness when weaning from CPB. * Anticipate events before they occur. Conclusion Chemical Compound The field of perfusion is constantly adapting to new challenges in a robust and ever changing patient population. With the influx of newer and popular drug regiments, coupled with an increase in personal wellness, a Perfusionist’s clinical decision making abilities will not always be indicated by normal biomarkers in the patients chart (ie: platelet function, HCT and Hb). The two drugs discussed are medicines that not only improve a patient’s quality of life, but have lasting effects on the circulatory systems. Careful management of these drugs; in combination with surgical procedures, can help to improve patient outcomes, decrease blood product usage and increase hospital savings. With proper assessment of the patient’s medical history, we can preemptively plan and address issues that if otherwise were unnoticed, could cause difficulty in stabilizing the patient. . Patient 1 [A] (CABGx5): 63 y/o male patient with five vessel coronary artery disease was seen at UMH for elective Coronary Bypass surgery. He has a H/O DM and Hep C. Diabetes is controlled with medication and patient is currently taking Sovaldi for Hep C treatment,. Bypass time 88 min, X-clamp time 61 min. ACT plateaud at 490 despite AT3 administration a 50KU heparin bolus and 22KU additionally. Patient had minor bleeding that was fully resolved after increase in Protamine administration. Patient 2 [B] (CABGx3): 70 y/o male patient with multi-vessel disease was seen at UMH for elective Coronary Artery Bypass Grafting. H/O HTN and DM for which symptoms are medically controlled. Patient is taking Saw Palmetto and a One day vitamin, no other OTC taken. Baseline Act 121. Bypass time 64 min, X-clamp time 41 min. Full reversal of heparin achieved. Post Protamine ACT 117, patient remained in OR until bleeding was controlled with the addition of products. FFP 330ml, Platelets 200ml. Patient bleeding corrected. Hospital Experience Managing the effects of these drugs can have a great affect on improving patient outcomes. The focal point would be at starting with the creation of a personal plan for each patient on the discontinuation of these drugs prior to surgery. Articles show evidence that stopping the use of these drugs 1-2 weeks prior to surgery can decrease the amount of surgical bleeding and blood product usage in addition to the patient’s time in the operating room (3) . The decision to discontinue these drugs prior to surgery must be evaluated on an individual level in each patient depending on their need and use of the drug (2) but will ultimately lead to increased awareness and better patient care. MANGEMENT (A)-Pancytopenia, Hemolytic Anemia. (B)-Slow Blood Clotting, Cross Rxn (A) Ribavirin-inhibition of intracellular energy metabolism and oxidative membrane damage, leading to an accelerated extravascular hemolysis by the reticulo-endothelial system (6) . (B) Interferes with fibroblast proliferation, anti- inflammatory effects, specifically the inhibition of cyclooxygenase and subsequent platelet dysfunction (5). Cox- > Prostanoids- > ( prostaglandins, prostacyclins, and thromboxanes) Cost Savings 1 RBC-(203.00) 1-Platelet- (565.00) 1-Cryoprecipitate- (700.00) 1-Fresh Frozen Plasma- (49.00) (A)SOVALDI [Sofosbuvir /Ribavirin] -New Treatment for Hep C SAW PALMETTO (B) -Treatment for BPH symptoms -Decreases Alopecia Medications Discussed Medications Used 1. National Center for Complementary and Integrative Health (2015 June 09) Retrieved from: https://nccih.nih.gov/research/statistics/2007/camsurvey_fs1.html 2.Therapeutic Research Center (2015 June 09) Retrieved from: http://www.nlm.nih.gov/medlineplus/druginfo/natural/971.html 3.Medline Plus (2015 February 02) Retrieved from: http://www.nlm.nih.gov/medlineplus/druginfo/natural/971.html 4. Soldavi Drug Fact Sheet (2015 Feb 02) Retrieved from: http://www.gilead.com/~/media/Files/pdfs/medicines/liver- disease/sovaldi/sovaldi_pi.pdf. 5.Open Anesthesia (2015 July 13) Retrieved from: https://www.openanesthesia.org/herbal_medicines_anticoagulation_effects/. 6. Russmann S, Grattagliano et al. Ribavirin-induced anemia: mechanisms,risk factors and related targets for future research.PubMed 2006;13(27):3351-7 Adverse Reactions