Cardioplegia contents

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Dear All and ,

Well I made a Tutorial on this. I will post it here and in total on

the overflow site at:

2

Try a folder on USP 797 where I will place some links to the FDA

warning about the CAPS products that is causing so much alarm.

But a simple answer to your question Karin is:

a high potassium solution with some other electrolytes.

Here is the tutorial I made just for YOU!

Tutorial - Cardioplegia

What is cardioplegia?

Cardioplegia is the willful or intentional temporary cessation of

cardiac activity, used mainly in cardiac bypass surgeries, and

typically using drugs. The solution MUST be filtered and use a special

delivery set. The solution is usually mixed with blood. Temperature

and rate of reperfusion is critical. The end of surgery is a critical

time: problems usually occur after cross clamp removal during the

surgery (near the end of surgery). (putting things back the way they

were).

Types of Solution:

The four types are: cold crystalloid cardioplegia, cold blood

cardioplegia, hyperkalemic warm blood cardioplegia or simple

oxygenated blood perfusion.

The standard has been a Crystalloid Cardioplegia Delivery System would

continually cool the solution during surgery.

Warm Cardioplegia is becoming widely accepted with a better post

bypass end-systolic pressure-volume relationship; which translates to:

improved preservation of the left ventricular systolic function after

the cardiac bypass surgery{ CABG surgery} which means it keeps the

left lower part of the heart functional.

The 37° C substrate-enriched warm cardioplegia consists of : glutamate

(13 mM/L), aspartate (13 mM/L)], hyperkalemic (25 mEQ/L) anterograde

and retrograde blood cardioplegic solution.

Temperature and Delivery Systems:

Photo of Temp Control device

http://www.medtronic.com/cardsurgery/arrested_heart/biocal.html

Photo of Cardioplegia delivery system/lines;

http://www.blmarket.com/cardioplegia-delivery-system.html

What is in this stuff?

Cardioplegia usually contains magnesium and potassium which stop the

heart beating and minimize the energy requirements of the heart during

surgery. In addition it contains procaine which protects the heart

muscle and helps stop the heart beating during the surgery. Procaine

also helps prevent disturbances in heart rhythm straight after the

surgery.

Blood cardioplegia formula consists of KCl 20 mmol/L, MgCl2 16 mmol/L,

CaCl2 1.2 mmol/L, Procaine 0.9 mmol/L, pH 6.9, osmoality 340 mOsm/L.

Another formula: High potassium " Rivero " cardioplegia solution,

60meq/L concentration.

Specific ingredients:

1. Potassium – main chemical that causes the cardioplegia and

prevents repolarization or `Diastolic arrest " BELIEVE it or NOT!

2. Procaine Membrane stabilisation – antidysrhythmicm Na+ channel

blocker [Class I] and as a vasodilator

3. Slow calcium channel blocker

4. Calcium to reverse excess Slow Ca++ blocker action.

5. Bicarbonate for buffering and blocking metabolic acidosis

secondary which occurs due to anaerobic metabolism. Tham can also be

used.

6. Mannitol to lessen the injury caused by cardiac reperfusion; also

counteracts the edema which causes impairment due to hypothermia &

ischemia.

7. Dextrose, electrolytes in specific amounts.

8. Adenosine and Propofol can help aid energy and be free radical

scavengers

Allergies to watch out for:

If the pt has allergies to any anesthetic ( `caine' ending) OR to

PABA a sunscreen agent aka: para-aminobenzoic acid. Anaphylactic

shock or PCN like reactions occur.

Disease State Contraindications are:

1. Myasthenia gravis (severe weakness of the muscles)

2. An electrical or heartbeat conduction impairment

3. Liver Disease

4. Kidney Disease

5. Abnormally high temps during anesthesia

Drug Interactions include:

1. anticholinesterases drugs that block the enzyme that destroys

cholinester. So in effect a drug that blocks the bodies normal or

abnormal ability to destroy the PSNS response so that the PSNS

response will continue. (example: pyridostigmine)

2. Sulfa antibiotics (examples are sulfonamides Septra, Bactrim,

sulfamethoxazole) and possibly antifungals.

Video of the Surgery and use of Cardioplegia:

Cold Crystalloid Cardioplegia used in Open heart Surgery

http://mmcts.ctsnetjournals.org/cgi/content/full/mmcts.2004.001040/DC1

Video 1 or 2

I could not get sound on it maybe you can.

Other Images:

http://www.visibleheart.com/objectives.html

http://www.visibleheart.com/videoclips.html

Addition of blood to cardioplegia solution:

The heart muscle (myocardium) that is perfused with blood cardioplegic

solution demonstrated a more rapid establishment of cardiac rhythm

(about 60%) compared to the crystalloid solution (45%). This is why

blood, particularly warm blood cardioplegia has gained ground.

Filtering the blood in cardioplegia:

Also the white blood cells or leukocytes can cause more myocardium

damage than when the blood has been filtered so that it contains less

or none. This is called " leukocyte filtered blood cardioplegia " (LCBC).

Image of the Pall Filter we used on the job:

http://www.pall.com/images/ds_pho_Cardioplegia_Plus.jpg

http://www.pall.com/datasheet_medical_6426.asp

Crystalloid + Chinese Herb works well:

I did some digging and found that a Chinese herb had been added to the

Crystalloid Cardioplegia and the study concluded that it may

significantly reduce `myocardial metabolism and reduce postoperative

myocardial enzymes and the damage of the myocardial ultrastructure

(mitochondria) following ischemia and reperfusion is also lessened. "

The name of the herb is: Puerarin.

Timing :

Intermittent profusion is better than antegrade.

Complications of the surgery and cardioplegia are:

1. Heart block (due to too much K+)

2. Air emboli (air clot in line then in heart)

3.

Want more technical: Here is a good link:

http://www.uspharmacist.com/oldformat.asp?url=newlook/files/Feat/Cardioplegic.ht\

m & pub_id=8 & article_id=873

Or go to the overflow site to this site and the folder marked USP 797

Hope this helps you … and leads you all to appreicate USP 797.

" We techs " in pharmacy back in l995, did NOT make the solution. But

we did supply the OR with the ingredients. We had to pack the box with

the vials and such the night before all surgeries. Then a pharmacist

went to the surgery in the early AM and I never knew if he/she or

he/she in conjunction with the surgeon or ??? made the cardioplegia.

But sometimes our pharmacist made it on graveyard in our hoods at

about 4 am.

The tutorial has more sites for reference and also powerpoint slides I

found. Enjoy!

Respectfully,

Jeanetta Mastron CPhT BS

Pharm Tech Educator

Founder/Owner of this site

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