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Treatment of Bleeding Problems

Treatment of Bleeding Problems. TYPES OF TREATMENT. Local Therapy Pressure Cautery Suturing Topical Thrombin. TYPES OF TREATMENT. Systemic Pharmacological Therapy Antifibrinolytic agents Tranexamic Acid: Cyklokapron Epsilon amino caproic acid: Amicar

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Treatment of Bleeding Problems

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  1. Treatment of Bleeding Problems

  2. TYPES OF TREATMENT Local Therapy Pressure Cautery Suturing Topical Thrombin

  3. TYPES OF TREATMENT Systemic Pharmacological Therapy Antifibrinolytic agents Tranexamic Acid: Cyklokapron Epsilon amino caproic acid: Amicar DDAVP: desmopressin Hormone preparations: estrogens

  4. BLOOD COMPONENT THERAPY Packed Red Blood Cells If hematocrit <25% Facilitates platelet function due to enhanced platelet margination Platelets Plasma

  5. BLOOD COMPONENT THERAPY Cryoprecipitate Factor VIII VWF Fibrinogen Coagulation factor concentrates Factor VIII Factor IX

  6. OTHER THERAPY ISSUES Treatment of associated (primary) conditions DIC ie. treat infection, deliver fetus Review of Medications Intramuscular injections Anticoagulant or anti-platelet drugs

  7. CONSIDERATIONS IN THE TX OF HEMOSTATIC PROBLEMS Urgency Empiric versus specific therapy Emergency use of a “hemostatic cocktail” Platelets Plasma Cryoprecipitate

  8. CONSIDERATIONS IN THE TX OF HEMOSTATIC PROBLEMS Transmissible Diseases HIV, Hepatitis A, B and C, Parvovirus, ??CJD Coagulation Factor Concentrates Donor screening Viral inactivation Donor pools Plasma and cryoprecipitate

  9. CONSIDERATIONS IN THE TX OF HEMOSTATIC PROBLEMS Volume overload very young/very old Alloimmunization Often to HLA antigens in cellular product to plasma proteins Cost Recombinant products

  10. CLINICAL CASE #1 • 78 Year old male - known metastatic prostatic carcinoma • Seen in the ER at 8 a.m. with a headache and increasing drowsiness • Taking Coumadin to prevent thrombotic complications from a prosthetic heart valve • No bleeding problems at cardiac surgery

  11. Exam Several bruises on limbs and trunk Bleeding from nose weakness of the right arm and leg CT Scan Large left subdural hematoma

  12. Screening tests Complete blood count PT/International Normalized Ratio (INR) PTT Thrombin Time Liver Function Studies

  13. Hgb 141 WBC 9 Platelets 255 PT 48 secs /INR 8.5 (control 12-14secs) 50:50 12 secs PTT 85 secs (normal <34 secs) 50:50 32 secs TCT 10 secs (normal 10-12 secs)

  14. Vitamin K Dependent Procoagulant Proteins

  15. Extrinsic Pathway (prothrombin time - PT)

  16. Intrinsic Pathway (aPTT)

  17. Thrombin time unaffected by coumadin

  18. Additional Considerations Diet Antibiotics Liver Metastases Infection

  19. Differential Diagnosis Oral anticoagulant overdose Vitamin K Deficiency Liver Disease DIC Inherited bleeding disorder

  20. Clinical Priority CNS Bleed Other Consideration Prosthetic heart valve thrombotic risk

  21. Therapy Stop Coumadin Vitamin K replacement Route - PO, IV, SC - NOT IM Dose 1-10 mg (NB. Prolonged effect) Transfusion of Vitamin K dependent factors (Plasma)

  22. Post-operative management Major concern - valvular thrombosis therefore Begin parenteral anticoagulant therapy early

  23. CLINICAL CASE #2 27 year old woman seen in E.R. 24 hour history of feeling unwell 6 hour history of headache, photophobia and vomiting

  24. Clinical Examination Temperature 40°C Bleeding from gums and venipuncture sites Widespread purpuric rash Stiff neck

  25. Investigations CBC PT PTT Thrombin Time Microbiological Work up

  26. Hgb 95 g/l WBC 26 x 109 /L Platelets 35 x 109/L Blood smear RBC Fragments

  27. PT 19 secs (control 11-13 secs) 50:50 12 secs PTT 59 secs (normal <34 secs) 50:50 32 secs TCT 21 secs (normal 10-12 secs)

  28. Fibrinogen level 0.6 g/l (normal 1.5 - g/l) Fibrin degradation products (FDP’s) Elevated

  29. Differential Diagnosis DIC Vitamin K Deficiency Liver disease Inherited disease Treat the primary disorder

  30. Differential Diagnosis DIC other thrombotic microangiopathic angiopathies Thrombotic thrombocytopenic purpura (TTP) Hemolytic uremic syndrome (HUS) thrombocytopenia/hemolysis predominant – coagulopathy unusual

  31. Is treatment required for the bleeding disorder? Yes - active bleeding Multicomponent Approach Platelets >50 All coagulation factors Plasma Fibrinogen Cryoprecipitate

  32. Further Management Follow clinically and with lab values Serial platelet counts and fibrinogens Additional transfusions

  33. CLINICAL CASE #3 • 45 yr old male • Pre-cholecystectomy blood work • No previous history of bleeding problems • No family history of bleeding

  34. Hb 143 g/L WBC 7.6 Plats 316 PT 12 secs (normal 12-14 secs) PTT 48 secs (normal <34 secs) TCT 12 secs (normal 10-12 secs)

  35. PT 12 secs (normal 12-14 secs) PTT 48 secs (normal <34 secs) PTT 50:50 mix 29 secs

  36. Extrinsic Pathway (prothrombin time - PT)

  37. Intrinsic Pathway (aPTT)

  38. FVIII:C 115% (1.15 U/ml) FIX:C 136% (1.36 U/mL) (normal ranges 50-150% [0.50 – 1.50 U/mL])

  39. FVIII:C 115% FIX:C 136% FXI:C 13% Diagnosis - Inherited FXI deficiency (normal ranges 50-150%)

  40. Peri-operative Management • Observation • Have plasma available in blood bank Assess other family members

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