Clotting

Book Notes

A. Blood product therapy

a. Packed RBC
i. Indication: severe or symptomatic anemia, acute blood loss,
ii. Prepared from whole blood by sedimentation or centrifugation.

b.

c.

d.

e.

f.

One unit contains 250-350 mL.

iii. Can be stored up to 35 days depending on processing
iv. Is a less danger of fluid overload and are preferred choice since
they are more component specific
Frozen RBC
i. Indication: autotransfusion, stockpiling or rare donors for pts. w/
alloantibodies
ii. Are prepared from RBC using glycerl for protection and frozen.
Can be stored for 10 yrs.
iii. Must be used w/I 24 hrs of thawing
Platelets
i. Indication: bleeding caused by thrombocytopenia; but not for
ITP, heparin induced thrombo unless life threatening
ii. Are prepared from fresh whole blood and contains 30-60 mL of
plt. Concentrate.
iii. Can be kept at room temp for 1-5 days depending on type of
collection and storage bag.
Fresh frozen plasma
i. Indication: bleeding due to deficiency in clotting factors, (DIC,
hemorrhage, massive transfusion, liver disease, vitamin K
deficiency, excessive warfarin)
ii. Is rich in clotting factors but contains no platelets.
iii. Can be stored for >1 yr but must be used w/I 24hr after thawing
Albumin
i. Indication: hypovolemic shock, hypoalbuminemia
ii. Albumin is prepared from plasma. It can be stored for 5 yr.
iii. Acts by moving water from extravascular to intravascular space.
It is heat treated and does not transmit viruses
Cryoprecipitate and Commercial Concentrates
i. Indication: replacement of clotting factors (VIII, von willebrand
factor, and fibrinogen)
ii. Prepared from fresh frozen plasma and can be stored for 1 yr.
once thawed must be used w/I 5 days.

B. DIC (Disseminated Intravascular Coagulation)

a. Definition: serious bleeding and thrombotic disorder that results from

abnormally initiated and accelerated clotting.

i. It is not a disease but an abnormal response to disease process
or disorder

b. Cause --------excessive clotting & hemorrhaging

i. Antithrombin III and protein C, are depressed. Excessive clotting
activates fibrinolytic system, which in turn breaks down already
formed clots which creates fibrin split products (FSP). These
products have anticoagulant properties inhibiting normal blood
clotting.
1. Can lead to shock, organ failure, or death

c. Risks
i.
ii.
iii.
iv.

Hemorrhagic/ cardiogenic/anaphylactic shock,

septicemia,
transfusion of mismatched blood, acute hemolysis,
abrupto placentae, amniotic fluid embolism, septic abortion,
HELLP,
v. acute leukemia, lymphoma tumor syndrome
vi. burns/trauma, heatstroke, severe head injury, transplant
rejection, postop damage, fat/pulmonary emboli, snakebites,
glomerulonephritis, acute anoxia, prosthetic devices fulminant
hepatitis
vii. liver disease, lupus, malignancy
d. S&S
i. Integumentary manifestations: pallor, petechiae, purpura,
oozing blood, venipuncture site bleeding, hematomas, and
occult hemorrhage
ii. Respiratory: tachypnea, hemoptysis, orthopnea
iii. Cardio: tachycardia, hypotension
iv. GI/ GU: upper and low GI bleed, abd. Distention, bloody stool,
hematuria
v. Neuro: vision change, dizzy, headache, change in mental status,
irritability
vi. Skeletal: bone and joint pain.
e. Diagnostic tests
i. D-Dimer, PT, PTT, aPTT, fibrinogen, plts, fibrin split products,
factor assay, Antithrombin III, protein C&S, peripheral blood
smear
f. Treatment: underlying cause must be treated
i. If caused by malignancy-chemotherapy is treatment of choice
g. Interventions
i. Provide oxygen and volume replacement
ii. Blood products such as plts, cryoprecipitate, fibrinogen, fresh
frozen plasma (FFP)
1. Plts are usually given if less than 20,000 or 50,000
2. Cryopreciptate is given to replace factor VIII
3. Fibrinogen is given if less than 100
4. FFP replaces all clotting factors except plts.
iii. Heparin is only give if the benefit (reduce clotting) outweighs
the risk (further bleeding)

C. Thrombocytopenia
a. Definition: A reduction of plt below 150,000.

i. Acute, severe, or prolonged decrease can result in abnormal

b.

c.

d.

e.
f.

hemostasis and manifest prolonged bleeding from minor trauma

or spontaneous bleeding w/o injury
1. ITP (idiopathic thrombocytopenic purpura): autoimmune
disease in which Plts are coated w/ antibodies, the spleen
then recognizes them as foreign and destroyed.
2. TTP (Thrombotic thrombocytopenic purpura): hemolytic
anemia, thrombocytopenia, neuro abnormalities, fever,
and renal abnormalities. Plasma enzyme is deficit which in
return vWF attaches to activated plts, promoting plt.
Aggregation.
3. Heparin-induced thrombo: typically occurs 5-10 days after
heparin therapy.
Cause:
i. Typically inherited but can be caused by ingestion of certain
herbs or drugs
1. Hep. C, HIV, aplastic anemia, tumor infiltrating bone
marrow, radiation, sepsis, splenomegaly, DIC,
2. Alcohol, thiazide diuretics, chemotherapy, digoxin,
NSAIDs, penicillin, sulfonamides, rifampin, aspirin, Haldol,
lithium, ginger, cumin, turmeric, cloves, Vitamin C/E,
heparin, garlic, ginkgo biloba, ginseng
ii. Decreased production of plts. In bone marrow, increased
destruction of plts, increased consumption of plts.
S&S
i. Typically asymptomatic but could have epistaxis or gingival
bleeding.
ii. Petechiae, purpura, superficial ecchymosis, prolonged bleeding
during venipuncture or IM injection, confusion, headache,
seizures/coma could occur
iii. Biggest concern is hemorrhaging
Diagnostic (Table 31-13 pg. 652)
i. Plt below 150,000 if below 20,000 life threatening hemorrhage
could occur.
ii. Pt, aPTT, hgb
Treatment: treat the initial cause
Interventions
i. Drug therapy
1. Provide corticosteroids
2. Plt transfusion
ii. Discourage excessive use of Over the counter medications
iii. Wear all protective gear when performing an active sport
iv. Do not blow nose forcefullyif nose starts to bleed, keep head
up and apply firm pressure. Place an ice bag over bridge if
necessary
v. Prevent constipation or straining when using the restroom

vi.
vii.
viii.
ix.

Shave only w/ electronic razor and do not pluck eyebrows

No tattoos or body piercings
Use soft bristle toothbrush to prevent gum injury
Ask doctor if it is okay to get dental cleaning, manicure, or
pedicure before doing it.

D. ITP (Idiopathic Thrombocytopenia Purpurua)

a. Definition:
i. autoimmune disease where the plts. Are coated with antibodies.
b.
c.
d.

e.

The spleen recognizes these antibodies as foreign and destroys

the plts. Reducing the amount of plts. In the body.
Cause: Autoimmune disease
Diagnostic
i. Plts decreased, ITP plt. Antigen-specific assay, C-serotonin
release assay, Helicobacter pylori, bone marrow biopsy
Treatment
i. Drug therapy
1. Corticosteroids are used because of their ability to
suppress the phagocytic response of splenic
macrophages.
a. Danazol(Danocrine), an androgen, may also be
used w/ corticosteroid therapy
2. If unresponsive to corticosteroid used will typically get iV
immunoglobulin (Anti-Rh(D)) (Anti-D, WinRho)
3. if chronic ITP than Romiplostim(Nplate) and eltrombopag
(Promacta) is used which increate plt. Production
ii. Splenectomy may be indicated if pt. does not respond to drug
therapy
iii. Plt. Are only transfused to increase plt. Count in life-threatening
hemorrhage but not prophylactically
Interventions
i. Same Interventions as above
ii. Educate about setting up periodic medical evaluations to assess
their status

E. HELLP Syndrome (hemolysis, elevated liver, low platelet)

a. Pregnancy
i. Definition: severe preeclampsia that involved hepatic

dysfunction. Also known as hemolysis, elevated liver enzyme,

and low plt. Count
1. Typically in 3rd trimester, or w/I 48 hrs after birth
2. Life-threatening pregnancy complication & difficult to
diagnose
3. If baby weighs less than 2 lbs. there is a higher risk of
fetal demise
ii. Patho

iii.

iv.

v.

vi.

vii.
viii.

1. Caused due to arteriolar vasospasm, dysfunction in fibrin

deposits, and adherence of plt. In blood vessel. RBC are
damaged as they pass through blood vessel and become
hemolyzed, causing decreased RBC, low plts, and
hyperbilirubinemia. Damaged fibrin deposits in liver
leading to impaired liver function
Class
1. Class I (Severe thrombocytopenia): AST >60, Plt. Under
50,000
2. Class II (moderate): AST >60, platelet between 50,000
and 100,000
3. Class III (Mild): AST>40 and plt between 100,000 &
150,000
Complications
1. Placenta abruption, pulmonary edema, DIC, ARDS, liver
hematoma, renal Failure, infant respiratory distress
syndrome,
Risks
1. Caucasian women, preeclampsia, women over the age of
25, multiparous (two or more pregnancies), pulmonary
edema, acute renal failure, DIC, placental abruption, liver
hemorrhage or failure, ARDS, sepsis, stroke
S&S
1. Typically have malaise, flu-like symptoms, epigastric/right
upper quadrant abd. Pain, N/V, headache, visual
disturbance, bleeding
2. May have thrombocytopenia like symptbruising/
hematuria
3. Blood pressure is typically high and protein is in
the urine as well as elevated liver enzymes
Diagnostic: no definitive diagnostic tests
1. CBC, H&H, bilirubin >1.2, plt count, serum aspartate >70,
lactate dehydrogenase >600
Interventions
1. For fetus <34 wks
a. Bed rest
b. Corticosteroid
c. Meg sulfate
d. Blood transfusion if plt too low
e. Blood pressure medication (must be approved)
f. Fetal monitoring and test including biophysical
test, sonograms, etc.
2. For fetus >34 wks
a. Deliver is needed.
b. Should be given a trial of labor