HAEMOSTASIS

Presented by Dr.Geetika MODERATOR :Dr.A.Prakash

PHASES OF COAGULATION

Initiation-Endothelial damage and response in the form of platelet adherence and plug formation Acceleration-protein and cellular activation. Control-Feedback mechanisms to control coagulation. Lyses-Breakdown of clots and initiation of healing and recannulization.

VASCULAR INTEGRITY

VASCULAR DAMAGE TXA2,Serotonin,NO Vasoconstriction . Exposure of collagen in subendotheliumplatelet plug Platelets attach to injured vessel by GP 1b receptor to vWF. GP1a/2a or GP4 receptors to collagen. GP1c/2a receptor to laminin/fibronectin. GP4 receptor to thrombospondin. GP2b/3a receptor is for fibrinogen.-essential for platelet aggregation.exposed only after platelet activation.main site for platelet to platelet adherence.

PLATELET FUNCTION

Formation of temporary vascular plug later reinforced by fibrin. Exposure of phospholipid surface (PF3)to serve as reaction site for the coagulation cascade Release of active biochemicals Mechanical clot retraction.

PLATELET RELEASE PRODUCTS

Granules: thromboglobulin; PDGF; PF4; vWF. Dense granules : ADP,ATP,Calcium, adrenaline. Platelet cytoplasm:fibrinogen,PG intermediates;thrombospondin;TXA2;TFPI

COAGULATION FACTORS

1 FIBRINOGEN;2 PROTHROMBIN 3 TISSUE EXTRACT;THROMBOPLASTIN;PLATELET FACTOR 3 4 CALCIUM 5 LABILE FACTOR 6 NOT USED

COAGULATION FACTORS

7-Stable Factor 8-Antihaemophilic factor A 9-Antihaemophilic factor B 10-Stuart Prower factor 11-Antihaemophilic factor C 12-Hageman Factor 13-Fibrin Stabilizing Factor

CLOT LYSES

Antithrombin 3,protein C&S,Tissue factor pathway inhibitor are the various antithrombotic mechanisms. Fibrin formation that occurs despite the above is degraded by the fibrinolytic system i.e. urokinase and tpa

TESTS OF COAGULATION

Prothrombin time:Conducted by adding thromboplastin (containing tissue factor) to plasma. Normal value is 10-14s. Used to monitor warfarin therapy. Varying sensitivity due to source of thromboplastin.So now INR preferred over PT. Raised in deficiency of factor7,9,10,fibrinogen and prothrombin.

TESTS OF COAGULATION

INR-International Normalized Ratio Normal value-1 Surgery possible if below 1.5.

TESTS OF COAGULATION

aPTT-Adding kaolin/silica/celite to citrated plasma. Normal value is 22-40s. Used to monitor heparin therapy or thrombin inhibitor administration. Prolonged in factors 2,5,8,9,10 or fibrinogen deficiency.

TESTS OF COAGULATION

Thrombin clotting time-conducted by adding excess amount of thrombin to plasma Prolonged with heparin,thrombin inhibitors or low fibrinogen. Used for monitoring LMWH,Hirudin,Bivalirudin.

TESTS OF COAGULATION

Thromboelastography -PT and aPTT assess only the initial phases of clot formation ,whereas TEG assesses all phases of clot formation Used to evaluate hypocoagulable states,hemophilia,anticoagulant therapy, dilutional coagulopathies, clinical efficacy of haemostatic interventions and coagulation problems of liver transplant.

TESTS OF COAGULATION

Bleeding time-test for platelet function. Not a reliable test as operator and institutional variation occurs Insensitive to many mild platelet disorders. Now PFA-100 is the preferred test.

TESTS OF COAGULATION

PFA-100- New global test of high shear dependent platelet adhesion and aggregation. Contains collagen ADP or collagen epinephrine coated membranes. Requires 0.8ml of blood. Noninvasive;very sensitive for platelet dysfunction due to von WFD,NSAIDS and dietary factors. Monitoring of DDAVP AND PLATELET TRANSFUSIONS.

TESTS OF COAGULATION

Sonoclot- real time coagulation measurement from fibrin formation to clot retraction and fibrinolysis. Measures changing impedance on ultrasonic probe immersion in coagulating blood sample.

TESTS OF COAGULATION

aPTT raised -Hemophilia A, Hemophilia B, vWF disease. aPTT & INR raised -liver disease, vitamin K deficiency.,warfarin therapy aPTT & INR& TT raised-DIC aPTT & INR raised with platelets-massive transfusion aPTT & TT &antiX-a -heparin antiX-a-LMWH

ASRA GUIDELINES FOR PREOPERATIVE LMWH

Needle placement should be done after 1012 hrs after last dose of LMWH (for thromboprophylaxis). Needle placement should be done at least 24 hrs after last dose of high dose LMWH therapy. Neuraxial technique to be avoided if LMWH given 2 hrs before surgery.

ASRA GUIDELINES FOR POSTOPERATIVE LMWH

Twice daily dosing-1st dose to be given no sooner than 24 hrs postop regardless of the anesthetic technique .epidural catheter to be removed 2 hrs before 1st dose. Once daily dose-1st dose to be given 6-8 hrs postop and 2nd dose only 24 hrs after the 1st dose.Catheter removal to be done after at least 10-12 hrs of last dose and 2 hrs before next dose.

ASRA GUIDELINES FOR ORAL ANTICOAGULANTS

Warfarin to be stopped 4-5 days before surgery and INR to be measured on the day of surgery If patient has received 1 or 2 doses of warfarin preop then check INR before using a Neuraxial technique.

ASRA GUIDELINES FOR ORAL ANTICOAGULANTS

If thromboprophylaxis with warfarin is initiated ,then epidural catheter to be removed when INR <1.5 Routine Neurological testing for all patients on warfarin therapy with epidural catheters. local anesthetic solutions to be tailored to minimize sensory and motor blockade. monitoring to continue for 24 hrs post removal of epidural catheter.

ASRA GUIDELINES FOR ANTIPLATELET DRUGS

This category includes NSAIDS,THIENOPYRIDINES(Ticlopidine and clopidogrel) &GP2B/3A INHIBITORS(abciximab,eptifibatide,tirofiban). No risk with NSAIDS.DO NOT DISCONTINUE BEFORE SURGERY. DISCONTINUE ticlopidine 14 days preop and clopidogrel 7 days preop. Abciximab to be withheld for 24-48 hours preop and tirofiban and eptifibatide for 4-8 hrs.

FONDAPARINUX

Fondaparinux-prophylaxis of venous thromboembolism in major orthopedic surgery of lower limbs-initial dose only after 6 hrs of surgery. Use single needle pass, atraumatic needle pass and avoidance of neuraxial catheter.

FFP ADMINISTRATION

Non cellular fraction of blood. Contains all plasma proteins particularly V and VIII. Carries infection risk. 200-250 ml.1 unit increases clotting factors by 2-3%. Use ABO compatible Rh incompatible is ok. Once a unit is thawed refrigerate and transfuse within 4 hrs. Indicated volume is 10-15 ml/kg. 4-5 platelet concentrates,1 unit of single donor aphaeresis platelets and 1 unit of whole blood contribute the same amt. of coagulation factors as 1 unit of FFP.

FFP ADMINISTRATION INDICATIONS

Urgent reversal of warfarin. Dose is 5-8ml/kg. Indicated in microvascular bleeding in presence of prolonged PT(>1.5 times) or aPTT (more than 2 times normal) or INR>2 in absence of bleeding. Correction of known coagulation factor deficiencies for which no concentrates are available Antithrombin 3 deficiency. heparin resistance in patients requiring heparinisation. Correction of microvascular bleeding in patients transfused with more than 1 blood volume. Not indicated for volume expansion, nutritional support or for maintaining plasma oncotic pressure.

CRYOPRECIPITATE

When FFP is thawed at 4C, some plasma proteins remain precipitated. when solubilized by further warming, this cryoppt becomes 20-25ml of plasma containing30-60% of factor VIII, and25%of fibrinogen in a unit of blood. Factor XIII,vWF,and fibronectin also present. Administer as ABO compatible but not very important. Administer through a filter and as rapidly as possible (at least 200 ml/hr) infusion should be complete within 6 hrs of thawing

CRYOPRECIPITATE

a)
b) c)

d)

e)

f)

Indicated in Haemophilia A Active bleeding or major surgery in vWF. Factor12 or fibrinogen deficiency Rarely when fibrinogen is more than 150 mg/dl Fibrinogen<80mg/dl in presence of microvascular bleeding During massive blood transfusion.

PLATELET TRANSFUSION

NORMAL count 1.5-4 lakh Intracranial,paraspinal and eye surgery contraindicated in counts below 100000. Neuraxial block contraindicated below 100000. Minor surgery possible if count<50000. Contraindicated in HIT,ITP,TTP. B.T sets with pore size less than 170 mm should not be used. Use 18G I.V cannula or a larger one.

PLATELET TRANSFUSION

Platelets can only be stored at 22C for 5 days. Half life of 7.3 days. In vivo recovery after 72 hrs of storage is 50%. Each unit increases count by 5000-10000. Another dosage guideline is 1 unit per 10 kg body wt. When possible ABO compatible platelets should be used

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