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Coagulation and cardiac ITU. 2 Approaches. Understand and treat appropriately Give platelets and FFP. Overview. How clotting system works Drugs that affect it Effect of CPB on coagulation Medical conditions that affect it Tests of coagulation Assessing the bleeding patient

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Presentation Transcript
2 approaches
2 Approaches
  • Understand and treat appropriately
  • Give platelets and FFP
overview
Overview
  • How clotting system works
  • Drugs that affect it
  • Effect of CPB on coagulation
  • Medical conditions that affect it
  • Tests of coagulation
  • Assessing the bleeding patient
  • Treatments
coagulation system
Coagulation system
  • Why have it ?
  • What stops it working ?
  • What causes its activation ?
how it works 1
How it works 1

Activation

intrinsic- collagen and connective tissue and extrinsic- tissue factor from damaged cells

Platelets

Soluble clotting factors

Fibrin

RBC

Clot

how it works 2 soluble coagulation factors
How it works 2 soluble coagulation factors
  • Factor X11 Factor X11a
  • Factor X1 Factor X1a factor V111
  • Factor 1X Factor 1Xa Factor V11
  • Factor X PL, Factor V & Ca2+
  • Prothrombin Thrombin
  • Fibrinoigen Fibrin monomer Fibrin polymer
  • Factor X111
how it works 4 thrombin
How it works 4 Thrombin

Soluble factors

Thrombin

Platelet

Clot

drugs that affect coagulation
Drugs that affect coagulation
  • Bleed
    • Aspirin
    • Warfarin
    • Heparin / LMWH
    • Clopidogrel / Ticlopidine
    • ReoPro / Integrilin
    • Steptokinase / Alteplase
    • Non steroidal anti inflammatory drugs
  • Clot
    • Protamine
    • Tranexamic acid
    • Aprotinin
    • Vit K
aspirin
Aspirin

TxA2

Platelet

PgI2

Endothelium

warfarin
Warfarin
  • Inhibits Vitamin K
  • Factors 11, V11, 1X, and X
  • Factor 11 most important “thrombin”

Soluble factors

Thrombin

Platelet

Clot

heparin lmwh
Heparin / LMWH
  • Complex molecule of multiple sugars molecules

AT 111

Thrombin

Heparin

reopro integrilin
ReoPro / Integrilin

Platelet

Platelet

GP 11b/111a

Fibrin

GP 11b/111a

steptokinase alteplase tpa
Steptokinase / Alteplase / TPA

Steptokinase / Alteplase / TPA

Plasmin

Plasminogen

Fibrin

Degradation

products

Fibrin

Fibrinogen

Coagulation cascade

non steroidal anti inflammatory drugs
Non steroidal anti inflammatory drugs

TxA2

Platelet

PgI2

Endothelium

protamine
Protamine

Protamine

Heparin

Inactive complex

tranexamic acid
Tranexamic acid

Plasmin

Plasminogen

Fibrin

Degradation

products

Fibrin

Fibrinogen

Coagulation cascade

Tranexamic acid

aprotinin
Aprotinin
  • Kallikrein Kinin inhibitor
  • PAR-1 antagonist
  • Anti fibrinolytic
  • Multiple different doses
  • Full dose / half dose / pump prime
vit k
Vit K
  • Slow IV
  • Liver disorders
effect of cpb on coagulation
Effect of CPB on coagulation
  • Soluble factors
    • Consumption
    • denatured
  • Platelets
    • Consumption
    • Desensitisation
medical conditions that affect
Medical conditions that affect
  • Drugs
  • Renal / liver failure
  • Haemophilia
  • Christmas disease
  • Von Willebrands
drugs
Drugs
  • Discussed already
renal failure
Renal failure
  • Platelets don’t work
  • Uraemia

Liver failure

  • All clotting factors other than V111 produced in liver
haemophilia christmas disease
Haemophilia / Christmas disease
  • Factor X11 Factor X11a
  • Factor X1 Factor X1a factor V111
  • Factor 1X Factor 1Xa Factor V11
  • Factor X PL, Factor V & Ca2+
  • Prothrombin Thrombin
  • Fibrinoigen Fibrin monomer Fibrin polymer
  • Factor X111
von willebrands
Von Willebrands

Platelet

Factor V111

vWF

Endothelium

tests of coagulation
Tests of coagulation
  • PT / INR
  • APPT
  • Fibrinogen
  • D-Dimer
  • ACT / KCT
  • Platelet function tests / thromboelastography
assessing the bleeding patient
Assessing the bleeding patient
  • Blood pressure
  • Acid base
  • CXR
  • Pumping up tubing
  • Sudden stop of bleeding esp 2nd clotting factors
  • Drop in Hb
  • TAMPONADE

Clotting studies / Preop medications & conditions / what operation

treatments
Treatments
  • Surgical factor VII (prolene 7-0)
  • FFP
  • Cryoprecipitate
  • Specific isolated factors
  • Platelets
  • Blood / Hb
ffp fresh frozen plasma
FFP fresh frozen plasma
  • All soluble clotting factors except 1 and V111
cryoprecipitate
Cryoprecipitate
  • Fibrinogen
  • vWF
  • V111
platelets
Platelets
  • Depends on preop med’n, count and operation
slide33
Specific isolated factors
    • 1
    • V111
    • 1X
    • vWF
  • Blood / Hb