Title: ACQUIRED BLEEDING DISORDERS
1ACQUIRED BLEEDING DISORDERS
- Kevin A Rickard
- Royal Prince Alfred Hospital
2ACQUIRED BLEEDING DISORDERS
- HAEMOSTASIS
- EVALUATION
- History and Examination
- Laboratory Tests
- FBC Hb WCC Platelets
- Coagulation Prothrombin time
- II V VII X
-
- APTT
- VIII IX XI XII
- Factor assays
- Prothrombin Time 10 secs N
- Prothrombin Ratio 20 secs P 20 2
- 10
3ACQUIRED BLEEDING DISORDERS
- HAEMOSTASIS
-
- Platelets Coagulation Fibrinolysis
- HAEMOSTATIC FAILURE
-
- Congenital or acquired disorders affecting the
above - Coagulation Defects
- Platelet abnormalities
- Fibrinolysis
- Combination defects
4ACQUIRED BLEEDING DISORDERS
- COAGULATION DEFECTS
- LIVER DISEASE Multiple factors
- DEFIBRINATION SYNDROME
- ANTICOAGULANT OVERDOSE
- Heparin
- Warfarin
- VITAMIN K DEFICIENCY
- CIRCULATING ANTICOAGULANTS
- FVIII inhibitors
- Lupus like
- Antiphospholipid
- Anticardiolipid
5ACQUIRED BLEEDING DISORDERS
- PLATELET DEFECTS
- Dilutional thromocytopenia
- Thombopathy
- Nutritional
- Infective
- FIBRINOLYSIS
- Fibrinolytic agents
- Secondary fibrinolysis
6LIVER DISEASE
- Acute or Chronic
- Acute Hepatitis Hepatic failure
- Chronic Chronic Active Hepatitis
- Cirrosis
- Mechanisms
- Coagulation proteins synthesised in the liver
- Portal circuit hypertension
- Splenomegaly - hypersplenism
- Oesvarices - Tpenia
- Fibrinolytic activation
- Non clearance of activators
- Reduced inhibitors ?2 antiplasmin
- Naturally occurring anticoagulants
- ATIII, protein C, protein S ?
- ? Haemostatic balance lower level
7LIVER DISEASE
- Hepatic impairment - insufficiency
- Lab Tests
- PT ? APTT ? Fibrinogen ?
- Assays II, V, VII, IX, X, ?
- VIII ?
- Tpenia
- Fibrinolysis ?
- Clinically
- Bruising
- Bleeding
- General
- Gastro intestinal
- Bleeding multifactorial
- Coag factors ?
- Tpenia ?
- Physical site
8LIVER DISEASE
- Haemostatic Failure
- Therapy
- Underlying condition
- Vitamin K iv
- Replacement clotting factors
- FFP (Temporary)
- Half life II, V, VII, IX, X
- Volume
- Na Load
- Platelet infusions
- Avoid FIX concentrates !! ?? !!
- Thrombogenic
- Antifibrinolytics, role in upper GIT bleeding
- Liver transplant now an option
9DISSEMINATED INTRAVASCULAR COAGULATION DIC
- Defibrination Syndrome
- Consumption Coagulopathy
- Pathogenesis
- A trigger (thromboplastic) conditioning
factors RE block - Thrombin generation
- Intravascular coagulation
- Clotting factors platelet consumption
- FV, FVIII, fibrinogen, platelets ?
- Clinical Settings
- Childbirth, amniotic fluid embolus
- Septicaemia, meningococcus,
- Shock, trauma
- Incompatible transfusions
- Anaphylaxis
- Manifestations
- Bleeding Bruising
10DISSEMINATED INTRAVASCULAR COAGULATION
- Classification
-
- Acute Self limiting if correct Rx
-
- Chronic Self perpetuating
- Laboratory Tests
-
- FBC Anaemia Tpenia
-
- Coagulation PT ? (V ?)
-
- APTT ? (VIII ?)
-
- Fibrinogen ? D-Dimer ?
-
- Fibrinolysis (2º)
11DISSEMINATED INTRAVASCULAR COAGULATION
- Acute
- Therapy Remove trigger
- Correct conditioning factors
- Replace deficient factors
- Triggers Infection, Fetus, Trauma
- Conditioning factors Hypoxia O2
- Acidosis HC03
- Pregnancy
- Leukaemia (APML)
- Replace V VIII FFP /or FVIII cone
- Platelets Platelet infusions
- Inhibitors ATIII
- Chronic
- Therapy Malignant Remove
- Pre eclampsia Control
- Chronic infection Correct
- The debatable role of Heparin in DIC
12ANTICOAGULANT OVERDOSE
- Oral anticoagulants Warfarin
- Mechanism
- Vitamin K antagonists
- Inhibit reductase enzyme
- Vit K epoxide ? Vit K
- Inhibition of carboxylation of precursors of
- II, VII, IX, X
- Cant combine Ca Plipids for coagulation
- PIVKA
- Protein induced Vit K absence
- Precursors. Non COOH
13ANTICOAGULANT OVERDOSE
- Oral Anticoagulants - WARFAIN
- Monitoring
- Prothrombin Time
- II, V, VII, X
- NB Not monitoring FIX
- INR PR1SI
- Range INR
- DVT 2.3
- PE 2.5 - 3.5
- Heart valve 3 - 4
14ANTICOAGULATION OVERDOSAGE
- Oral Anticoagulants - Warfarin
- Warfarin Usage Long(er) Term
- Heart Valve
- Pulmonary emboli
- Recurrent DVT
- Thromboembolic
- Warfarin Overdose INR gt 5
- Risk of bleeding
- Haematoma
- Haematuria
- Intercranial
- Trauma
- Precipitating Factors Simple overdose. Monitoring
? - Intercurrent infection
- Antibiotic use
- Diet change
- Analgesics, eg. paracetemol
- C2H5OH XS
15ANTICOAGULANT OVERDOSE
- Heparin
- Mechanism
- IV Standard heparin. Short acting (1 1/2 hour)
- Combine with ATIII
- Inhibits thrombin, Fibrinogen - Fibrin
- Not clot bound thrombin
- Neutralised by PF4 on platelets
- Value, acute therapy of thrombosis
- SC LMW Heparin
- Delayed absorbtion. Smaller doses
- Prolonged action
- Specific anti Xa
- Value in prophylaxis
- Wider acceptance for therapy
- Monitor IV or Standard heparin
16ANTICOAGULANT OVERDOSAGE
- Heparin
- Heparin overdose
- Clinical Usually IV
- Administered by iv infusion pump
- Retroperitoneal bleeding - shock
- Intracranial bleeding
- Therapy Stop Heparin
- May administer Prot-SO4
- Weight for weight neutralisation
- 1mg P ? 1mg Hep - 100u
- Average dose - 10mg of Prot-SO4
- Often expectant Rx
- Mainly transfusion
17VITAMIN K DEFICIENCY
- Mechanism Essential co-factor synthesis of
- II, VII, IX, X
-
- Protein C
- Protein S
- Clinical
- Adults Rare
- Bowel resection
- Obstructive jaundice
- Sick prolonged iv, no suppls
- Children Neo nat
- Above
- Presentation Precipitously
- Bruising
- Tissue bleeding
- Intracranial haemorrhage - neonates
18CIRCULATING ANTICOAGULANTS
- FVIII Inhibitors Acquired
- Lupus like anticoagulant
- Anti phospholipid syndrome
- Anti cardiolipid antibody
- Lab Test Coagulation
- APTT ? IRN N
- Mixing ?
- FVIII ?
- FVIII Inhibitors
- Rare
- Major bleeding problems - subcutaneous
- Occur Elderly, spontaneous
- Post partum
- Autoimmune disorders
- Rheumatoid arthritis
- Therapy Difficult - Resistant
19CIRCULATING ANTICOAGULANTS
- Lumpus like inhibitor
- Occurs DLE
- Other autoimmune disorders
- Lab Test APTT ? INR N
- Mixing prolonged
- Lipids correct
- Clinical Not usually association with bleeding
- Thrombotic association, anomolous
- Therapy Surgery
- ? LMW heparin
- Ante Phospholipid Syndrome
- Recurrent miscarriages
20ACQUIRED DISORDERS OF PLATELET FUNCTION
- Thrombopathy Impaired platelet function
- in vitro ? in vivo
- Asprin effects Impair ADP release
- Bruising , bleeding post op
- Not reversible
- Cardiac situation
- Rx May need platelet infusions
- for surgery
- Uraemia Renal metabolite not excreted
- Platelet mal function
- Bruising bleeding
- ? Platelet infusion or Cryoprecipitate
- Paraproteins
21ACQUIRED DISORDERS OF PLATELET NUMBERS
- Thrombocytopenia
- Drug induced. Immune
- Chemotherapy suppression
- Drug Induced Quinine/Quinidine
- Acute Tpenia ? 5x10???
- Drug as haptene
- Therapy Stop drugs
- Steroids
- HEPARIN INDUCED TPENIA THROMBOSIS
- 2-3 people with iv Heparin
- Antibody IgG to PF4 platelet complex
- Thrombin generation - thrombosis
- Tpenia
- Therapy Regular platelet counts