Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC, CNRN, CEN, NP

Education Specialist

LRM Consulting

Nashville, TN

ObjectivesIdentify the most likely type of

coagulopathy with regards to INR, aPTT, platelet numbers and function.

Discuss the four causes of thrombocytopenia.

Describe the priorities in the management of patients with life – threatening coagulopathies.

Admission Screening • identify defects in

hemostasis that can be corrected

• guide the management of hemostatic defects that cannot be corrected

• help manage the bleeding that cannot be prevented

Preoperative Screening • History & Physicalunlikely congenital or familial

coagulopathy– no personal or family history

of bleeding– no abnormal bleeding

associated with:• dental extractions• previous surgery• routine childhood trauma

Preoperative Screening • CBC

– Hgb/Hct – platelets

• PT/PTT• Bleeding Time

Admission Screening • Assessment of Coagulopathy

– CBC with coagulation studies– check for and correct

hypothermia– review the history– review medications

Symptom INR aPTT Platelet # PlateletFunction

History Diagnosis

Major/minorbleeding

N N N Massive transfusion;

fluids

Dilutional thrombocytopenia

Major/minorbleeding

N Prolonged N N negative Drug induced - heparin

Major/minorbleeding

N N n/a Vitamin K deficiency

Liver disease, warfarin, antibiotics

Major bleeding

prolonged prolonged N DIC

Postoperative Bleeding

•Vascular integrity disruption–reoperation

Medical Causes of Bleeding • residual heparin effect• platelet consumption (CPB)• preoperative platelet

inactivation

Protamine Reactions • Type I

– benign reaction– Histamine release

systemic hypotension– administer protamine

slowly

Protamine Reactions • Type II

– anaphylactoid reaction– occurs within 10 to 20

minutes of administration– symptoms

• hypotension• flushing• edema• bronchospasm

Protamine Reactions • Type III

– catastrophic pulmonary vasoconstriction

• elevated pulmonary pressures• cardiopulmonary collapse• noncardiogenic pulmonary

edema

– reaction occurs between 10 to 20 minutes after start of administration

Medical Causes of Bleeding • depletion of clotting factors• pre-existing coagulopathy• fibrinolysis

•Thrombocytopenia– platelet destruction

•drug – induced•DIC

Differential diagnosis

• A platelet count fall that begins 5 to 10 days after cardiac surgery or that occurs abruptly after starting heparin in a patient previously exposed to heparin within the past 5 to 100 days, is very suggestive of HIT.

•Thrombocytopenia– Etiology

•abnormal distribution or sequestration in spleen

–portal hypertension

•Thrombocytopenia– Etiology

•dilutional after hemorrhage, RBC transfusions

•Thrombocytopenia– Diagnosis

hemoglobin,hematocrit, platelets

•prolonged bleeding time, PT, PTT

Definition•serious bleeding

disorder• thrombosis; then

hemorrhage

Disseminated Intravascular Coagulation

Pathophysiology• Intrinsic Clotting

Cascade–endothelial injury

–assessed by PTT

Pathophysiology•Extrinsic Clotting

Cascade–tissue thromboplastin

–assessed by PT

Etiology of DIC•Obstetric

–abruptio placentae

–amniotic fluid embolus

–eclampsia

Etiology of DIC•Hemolytic/Immunologic

–anaphylaxis–hemolytic blood reaction–massive blood transfusion

Etiology of DIC• Infectious

–bacterial–fungal–viral–rickettsial

Etiology of DIC• Vascular

–shock–dissecting aneurysm

Etiology of DIC• Miscellaneous

– Emboli (fat)– ASA poisoning– GI disturbances -

pancreatitis

Laboratory Findings

• platelets• fibrinogen• PT &/or PTT• d - dimer or FSP• ATIII

Management•Treat underlying

cause–surgery–antimicrobials–antineoplastics

Management•Stop Thrombosis

– IV heparin–AT III–plasmapheresis

Management•Administer blood

products–pRBCs–platelets–FFP–cryoprecipitate

Complications•hypovolemic shock

•acute renal failure•infection•ARDS

Postoperative Bleeding •Platelet Dysfunction

–Platelets–FFP/cryoprecipitate–DDAVP

Postoperative Bleeding •Coagulation Factor Deficiency–FFP/cryoprecipitate–protamine

Postoperative Bleeding

•Hyperfibrinolysis–DDAVP–Antifibrinolytics

•Amicar

Case Study• 62 – year old male• admitted to CVICU

post bypass • complications

postop (tamponade) – stabilized & on IABP

• required CPR several times

Case Study• 3 days later

diminished leg circulation – IABP removed

• pneumonia, groin infection, renal failure

• step – down develops sternal wound infection

Lab Values• ABGs

pH 7.26

pO2 55

pCO2 52

HCO3 18

SaO2 84%

CV Status

BP 88/56

MAP 67

CVP 4

ECG ST

T 39.2°C

Case StudyHgb/Hct 8.8 / 30%PT 38 secondsFibrinogen 102 mg/dLPlatelets 50,000/mm3

D – dimer > 2500 ng/dL

FSP 80 mcg/dL

IN CONCLUSION