Transcript Coagulation and cardiac ITU

Coagulation
and
cardiac ITU
2 Approaches
1. Understand and treat appropriately
2. Give platelets and FFP
Overview
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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
• Why have it ?
• What stops it working ?
• What causes its activation ?
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
• Factor X11
Factor X11a
• Factor X1
Factor X1a
factor V111
• Factor 1X
Factor 1Xa
Factor V11
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Factor X
• Prothrombin
Thrombin
• Fibrinoigen
Fibrin monomer
• Factor X111
PL, Factor V & Ca2+
Fibrin polymer
How it works 3 – The platelet
Thrombin
PAR-1 AP
Adrenaline
ADP Collagen
Aprotinin
PAR-1 receptor
G protein
PMA
PKC
Ca2+ Flux
Platelet
Platelet aggregation
How it works 4 Thrombin
Soluble factors
Thrombin
Platelet
Clot
Drugs that affect coagulation
• Bleed
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Aspirin
Warfarin
Heparin / LMWH
Clopidogrel / Ticlopidine
ReoPro / Integrilin
Steptokinase / Alteplase
Non steroidal anti inflammatory drugs
• Clot
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Protamine
Tranexamic acid
Aprotinin
Vit K
Aspirin
TxA2
Platelet
PgI2
Endothelium
Warfarin
• Inhibits Vitamin K
• Factors 11, V11, 1X, and X
• Factor 11 most important “thrombin”
Soluble factors
Thrombin
Platelet
Clot
Heparin / LMWH
• Complex molecule of multiple sugars
molecules
Thrombin
Heparin
AT 111
Clopidogrel / Ticlopidine
Thrombin
PAR-1 AP
Adrenaline
ADP Collagen
Aprotinin
PAR-1 receptor
G protein
PMA
PKC
Ca2+ Flux
Platelet
Platelet aggregation
ReoPro / Integrilin
Platelet
GP 11b/111a
Platelet
GP 11b/111a
Fibrin
Steptokinase / Alteplase / TPA
Steptokinase / Alteplase / TPA
Plasmin
Plasminogen
Fibrinogen
Fibrin
Coagulation cascade
Fibrin
Degradation
products
Non steroidal anti inflammatory
drugs
TxA2
Platelet
PgI2
Endothelium
Protamine
Heparin
Protamine
Inactive complex
Tranexamic acid
Plasmin
Plasminogen
Fibrinogen
Fibrin
Coagulation cascade
Fibrin
Degradation
products
Tranexamic acid
Aprotinin
• Kallikrein Kinin inhibitor
• PAR-1 antagonist
• Anti fibrinolytic
• Multiple different doses
• Full dose / half dose / pump prime
Vit K
• Slow IV
• Liver disorders
Effect of CPB on coagulation
• Soluble factors
– Consumption
– denatured
• Platelets
– Consumption
– Desensitisation
Medical conditions that affect
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Drugs
Renal / liver failure
Haemophilia
Christmas disease
Von Willebrands
Drugs
• Discussed already
Renal failure
• Platelets don’t work
• Uraemia
Liver failure
•All clotting factors other than V111
produced in liver
Haemophilia / Christmas disease
• Factor X11
Factor X11a
• Factor X1
Factor X1a
factor V111
• Factor 1X
Factor 1Xa
Factor V11
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Factor X
• Prothrombin
Thrombin
• Fibrinoigen
Fibrin monomer
• Factor X111
PL, Factor V & Ca2+
Fibrin polymer
Von Willebrands
Platelet
Factor V111
vWF
Endothelium
Tests of coagulation
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PT / INR
APPT
Fibrinogen
D-Dimer
ACT / KCT
• Platelet function tests / thromboelastography
Assessing the bleeding patient
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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
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Surgical factor VII (prolene 7-0)
FFP
Cryoprecipitate
Specific isolated factors
Platelets
Blood / Hb
FFP fresh frozen plasma
• All soluble clotting factors except 1 and
V111
Cryoprecipitate
• Fibrinogen
• vWF
• V111
Platelets
• Depends on preop med’n, count and
operation
• Specific isolated factors
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1
V111
1X
vWF
• Blood / Hb