Coagulation Disorders and Anesthesia-Basic pathophysiology

COAGULATION DISORDERS AND ANAESTHESIA PRESENTERS: DR UNNIKRISHNAN P DR SUNEESH THILAK CO-ORDINATOR DR C MADHUSOODHANAN PILLAI MODERATORS: DR GEETHA N K DR ASHA K S

What is normal hemostasis? ,[object Object],[object Object]

Components of hemostasis Interactive

Components: vascular Intact endothelium: Non-thrombogenic (-) (-)

Components: vascular Endothelial damage: (+) (+) Stress hormones Trauma Surgery Plaque rupture Inflammation… ,[object Object],[object Object]

The first event….. ,[object Object],[object Object],[object Object],[object Object]

So the well equipped guy comes ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Components: platelets Adhesion Activation Aggregation Secretion Procoagulant activity

Endothelial damage: Platelet plug formation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

No one can hide the insults from them…… ,[object Object],[object Object],[object Object],[object Object]

Leads to…. PRIMARY HEMOSTASIS ,[object Object]

The balancing act ,[object Object],[object Object],[object Object],[object Object]

In need of…. FIBRIN ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Prompt………. But finely controlled ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

For example… ,[object Object],xii------>xii a Ca

Components: coagulation pathways Extrinsic (TF) Intrinsic Initiation Amplification Thrombin Pivotal point of coagulation

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Thrombin generation to fibrin-platelet clot formation

Cascade vs. cell-based model ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Tissue factor bearing cells 1. Initiation Platelets Activated platelets 2. Amplification 3. Propagation IIa IIa

Cellular components ,[object Object],[object Object],[object Object],[object Object]

Molecular components ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Normal Hemostasis Hoffman et al. Blood Coagul Fibrinolysis 1998;9(suppl 1):S61 . X II II X IX TF-Bearing Cell Activated Platelet Platelet TF VIIIa Va VIIIa Va Va VIIa TF VIIa Xa IIa IX V Va II VIII /vWF VIIIa IXa X IXa IXa VIIa Xa IIa IIa Xa

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Endothelial damage: Initiation of thrombin generation ,[object Object],Exposure to tissue factor Initiation of extrinsic pathway Initiate thrombin generation Activate FXI (intrinsic pathway) Amplify thrombin generation

Soldiers….. I FIBRINOGEN II PROTHROMBIN III THROMBOPLASTIN/TISSUE FACTOR IV CALCIUM V PROACCELERIN/LABILE FACTOR VII PROCONVERTIN/STABLE FACTOR VIII ANTIHAEMOPHILIC FACTOR A IX ANTIHAEMOPHILIC FACTOR B X STUARTPROWER FACTOR XI ANTIHAEMOPHILIC FACTOR C / PTA XII HAEGEMAN FACTOR / GLASS FACTOR XIII FIBRIN STABILIZING FACTOR PREKALLIKREIN / FLETCHER FACTOR KALLIEKREIN PLATELET PHOSPHOLIPID … They work in concert to form a beautiful definitive clot!

Clot: The end product of hemostasis

The rebels…. ,[object Object],[object Object],[object Object]

Antithrombin iii ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Protein C & Protein S ,[object Object],[object Object]

TFPW-inhibitor ,[object Object]

Two more… ,[object Object],[object Object],[object Object],[object Object],[object Object]

Serine Proteases ,[object Object],[object Object],[object Object],[object Object],[object Object]

Cofactors ,[object Object],[object Object],[object Object],[object Object],[object Object]

VITAMIN-K dependent Factors ,[object Object]

Question hour in AAC INFANCY SURGERIES FAMILY HISTORY DRUGS HORMONAL REPLACEMENT / OCP HISTORY OF BLEEDING IN THE PAST

What to look for…? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Surgery induces an increase in.. ,[object Object],[object Object],[object Object],[object Object],[object Object]

These factors arise concern about the hemostasis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

MONITORING HEMOSTASIS ,[object Object]

Feel.. There is no plan to stop ,[object Object]

Monitoring hemostasis Cascade vs. cell-based model ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

BLEEDING TIME ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Platelet count ,[object Object],[object Object],[object Object],[object Object]

Prothrombin Time ,[object Object],[object Object],[object Object]

Prothrombin Time Intrinsic Pathway Extrinsic Pathway Common Pathway CLOT PT

What is INR? ,[object Object],[object Object],[object Object],[object Object]

Prolonged??? Think of…. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

aPTT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Activated Partial Thromboplastin Time Intrinsic Pathway Extrinsic Pathway Common Pathway CLOT APTT

Thrombin Time ,[object Object],[object Object],[object Object],[object Object],[object Object]

Thrombin Time Intrinsic Pathway Extrinsic Pathway Common Pathway CLOT TT

CLOTTABLE FIBRINOGEN CONCENTRATION ,[object Object],[object Object]

Activated clotting time ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Activated Clotting Time Intrinsic Pathway Extrinsic Pathway Common Pathway CLOT ACT

Thromboelastography ,[object Object],[object Object]

The TEG® System ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

PLOT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Application of TEG analysis ,[object Object]

TEG analysis and clinical outcomes ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

???? ,[object Object],[object Object],[object Object],[object Object],Next

Platelet function analyzers ,[object Object],[object Object]

Still not over…?$# ,[object Object]

DISORDERS OF COAGULATION ,[object Object]

DISEASE OF KINGS ,[object Object]

What is Hemophilia? ,[object Object]

Degrees of Severity of Hemophilia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Types of Bleeds ,[object Object],[object Object],[object Object],[object Object],[object Object]

Life-Threatening Bleeding ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Investigations… ,[object Object],[object Object]

8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Recommendations SOFT TISUE BLEED- 15 TO 20 % HEMARTHROSIS/RETROPERITONEAL-25-50% x72h MAJOR Sx/ LIFE THREATENING BLEED- 50% x2 wk

These should be kept in mind..

Iron deficiency anemia ???? ,[object Object],[object Object]

Anesthetic Implications ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Hemophilia B ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

=….HEMOPHILIA B ,[object Object]

Any factor concentrate for exhausted audience..???

Who am I ? ,[object Object],[object Object],[object Object]

vWD 1/100-500 10mg/L AUTOSOMAL DOMINANT Affect PLATELET adhesion

Treatment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Hereditary Haemorrhagic Telengiectasia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Can our routine tests detect a fibrinolytic defect? ,[object Object],[object Object],[object Object],[object Object]

HYPERCOAGULABLE STATES ,[object Object],[object Object],[object Object]

What’s it? ,[object Object],[object Object],[object Object],[object Object],[object Object]

Protein C Deficiency ,[object Object],[object Object],[object Object],[object Object],[object Object]

Antiphospholipid antibody syndrome

Strategy ?? ,[object Object],[object Object],[object Object]

References ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

… ,[object Object],[object Object],[object Object],[object Object],[object Object]

Coagulation Disorders and Anesthesia-Basic pathophysiology

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Coagulation Disorders and Anesthesia-Basic pathophysiology