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R9 > Chapter 37 - Coagulopathy and hemorrhage > Flashcards

Chapter 37 - Coagulopathy and hemorrhage Flashcards

1
Q

Rapaport 4 level risk stratification scheme for bleeding disorder

A

LEVEL 1 = no history no signs LEVEL 2 = no history but major operation LEVEL 3 = history raise concerns LEVEL 4 = highly suggestive history

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2
Q

Pre-operative assessment based on Rapaport 4 level risk stratification

A

LEVEL 1 = no test LEVEL 2 = aPTT, plt count LEVEL 3 = bleeding time, plt count, PT, aPTT, test factor 13 and fibrinolysis screening LEVEL 4 = bleeding time after ASA (wWD or plt disorder), factor 8 and 9 levels, TT (dysfibrinogenemia)

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3
Q

Proper blood to citrate ratio when drawing blood

A

9:1 tests done within 2 hr if room temp 4 hours if 4C

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4
Q

Test of coagulation and clinical uses

A

TABLE 37.1

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5
Q

Bleeding time cut off

A

5 min = abnormal

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6
Q

Euglobulin lysis time (ELT)

A

1) assess global function of plasma fibrinolytic system 2) time required for clot to lyse in tube 3) normal 90-240 min 4) help to differentiate primary fibrinolytic state from DIC

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7
Q

wWF function

A

1) bind platelet and endothelial component 2) contribute to clot formation 3) carrier protein for factor 8

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8
Q

wVD incidence

A

1% of population only 5% affected as symptomatic worse if taking antiplatelet or NSAID

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9
Q

Types of vWD

A

TABLE 37.2

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10
Q

tests for vWD

A

TABLE 37.3

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11
Q

Giant platelet disorders

A

1) Bernard-Soulier syndrome - structural defect 2) May Hegglin anomaly - abnormal neutrophil inclusion 3) Hereditary macrothrombocytopenia with hearing loss 4) Mediterranean macrothrombocytopenia - non-specific

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12
Q

Bernard Soulier syndrome

A

1) thrombocytopenia 2) large platelets 3) bleeding 4) dysfunction or absence of GP-Ib/IX/V complex 5) treat with platelet transfusion

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13
Q

Glanzmann’s thrombasthenia

A

1) Defect GP-IIb/IIIa 2) platelet attach to endothelium but cannot aggregate 3) mucocutaneous bleeding

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14
Q

Platelet dense granules

A

ADP, serotonin

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15
Q

Gray platelet syndrome

A

1) Alpha-granule storage disorder 2) bleeding, moderate thrombocytopenia and prolonged bleeding time 3) preprocedural DDAVP and plt transfusion as treatment

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16
Q

Platelet dense granule storage disorder

A

1) Chédiak-Higashi syndrome 2) Wiskott-Aldrich syndrome 3) thrombocytopenia-absent radius syndrome

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17
Q

Wiskott-Aldrich syndrome

A

1) X-chromosome linked immunodeficiency 2) thrombocytopenia 3) eczema 4) defect glycoprotein L115 = unable to aggregate 5) treat = bone marrow transplant

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18
Q

Factor 8 half life

A

12 hours protected from premature degradation by vWF

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19
Q

Hemophilia bleeding along the coagulation stages

A

Secondary hemostasis failure platelet plug forms but fibrin plug defective

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20
Q

Mild moderate and major hemophilia

A

Mild: factor 8 or 9 level 5-40% normal moderate: 1-5% normal Severe: < 1% normal

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21
Q

Hemophilia A, B, C

A

A = X-linked deficiency Factor 8 B = X-lined Factor 9 C = Autosomal Factor 11

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22
Q

Treatment of hemophilia

A

1) DDAVP 2) factor 8 or 9 concentrates 3) activated prothrombin complex concentrates

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23
Q

Uremia effect on hemostasis pathway

A

1) intrinsic platelet defects 2) alteration of platelet-endothelial interaction 3) treatment = DDAVP, transfusion, estrogen, dialysis

24
Q

Molecular causes of DIC

A

uncontrolled production of thrombin leads to systemic intravascular deposition of fibrin

25
Q

Diseases that cause DIC

A

TABLE 37.4

26
Q

Coaguation parameteres in DIC

A

TABLE 37.5

27
Q

Fibrinogen target in DIC

A

> 100 mg/dl

28
Q

Primary fibrinolysis

A

1) pathologic direct activation of plasminogen 2) plasmin overwhelms PAI-1 and alpha 2 antiplasmin 3) cleaves fibrin and clotting factors 5, 8 4) excessive thrombin generation as counter measure 5) microvascular thrombosis

29
Q

Causes of primary hyperfibrinolytic state

A

1) malignancy 2) liver failure 3) trauma 4) congenital deficiency of fibrinolysis inhibitors

30
Q

Differentiating DIC from primary fibrinolysis

A

PRIMARY FIBRINOLYSIS HAS 1) Short euglobulin lysis time 2) no thrombocytopenia 3) schistocytes

31
Q

Treatment of fibrinolysis

A

1) lysine analogues 2) factor replacement, 5, 8

32
Q

Heparin molecule

A

1) sulfated glycosaminoglycan 2) binds and activates antithrombin

33
Q

Half life of heparin

A

SC 8 hours IV 1.5 hours

34
Q

Reversal of heparin

A

protamine 1 mg / 100 Units

35
Q

Direct thrombin inhibitors

A

TABLE 37.6

36
Q

Treatment of warfarin induced skin necrosis

A

Stop warfarin IV heparin

37
Q

Off label use of DOAC reversal

A

1) prothrombin concentration complex (PCC) 2) recombinant factor 7a

38
Q

ASA effect

A

inactivate platelet cyclooxygenase –> blocks thromboxane A2 production

39
Q

Clopidogrel and ticlopidine effect

A

block ADP receptor –> reduce GPIIb/IIIa expression

40
Q

Abciximab and eptifibatide effect

A

block GPIIb/IIIa short half life so return to normal 24-48 hours

41
Q

P2Y12 receptor antagonists

A

IV (elinogrel, cangrelor ORAL (ticagrelor, elinogrel)

42
Q

Blood transfusion products for hemostasis

A

TABLE 37.7

43
Q

Cautery setting

A

Cutting (continuous) = high current density –> heat rapidly vaporization Coag (interrupted) = less heat and produce coagulum

44
Q

Ligasure

A

Bipolar electrocautery with pressure application Fuse collage and elastin in vessel wall

45
Q

Argon beam coagulator

A

Monopolar with stream of argon innerg gas disperses pooled blood arcing of current to produce diffuse coagulation

46
Q

Tissuelink device

A

Combines radiofrequency with continuous saline irrigation can cause steam popping which is undesirable

47
Q

Pusateri description of ideal topic hemostatic

A

1) stop bleeding within 2 min even in pooled blood 2) ready to use without mixing 3) apply with minimal training 4) lightweight and durable 5) easy to store and last long 6) safe to use without infection risk 7) cheap

48
Q

Gelatin foam key points

A

1) Gelfoam 2) absorbed within 4-6 weeks 3) non-antigenic 4) pH neutral so can use with thrombin

49
Q

Oxidized cellulose key points

A

1) surgicel 2) trimmable 3) applied dry 4) decreases pH cannot be used with thrombin 5) hematin generation from RBC lysis discolors this

50
Q

Microfibrillar collagen

A

1) powder, sheet, sponge, pad 2) hemostasis 2-5 min with platelet aggregation 3) cannot return blood back to patient because materials pass through filters

51
Q

Polysaccharide spheres

A

1) Arista, trauma Dex 2) absorb plasma/blood to concentrate clotting factors and platetes 3) swells and contains high sugar

52
Q

Active hemostatic agents

A

1) thrombin liquid/gel 2) thrombin solid

53
Q

Sealants types

A

1) Tisseel - fibrinogen, thrombin, calcium + aprotinin 2) Evicel - firinogen, thrombin 3) Floseal - bovine collagen, microgranules, glytaraldehyde, human thrombin 4) dry fibrin sealant - gauze with fibrinogen and thrombin 5) tissue glue - glutaraldehyde with bovine serum

54
Q

Newer hemostatic agents

A

1) Chitins: stimulate coagulation and agglutination; generate thrombin and fibrin 2) Chitosan: deacetylated chitin 3) Mineral zeolite: absorb water, concentrate factors and activate factor 12; exothermic 4) lysine analogues

55
Q

Types of hemostatic agents

A

Mechanical 1) gelatin 2) oxidized cellulose 3) microfibrillar collage 4) polysaccharide spheres Active agents 1) synthetic or plasma derived Sealants 1) polyethylene glycol 2) fibrin sealants 3) thrombin sealants 4) bovine-derived factors New agents 1) chitin 2) chitosan 3) mineral zeolite 4) lysine analogues

56
Q

Management of perioperative bleeding flow chart

A

FIGURE 37.1

R9 (200 decks)

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