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FRCPath Haematology Part 2 > Haemostasis > Flashcards

Haemostasis Flashcards

1
Q

Splanchnic vein (PV, Budd Chiari, mesenteric)

Aetiology

A

Cirrhosis, inflammation, malignancy

If no cause clear do MPN and PNH screen - 30% PV, 50% BC

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2
Q

Splanchnic vein (PV, Budd Chiari, mesenteric)

Management

A

Anticoag

Cirrhosis
Start LMWH
Convert warfarin
Consider DOAC in compensated CP A-B
Duration 3-6mo, lifelong if no bleeding

Malignancy
LMWH for intraluminal cancer, otherwise DOAC

Other aetiology
DOAC 3-6 months, long term in MPN or PNH or BC

Check varices

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3
Q

Haemophilia prophylactic dosing

A

2nd/3rd gen factor
20-40 IU/kg EOD

Modify for sports etc

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4
Q

Time off dabigatran pre-procedure

A

Low risk procedures
CrCl
>80 - 1d
>50 - 1.5d
>30 - 2d

High risk procedures - double duration

NO NEED FOR LMWH!

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5
Q

Time off DOAC pre-procedure

A

Low risk procedures
CrCl
>80 - 1d
>50 - 1d
>30 - 1d
>15 - 36h

High risk procedures - 48 for all

NO NEED FOR LMWH!

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6
Q

ISTH definition major bleeding on anticoag

A

Fatal bleeding
Symptomatic bleeding in critical site (brain/spine/eye/retroperitoneal/joint/compartment syndrome)
Fall Hb >20g/L or needs 2x RBC transfusion

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7
Q

Anticoagulation in extreme obesity

A

ISTH 2022
DOAC for all
No need for peak and trough levels
Dose reduction after 6 months possibly bad

Bariatric surgery - no DOAC for 4 weeks, consider using trough levels thereafter

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8
Q

DOAC dosing per renal function

A

Dabigatran
CrCl
>50 - 150mg BD
>30 - 110mg BD
<30 - stop

Rivaroxaban
>50 - 20mg OD
>15 - 15mg OD

Apixaban
>30 - 5mg BD
>15 - 2.5mg BD

Edoxaban
>50 - 60mg
>15 - 30mg

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9
Q

DOAC choice GI surgery

A

LMWH for 4 weeks
Then apix or riva with trough levels
Or VKA

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10
Q

Recurrent VTE on anticoag

A

Cancer
APLS
Pregnancy
COCP
MPN
PNH
Inflammatory disease
Behcets syndrome

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11
Q

Emicizumab

A

Cross links F9 and F10
Approved for prophylaxis in severe with or within inhibitors
SC fortnightly
NOT for bleeding
Must use chromogenic F8 or Bethesda
APTT should be short or normal
Long APTT might mean anti-emi ab
FEIBA contraindicated
Avoid high dose novoseven

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12
Q

DRVVT - process

A

RVV potent FX activator in presence of PL
Lupus anticoagulant antibody presence inhibits ability to activate FX
Measure clotting time between patient and reference plasma
If LA is present the patient sample will take longer than reference plasma
If ratio in clotting time is >1.05 LA May be present
Then calculate %correction when excess PL added
Excess PL mops up lupus anticoag
If correction brings time down to close to 1 then LA is likely (correction more than 10%)
If no correction then likely a factor deficiency

2nd test then needed - diluteAPTT or silica clotting time

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13
Q

APTT process

A

PPP
Incubate 2 min kaolin (contact activator) + phospholipid
Add calcium
Measure time to clot

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14
Q

Prolonged APTT differential

A

Factor def
Lupus Anticoag

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15
Q

Mechanism UFH

A

Changes AT - Potentiates effect against 10, 2, 9, 11, 12
Plus others

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16
Q

What is ISI?

A

Correction factor used to generate INR from PT and reference PT
(Ratio raised to ISI)
ISI derived from comparing reference thromboplastin to test reagent
Usually provided by manufacturer

ISI sets the reference range for PT

17
Q

How does anti-Xa assay work?

A

Measures ability of bound anti-thrombin to inhibit FX

Incubate sample with FXa
FXa is inactivated by drug
Measure residual FXa with chromogenic reaction
Compare to standard curve
Independent of patient clotting Fs

18
Q

Clauss Fn process

A

Plasma mixed with high conc thrombin
Thrombin activates clotting
Fn the rate limiting step
Measure clot time

19
Q

Thrombin time

A

Mix plasma with low conc thrombin
Thrombin activates clotting
Measure clot time

20
Q

ISTH DIC score

A

Plt: >100 - 0 points / >50 - 1 points / <50 - 2 points

PT: <3s over - 0 points / 3-6s over - 1 point / >6s over - 2 points

Fibrinogen: >1 - 0 points / <1 - 1 point

D-dimer: normal - 0 points / 250-5000 - 1 point / >5000 - 2 points

21
Q

Unselected stroke patient with single pos APLS

A

Aspirin
i.e. manage as a normal stroke

Unless <50yrs - May benefit from warfarin

22
Q

Indication for PNH anticoag

A

Previous VTE
Any clone size >50%

Use warfarin INR 2.5

23
Q

DOAC peri-op

A

See other card

24
Q

Apixaban extension trial

A

Apix 2.5mg BD after 6/12 treatment VTE
Less clinically relevant bleeding vs full dose
Same rate repeat thrombosis
No change survival

25
Q

NG158

When to test for thrombophilia

A

Unprovoked VTE if planning to stop anticoag - test APLS

Hereditary screen if history of VTE in first degree relative and unprovoked VTE

26
Q

VWD inheritance

A

2N and 3 are AR
Rest are AD (with occasional exceptions)

27
Q

VWD T1 Vicenza genetic mutation

A

R1205H

Can’t give DDAVP due to short response

28
Q

VWD major surgery

A

Specialist centre
Documented plan
TXA
Trough F8:C and VWF:RCo 0.8-1.0 for 48 hours
Trough F8:C and VWF:RCo >0.5 for 7 days
Peak F8:C <150
Give thromboprophylaxis
Routine intraop care
Regular haem review

29
Q

Risk factors for F8 inhibitors

A

Race
FHx
Gene mutation
MHC class

Exposure days
Age at first exposure
Type of concentrate

30
Q

Andy haemophilia surgery plan

A

Tertiary centre
MDT involvement
Review desmopressin response if relevant
Documented plan
TXA
Relevant factor trough 0.8-1.0 for 3 days
Then >0.5 for 1 week
Routine haem review peri-op
VTE prophylaxis while IP and factor replaced

31
Q

Glanzmann clinical details

A

Platelets normal
Clotting screen normal
CD41/CD61 expression absent (GP IIb/IIIa)
Severe bleeding phenotype
Managed with TXA, HLA-selected platelets
Novoseven
Can make anti-CD41/61 abs (bad!)

32
Q

Bernard Soullier clinical details

A

Deficient CD42b
Platelet count low, large (differential for MYH9)
Mild-mod bleeding phenotype
Absent ristocetin response
Manage with TXA, random platelets
GP9 gene mutation

33
Q

Wiskott Aldrich clinical details

A

Severe eczema
Immune deficiency
Low MPV
Low platelet count
WASP Gene abnormality

34
Q

Gray platelet syndrome clinical details

A

Moderate bleeding phenotype
Mild-moderate thrombocytopenia
Gray platelets
Alpha granule disorder
Predisposition to MF

35
Q

Fibrinolytic defects

A

Factor 13 def
PAI-1 def
TAFI def
a2-antiplasmin def

Cause late bleeding

36
Q

How to monitor thromboprophylaxis in AT def

A

Anti-Xa 0.2-0.4
Assay WITHOUT exogenous antithrombin

37
Q

DOAC doses

A

See other card

FRCPath Haematology Part 2 (11 decks)

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