Rebalanced Hemostasis Basics Flashcards
(20 cards)
What is rebalanced hemostasis?
In liver disease, the procoagulant and anticoagulant pathways decline simultaneously, resulting in a newer neutral/balanced effect, which is very delicate.
What are the implications of rebalanced hemostasis in terms of surgery?
Patients usually don’t need product support for surgery but may end up with bleeding or thrombotic complications.
What are some risk factors that can alter the balance in rebalanced hemostasis?
Variceal bleed, uremia, infection, etc.
What productos are used in the treatment of patients with rebalanced hemostasis?
FFP
Low-volume coagulation factor concentrates
Antifibrinolytic agents
What do PT and PTT show in rebalanced hemostasis?
Frequently prolonged
It is common practice to prophylactically correct hemostatic abnormalities in patients with liver disease before invasive procedures by administration of blood products guided by the prothrombin time and platelet count. Is this apprpriate?
Not evidence-based
How is liver involved in platelet production?
Produces thrombopoietin
List 4 reasons why liver patients may bleed or clot
Decreased thrombopoietin production leads to decreased platelet production, thrombocytopenia
Decreased clotting factor synthesis
Increased intravascular activation of hemostasis leads to consumption of clotting factors and platelets
Constant low level systemic activation of endothelial cells means continual release or productionof vwf, other clotting proteins.
Portal hypertension activates endothelial cells and also contributes to splenomegaly and consequent platelet sequestration/pooling leading to thrombocytopenia.
You see that a pre-op patient has prolonged PT and PTT as well as thrombocytopenia but they are also a liver patient. What is your approach?
Although results suggest a bleeding diathesis, avoid prophylactic correction of prolonged PT and APTT with fresh-frozen plasma (FFP). If patient is actively bleeding, that’s a different scenario.
You see that a pre-op patient has prolonged PT and PTT as well as thrombocytopenia but they are also a liver patient. What is your approach?
Although results suggest a bleeding diathesis, avoid prophylactic correction of prolonged PT and APTT with fresh-frozen plasma (FFP). If patient is actively bleeding, that’s a different scenario.
Describe the hemostatic profile of a patient with liver failure.
Decreased:
Platelet count
coagulation factors
anti- fibrinolytic proteins
plasminogen
Factor VIII & VWF
Adamts13
Increased:
PT
PTT
tPA, PAI-1, NO, prostacyclin
Dysfunctional:
fibrinogen (dysfibrinogenemia)
Platelet function defects
How does coagulopathy of acute liver failure differ from that of chronic liver failure/cirrhosis?
In acute liver failure, thrombocytopenia is less common, coagulation factors are more severely decreased, and fibrinolysis is decreased
Hemostatic differences between patients with cholestatic and noncholestatic liver disease?
In patients with cholestatic liver disease the hemostatic balance is generally more preserved due to normal/ hyperreactive platelets, and preserved plasma coagulation factors
Hemostatic differences between patients with cholestatic and noncholestatic liver disease?
In patients with cholestatic liver disease the hemostatic balance is generally more preserved due to normal/ hyperreactive platelets, and preserved plasma coagulation factors
Two causes of thrombocytopenia in liver patients?
Splenic sequestration
Decreased TPO production
Platelets used up in clotting due to endothelial activation
Most common bleeding complication in cirrhosis?
Varices
How can FFP contribute to bleeding in liver patients?
Elevates venous pressure
What percentage of liver patients develop DVT or PE?
0.5-2%
What contributes to increased thrombotic risk in cirrhosis?
Decreased portal flow
Prothrombin mutation
What pro and anticoagulant factors are synthesized in the liver?
