1 / 24

A Case, and Something About It.

A Case, and Something About It. A patient with antithrombin III deficiency Preoperative evaluation of coagulation disorder. R1, SU HUNG CHANG. The Case. 66 year-old female antithrombin III deficiency with DVT history HTN, DM, CRF Family History : DVT Long-term oral anticoagulation.

jeffreyfontenot
Download Presentation

A Case, and Something About It.

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. A Case, and Something About It. • A patient with antithrombin III deficiency • Preoperative evaluation of coagulation disorder R1, SU HUNG CHANG

  2. The Case • 66 year-old female • antithrombin III deficiency with DVT history • HTN, DM, CRF • Family History : DVT • Long-term oral anticoagulation

  3. General weakness, malaise, soreness since late June • Multiple migratory aching • Fever

  4. Treating Course • 6/25 : admitted to 淡水馬偕 • Blood Culture : MRSA (+) • Image : abscess over R’t psoas muscle; ostemyelitis was noted. • Conservative treatment

  5. 7/15 : transferred to NTUH • 7/29 : Tarry stool (+) : coumadin suspended • PES : duodenal ulcer • No improvement; surgical management is indicated

  6. 某不具名的骨科住院醫師 負責其primary care的住院醫師 手術過程很順利, 對於病人有antithrombin III deficiency 這個因素, 並沒有發現在術中有特別的影響。 • 當初進行手術的indication, 在術後皆達到解決, 目前病人的復原情形大致良好。

  7. Why this case ? • Role of coagulation • Between anesthesia and coagulation • What can we do ?

  8. Preoperative Assessment of Coagulation Disorder • Miguel Cobas, MD • Int Anesthesiol Clin (39-1), 2001: p.1-15

  9. A Balance • The Vascular Compartment • Circulating blood platelets • Coagulation proteins

  10. Thrombin : the most important coagulation modulator Antithrombin III : the major physiological inhibitor of coagulation

  11. Bleeding or not bleeding, that is the question. • Personal History • Family History • Medication • Physical Examination

  12. The Evidence Speaking... • The platelet count was abnormally low in less than 1.5% of patients, and further work-up rarely revealed any significant hematological abnormality. • The PT and PTT were abnormal in 4.8% and 15.6% of patients, respectively. • The PTT had no ability to predict the occurrence or absence of hemorrhage in a low-risk group, but it was a predictor of modest strength in the high-risk group. Munro et al. : Health Technol Assess 1997 Suchman et al. : JAMA 1986

  13. Miguel Cobas said that... • Routine screening in an asymptomatic population yields no benefit or significantly changes the anesthetic plan or outcome. • “...all patients receive a platelet count, PT, and PTT preoperatively if for no other purpose than to delineate baseline values.”

  14. MGH : algorithm for preoperative coagulation testing

  15. Platelet Count • Quantitative rather than qualitative • <20,000/mm3 : spontaneous bleeding • 20,000-100,000/mm3 : bleeding associated with surgery/ trauma • >100,000/mm3 : adequate for any challenge of hemostasis, assuming that function is normal. • Qualitative test : PACT; PFA100

  16. Bleeding Time • Not an effective predictor of bleeding during surgery, particularly in patients with a negative bleeding history. • Too many factors interfering with BT. • No role in preoperative evaluation of a patient with negative history, even in those patients taking aspirin. Ferraris et al. : Surg Gynecol Obster, 1983

  17. Prothrombin Time An unspecific indicator of an extrinsic or common pathway defect

  18. Activated Partial Thromboplastin Time • The integrity of the entire intrinsic pathway • Sensitive to all of the factors other than VII and XIII • To monitor heparin therapy

  19. Hemochron 801 • Whole blood • 400-2000µl • Within 5 minutes • ACT, aPTT, PT

  20. When do we need it? • To monitor high-dose heparin anticoagulation, ex. cardiopulmonary bypass surgery • When an immediate measure of heparin anticoagulation is needed at bedside, ex. ECMO, vascular surgery, hemodialysis, cardiac catheterization...

  21. Etomidate and thiopental inhibit platelet function in patients undergoing infrainguinal vascular surgery • Etomidate & thiopental offered significant platelet inhibitory properties. • Higher transfusion rates & prolonged operation times may be possible A. GRIES et al. Acta Anaesthesiol Scand 2001; 45: 449–457

  22. Course of Molecular Hemostatic Markers During and After Different Surgical Procedures • The THR and hemicolectomy : strong activation of the procoagulatory and fibrinolytic systems. • Much less pronounced : endoscopic cholecystectomy, subtotal thyroid resection. • Maximum activation : 1 to 2 hours postoperatively. Hans-Joachim G. Siemens et al. Journal of Clinical Anesthesia 11:622–629, 1999

  23. A Prospective, Randomized Comparison of Thromboelastographic Coagulation Profile in Patients Receiving Lactated Ringer’s Solution, 6% Hetastarch in a Balanced-Saline Vehicle, or 6% Hetastarch in Saline During Major Surgery • LR Group : a hypercoagulative profile persisting into the postoperative period. • HS-BS Group : a lesser change in the coagulation profile • HS-NS Group : associated with a hypocoagulative state. G. Martin, et al. : J Cardiothorac Vasc Anesth, Vol 16, No 4 (August), 2002: pp 441-446

  24. Special Thanks to Tzong-Shiun Lee Steve Jobs All listeners, awake or asleep Tools used Keynote Photoshop OmniGraffle iBook Minolta X20

More Related