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Coagulation and cardiac ITU

Coagulation and cardiac ITU. 2 Approaches. Understand and treat appropriately Give platelets and FFP. Overview. How clotting system works Drugs that affect it Effect of CPB on coagulation Medical conditions that affect it Tests of coagulation Assessing the bleeding patient

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Coagulation and cardiac ITU

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  1. Coagulation and cardiac ITU

  2. 2 Approaches • Understand and treat appropriately • Give platelets and FFP

  3. Overview • How clotting system works • Drugs that affect it • Effect of CPB on coagulation • Medical conditions that affect it • Tests of coagulation • Assessing the bleeding patient • Treatments

  4. Coagulation system • Why have it ? • What stops it working ? • What causes its activation ?

  5. How it works 1 Activation intrinsic- collagen and connective tissue and extrinsic- tissue factor from damaged cells Platelets Soluble clotting factors Fibrin RBC Clot

  6. How it works 2 soluble coagulation factors • Factor X11 Factor X11a • Factor X1 Factor X1a factor V111 • Factor 1X Factor 1Xa Factor V11 • Factor X PL, Factor V & Ca2+ • Prothrombin Thrombin • Fibrinoigen Fibrin monomer Fibrin polymer • Factor X111

  7. How it works 3 – The platelet

  8. How it works 4 Thrombin Soluble factors Thrombin Platelet Clot

  9. Drugs that affect coagulation • Bleed • Aspirin • Warfarin • Heparin / LMWH • Clopidogrel / Ticlopidine • ReoPro / Integrilin • Steptokinase / Alteplase • Non steroidal anti inflammatory drugs • Clot • Protamine • Tranexamic acid • Aprotinin • Vit K

  10. Aspirin TxA2 Platelet PgI2 Endothelium

  11. Warfarin • Inhibits Vitamin K • Factors 11, V11, 1X, and X • Factor 11 most important “thrombin” Soluble factors Thrombin Platelet Clot

  12. Heparin / LMWH • Complex molecule of multiple sugars molecules AT 111 Thrombin Heparin

  13. Clopidogrel / Ticlopidine

  14. ReoPro / Integrilin Platelet Platelet GP 11b/111a Fibrin GP 11b/111a

  15. Steptokinase / Alteplase / TPA Steptokinase / Alteplase / TPA Plasmin Plasminogen Fibrin Degradation products Fibrin Fibrinogen Coagulation cascade

  16. Non steroidal anti inflammatory drugs TxA2 Platelet PgI2 Endothelium

  17. Protamine Protamine Heparin Inactive complex

  18. Tranexamic acid Plasmin Plasminogen Fibrin Degradation products Fibrin Fibrinogen Coagulation cascade Tranexamic acid

  19. Aprotinin • Kallikrein Kinin inhibitor • PAR-1 antagonist • Anti fibrinolytic • Multiple different doses • Full dose / half dose / pump prime

  20. Vit K • Slow IV • Liver disorders

  21. Effect of CPB on coagulation • Soluble factors • Consumption • denatured • Platelets • Consumption • Desensitisation

  22. Medical conditions that affect • Drugs • Renal / liver failure • Haemophilia • Christmas disease • Von Willebrands

  23. Drugs • Discussed already

  24. Renal failure • Platelets don’t work • Uraemia Liver failure • All clotting factors other than V111 produced in liver

  25. Haemophilia / Christmas disease • Factor X11 Factor X11a • Factor X1 Factor X1a factor V111 • Factor 1X Factor 1Xa Factor V11 • Factor X PL, Factor V & Ca2+ • Prothrombin Thrombin • Fibrinoigen Fibrin monomer Fibrin polymer • Factor X111

  26. Von Willebrands Platelet Factor V111 vWF Endothelium

  27. Tests of coagulation • PT / INR • APPT • Fibrinogen • D-Dimer • ACT / KCT • Platelet function tests / thromboelastography

  28. Assessing the bleeding patient • Blood pressure • Acid base • CXR • Pumping up tubing • Sudden stop of bleeding esp 2nd clotting factors • Drop in Hb • TAMPONADE Clotting studies / Preop medications & conditions / what operation

  29. Treatments • Surgical factor VII (prolene 7-0) • FFP • Cryoprecipitate • Specific isolated factors • Platelets • Blood / Hb

  30. FFP fresh frozen plasma • All soluble clotting factors except 1 and V111

  31. Cryoprecipitate • Fibrinogen • vWF • V111

  32. Platelets • Depends on preop med’n, count and operation

  33. Specific isolated factors • 1 • V111 • 1X • vWF • Blood / Hb

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