Coagulation and anti-coagulants March 2016. Normal physiology Patophysiology Diagnostic tests Anticoagulants Anticoagulants and anesthesia.

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Presentation transcript:

Coagulation and anti-coagulants March 2016

Normal physiology Patophysiology Diagnostic tests Anticoagulants Anticoagulants and anesthesia

Normal physiology 3 steps Vascular spasm Platelet plug Blood coagulation Venous vs arterial thrombus!!!

Platelet plug 1. Translocation 2. Adhesion 3. Aggregation 4. Activation 5. Thrombus formation

Blood coagulation

Arterial thrombi Normally arteries only clot when damaged (trauma) Need endothelial damage and Activated plaque!

Patophysiology 1. Disorders of blood vessels 2. Disorders of platelets - numbers ( decreased production/ increased destruction) - function ( drug related/ uremia) 3. Disorders of coagulation proteins - hemophilias - Von Willebrand disease

Diagnostic tests 1. Bleeding time platelets fx insensitive 2. APTT Intrinsic pathway 3. PT Extrinsic pathway 4. INR 5. TT 6. Fibrinogen essays 7. D Dimers

Anticoagulants

Clexane Prophylaxis 40mg/day sc Therapeutic 1mg/kg bd Morbid obesity can increase dose with 30% Renal impairment Cr Cl ml/min 0,8 mgkg bd Urgent reversal with Protamine 1mg:1mg Anti F10 activity will only recover 60% max

Anticoagulants and neuroaxial anesthesia Same principles apply plexus blocks Incidence of spinal hematoma 0,1/ /year Asperin, Nsaids safe Clopidogrel - stop 7 days Warfarin - INR < 1,4 Heparin - > 1 hour before block, remove catheter > 2-4 hours after last dose LMWH- start > 24 hours after catheter placement Next dose > 2 hours after catheter removal

Case study 75 yr old male with fracture femur neck. Booked for hemi-arthroplasty. He has significant COPD. Weight 60kg U+E: Na 130 K 3.4 Urea 12 Creatinine 128 Current Px: Diuretic, CaCB, Disprin150mg, Clexane 40mg at 22h00 You also notice Ginseng Biloa and Echinacea herbals between his meds. You decide on a neuroaxial block.

Questions: 1. What are your concerns regarding his medication 2. What other factors can influence his Anticoagulants 3. Timing interval between meds and neuroaxial? 4. Can you consider Cyklokapron intra-op to reduce blood loss and risk of spinal hematoma? 5. Postop measures to prevent DVT? 6. Do you still consider a neuroaxial anesthesia?

Contra-indications to anti-coagulants Active bleeding Uncontrolled HTS >180/110 Active peptic ulcer Abnormal hemostasis Severe liver disease Severe renal impairment Cr Cl <30ml/min