Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC, CNRN, CEN, NP Education Specialist LRM Consulting Nashville, TN

 Objectives  Identify the most likely type of coagulopathy with regards to INR, aPTT, platelet numbers and function.  Discuss the four causes of thrombocytopenia.  Describe the priorities in the management of patients with life – threatening coagulopathies.

Admission Screening identify defects in hemostasis that can be corrected guide the management of hemostatic defects that cannot be corrected help manage the bleeding that cannot be prevented

Preoperative Screening History & Physical unlikely congenital or familial coagulopathy –no personal or family history of bleeding –no abnormal bleeding associated with: dental extractions previous surgery routine childhood trauma

Preoperative Screening CBC –  Hgb/Hct –  platelets PT/PTT Bleeding Time

Admission Screening Assessment of Coagulopathy –CBC with coagulation studies –check for and correct hypothermia –review the history –review medications

SymptomINRaPTTPlatelet #Platelet Function HistoryDiagnosis Major/minor bleeding NN  N Massive transfusion; fluids Dilutional thrombocytopenia Major/minor bleeding N Prolonged NN negativeDrug induced - heparin Major/minor bleeding  NNn/a Vitamin K deficiency Liver disease, warfarin, antibiotics Major bleeding prolonged  N DIC

Postoperative Bleeding Vascular integrity disruption –reoperation

Medical Causes of Bleeding residual heparin effect platelet consumption (CPB) preoperative platelet inactivation

Protamine Reactions Type I –benign reaction –Histamine release  systemic hypotension –administer protamine slowly

Protamine Reactions Type II –anaphylactoid reaction –occurs within 10 to 20 minutes of administration –symptoms hypotension flushing edema bronchospasm

Protamine Reactions Type III –catastrophic pulmonary vasoconstriction elevated pulmonary pressures cardiopulmonary collapse noncardiogenic pulmonary edema –reaction occurs between 10 to 20 minutes after start of administration

Medical Causes of Bleeding depletion of clotting factors pre-existing coagulopathy fibrinolysis

Thrombocytopenia –  platelet destruction drug – induced DIC

Differential diagnosis A platelet count fall that begins 5 to 10 days after cardiac surgery or that occurs abruptly after starting heparin in a patient previously exposed to heparin within the past 5 to 100 days, is very suggestive of HIT.

Thrombocytopenia –Etiology abnormal distribution or sequestration in spleen –portal hypertension

Thrombocytopenia –Etiology dilutional after hemorrhage, RBC transfusions

Thrombocytopenia –Diagnosis  hemoglobin,hematocrit, platelets prolonged bleeding time, PT, PTT

Definition serious bleeding disorder thrombosis; then hemorrhage Disseminated Intravascular Coagulation

Pathophysiology Intrinsic Clotting Cascade –endothelial injury –assessed by PTT

Pathophysiology Extrinsic Clotting Cascade –tissue thromboplastin –assessed by PT

Etiology of DIC Obstetric –abruptio placentae –amniotic fluid embolus –eclampsia

Etiology of DIC Hemolytic/Immunologic –anaphylaxis –hemolytic blood reaction –massive blood transfusion

Etiology of DIC Infectious –bacterial –fungal –viral –rickettsial

Etiology of DIC Vascular –shock –dissecting aneurysm

Etiology of DIC Miscellaneous –Emboli (fat) –ASA poisoning –GI disturbances - pancreatitis

Laboratory Findings  platelets  fibrinogen  PT &/or PTT  d - dimer or FSP  ATIII

Management Treat underlying cause –surgery –antimicrobials –antineoplastics

Management Stop Thrombosis –IV heparin –AT III –plasmapheresis

Management Administer blood products –pRBCs –platelets –FFP –cryoprecipitate

Complications hypovolemic shock acute renal failure infection ARDS

Postoperative Bleeding Platelet Dysfunction –Platelets –FFP/cryoprecipitate –DDAVP

Postoperative Bleeding Coagulation Factor Deficiency –FFP/cryoprecipitate –protamine

Postoperative Bleeding Hyperfibrinolysis –DDAVP –Antifibrinolytics Amicar

Case Study 62 – year old male admitted to CVICU post bypass complications postop (tamponade) – stabilized & on IABP required CPR several times

Case Study 3 days later diminished leg circulation – IABP removed pneumonia, groin infection, renal failure step – down develops sternal wound infection

Lab Values ABGs pH7.26 pO 2 55 pCO 2 52 HCO 3 18 SaO 2 84%

CV Status BP 88/56 MAP 67 CVP 4 ECG ST T 39.2°C

Case Study Hgb/Hct 8.8 / 30% PT38 seconds Fibrinogen 102 mg/dL Platelets 50,000/mm 3 D – dimer > 2500 ng/dL FSP 80 mcg/dL

IN CONCLUSION