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

2.  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.

4. 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

5. 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

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

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

8. 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

9. Postoperative Bleeding Vascular integrity disruption –reoperation

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

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

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

13. 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

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

15. Thrombocytopenia –  platelet destruction drug – induced DIC

16. 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.

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

18. Thrombocytopenia –Etiology dilutional after hemorrhage, RBC transfusions

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

20. Definition serious bleeding disorder thrombosis; then hemorrhage Disseminated Intravascular Coagulation

21. Pathophysiology Intrinsic Clotting Cascade –endothelial injury –assessed by PTT

22. Pathophysiology Extrinsic Clotting Cascade –tissue thromboplastin –assessed by PT

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

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

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

26. Etiology of DIC Vascular –shock –dissecting aneurysm

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

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

29. Management Treat underlying cause –surgery –antimicrobials –antineoplastics

30. Management Stop Thrombosis –IV heparin –AT III –plasmapheresis

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

32. Complications hypovolemic shock acute renal failure infection ARDS

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

34. Postoperative Bleeding Coagulation Factor Deficiency –FFP/cryoprecipitate –protamine

35. Postoperative Bleeding Hyperfibrinolysis –DDAVP –Antifibrinolytics Amicar

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

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

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

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

40. 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

41. IN CONCLUSION