Coagulation and cardiac ITU

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Coagulation and cardiac ITU
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2 Approaches

• Understand and treat appropriately
• Give platelets and FFP

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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

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Coagulation system

• Why have it ?
• What stops it working ?
• What causes its activation ?

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

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How it works 3 The platelet
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How it works 4 Thrombin
Soluble factors
Thrombin
Platelet
Clot
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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

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Aspirin
TxA2
Platelet
PgI2
Endothelium
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Warfarin

• Inhibits Vitamin K
• Factors 11, V11, 1X, and X
• Factor 11 most important thrombin

Soluble factors
Thrombin
Platelet
Clot
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Heparin / LMWH

• Complex molecule of multiple sugars molecules

AT 111
Thrombin
Heparin
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Clopidogrel / Ticlopidine
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ReoPro / Integrilin
Platelet
Platelet
GP 11b/111a
Fibrin
GP 11b/111a
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Steptokinase / Alteplase / TPA
Steptokinase / Alteplase / TPA
Plasmin
Plasminogen
Fibrin Degradation products
Fibrin
Fibrinogen
Coagulation cascade
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Non steroidal anti inflammatory drugs
TxA2
Platelet
PgI2
Endothelium
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Protamine
Protamine
Heparin
Inactive complex
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Tranexamic acid
Plasmin
Plasminogen
Fibrin Degradation products
Fibrin
Fibrinogen
Coagulation cascade
Tranexamic acid
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Aprotinin

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

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Vit K

• Slow IV
• Liver disorders

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Effect of CPB on coagulation

• Soluble factors
• Consumption
• denatured
• Platelets
• Consumption
• Desensitisation

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Medical conditions that affect

• Drugs
• Renal / liver failure
• Haemophilia
• Christmas disease
• Von Willebrands

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Drugs

• Discussed already

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Renal failure

• Platelets dont work
• Uraemia

Liver failure

• All clotting factors other than V111 produced in
  liver

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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

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Von Willebrands
Platelet
Factor V111
vWF
Endothelium
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Tests of coagulation

• PT / INR
• APPT
• Fibrinogen
• D-Dimer
• ACT / KCT
• Platelet function tests / thromboelastography

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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

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Treatments

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

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FFP fresh frozen plasma

• All soluble clotting factors except 1 and V111

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Cryoprecipitate

• Fibrinogen
• vWF
• V111

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Platelets

• Depends on preop medn, count and operation

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