Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC, CNRN, CEN, NP

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Coagulopathies in the Critical Care Setting

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

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Coagulopathies in the Critical Care Setting

• 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.

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Coagulopathies in the Critical Care Setting
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Coagulopathies in the Critical Care Setting

• 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

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Coagulopathies in the Critical Care Setting

• 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

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Coagulopathies in the Critical Care Setting

• Preoperative Screening
• CBC
• ? Hgb/Hct
• ? platelets
• PT/PTT
• Bleeding Time

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Coagulopathies in the Critical Care Setting

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

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Coagulopathies in the Critical Care Setting
Symptom INR aPTT Platelet Platelet Function History Diagnosis
Major/minor bleeding N N ? N Massive transfusion fluids Dilutional thrombocytopenia
Major/minor bleeding N Prolonged N N negative Drug induced - heparin
Major/minor bleeding ? N N n/a Vitamin K deficiency Liver disease, warfarin, antibiotics
Major bleeding prolonged prolonged ? N DIC
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Coagulopathies in the Critical Care Setting

• Postoperative Bleeding
• Vascular integrity disruption
• reoperation

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Coagulopathies in the Critical Care Setting

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

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Coagulopathies in the Critical Care Setting

• Protamine Reactions
• Type I
• benign reaction
• Histamine release ? systemic hypotension
• administer protamine slowly

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Coagulopathies in the Critical Care Setting

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

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Coagulopathies in the Critical Care Setting

• 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

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Coagulopathies in the Critical Care Setting

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

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Coagulopathies in the Critical Care Setting

• Thrombocytopenia
• ? platelet destruction
• drug induced
• DIC

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Differential diagnosis
Coagulopathies in the Critical Care Setting

• 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.

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Coagulopathies in the Critical Care Setting

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

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Coagulopathies in the Critical Care Setting

• Thrombocytopenia
• Etiology
• dilutional after hemorrhage, RBC transfusions

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Coagulopathies in the Critical Care Setting

• Thrombocytopenia
• Diagnosis
• ? hemoglobin,hematocrit, platelets
• prolonged bleeding time, PT, PTT

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Coagulopathies in the Critical Care Setting
Disseminated Intravascular Coagulation

• Definition
• serious bleeding disorder
• thrombosis then hemorrhage

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Coagulopathies in the Critical Care Setting

• Pathophysiology
• Intrinsic Clotting Cascade
• endothelial injury
• assessed by PTT

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Coagulopathies in the Critical Care Setting

• Pathophysiology
• Extrinsic Clotting Cascade
• tissue thromboplastin
• assessed by PT

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Coagulopathies in the Critical Care Setting

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

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Coagulopathies in the Critical Care Setting

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

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Coagulopathies in the Critical Care Setting

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

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Coagulopathies in the Critical Care Setting

• Etiology of DIC
• Vascular
• shock
• dissecting aneurysm

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Coagulopathies in the Critical Care Setting

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

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Coagulopathies in the Critical Care Setting

• Laboratory Findings
• ? platelets
• ? fibrinogen
• ? PT /or PTT
• ? d - dimer or FSP
• ? ATIII

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Coagulopathies in the Critical Care Setting

• Management
• Treat underlying cause
• surgery
• antimicrobials
• antineoplastics

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Coagulopathies in the Critical Care Setting

• Management
• Stop Thrombosis
• IV heparin
• AT III
• plasmapheresis

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Coagulopathies in the Critical Care Setting

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

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Coagulopathies in the Critical Care Setting

• Complications
• hypovolemic shock
• acute renal failure
• infection
• ARDS

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Coagulopathies in the Critical Care Setting

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

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Coagulopathies in the Critical Care Setting

• Postoperative Bleeding
• Coagulation Factor Deficiency
• FFP/cryoprecipitate
• protamine

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Coagulopathies in the Critical Care Setting

• Postoperative Bleeding
• Hyperfibrinolysis
• DDAVP
• Antifibrinolytics
• Amicar

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Coagulopathies in the Critical Care Setting

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

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Coagulopathies in the Critical Care Setting

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

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Coagulopathies in the Critical Care Setting

• Lab Values
• ABGs
• pH 7.26
• pO2 55
• pCO2 52
• HCO3 18
• SaO2 84

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Coagulopathies in the Critical Care Setting

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

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Coagulopathies in the Critical Care Setting

• Case Study
• Hgb/Hct 8.8 / 30
• PT 38 seconds
• Fibrinogen 102 mg/dL
• Platelets 50,000/mm3
• D dimer gt 2500 ng/dL
• FSP 80 mcg/dL

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Coagulopathies in the Critical Care Setting

• IN CONCLUSION

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Coagulopathies in the Critical Care Setting
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