This document provides an overview of approach to bleeding and evaluation of bleeding disorders. It discusses the basics of hemostasis including platelets and clotting factors. Common bleeding disorders like thrombocytopenia, hemophilia, and von Willebrand disease are described. The evaluation of bleeding disorders includes history, physical exam, and screening laboratory tests. Specific coagulation factor deficiencies, liver disease, disseminated intravascular coagulation, and acquired coagulation factor inhibitors are also reviewed. Treatment focuses on supporting hemostasis and addressing underlying causes.
Approach to a bleeding disorder: These presentation has the approach for a patient of bleeding disorder. it has History, physical finding, Investigations.
Hemostasis, Coagulation, Intrinsic, Extrinsic & common Pathways of Clotting, Common bleeding disorders & their investigations, BT, CT, PT, APTT, TT, Blood & its products, Blood transfusion & its complication.
Approach to a bleeding disorder: These presentation has the approach for a patient of bleeding disorder. it has History, physical finding, Investigations.
Hemostasis, Coagulation, Intrinsic, Extrinsic & common Pathways of Clotting, Common bleeding disorders & their investigations, BT, CT, PT, APTT, TT, Blood & its products, Blood transfusion & its complication.
Factor v deficiency is rare
first described in a Norwegian patient in 1943, Identified by Dr. Paul Owren .
Fewer than 200 cases of congenital factor V deficiency have been reported worldwide since 1943.
inheritance of factor V deficiency is autosomal recessive.
usually only needed for severe bleeds or before surgery.
there is no concentrate containing only factor V.
fresh plasma or (FFP) infusions are used to correct the deficiency temporarily and should be given daily during a bleeding episode.
This would give an idea of the various bleeding disorders, associated clotting factors and more specifically management in the dental office of the patients with bleeding disorders
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Factor v deficiency is rare
first described in a Norwegian patient in 1943, Identified by Dr. Paul Owren .
Fewer than 200 cases of congenital factor V deficiency have been reported worldwide since 1943.
inheritance of factor V deficiency is autosomal recessive.
usually only needed for severe bleeds or before surgery.
there is no concentrate containing only factor V.
fresh plasma or (FFP) infusions are used to correct the deficiency temporarily and should be given daily during a bleeding episode.
This would give an idea of the various bleeding disorders, associated clotting factors and more specifically management in the dental office of the patients with bleeding disorders
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
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We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
2. Objectives
Understand the basics of hemostasis
Platelets
Clotting factors
Blood Vessel
Clinical features of a bleeding disorder
Laboratory evaluation
Common bleeding disorders
• Thrombocytopaenia
• Hemophilia
3. Haemostasis
•Primary Hemostasis
– Involves platelets, vWF, and vessel wall
– Goal is platelet plug formation at site of injury
– Platelet plug stops bleeding, but is unstable
• Secondary Hemostasis
– Involves the clotting factors
– Goal is stabilization of platelet plug
– Leads to fibrin clot formation
6. Evaluation of bleeding disorders
History Taking
Physical examination
Screening clinical laboratory tests
7. History
Observation of excessive bleeding following a surgical procedure
Bleeding problems in relatives
Bleeding problems following operations and tooth extractions, trauma, heavy
menses, post partum haemorrhage
Use of drugs for prevention of coagulation or pain
Spontaneous bleeding from nose, mouth etc..
8. Physical examination
Jaundice
Petechiae: < 0.2 cm
Purpura: 0.2 cm-1 cm
Eccymoses > 1 cm
Spider angioma
Oral ulcer
Hyperplasia of gingiva
Haemarthrosis
Mucosal bleeding
9. Screening laboratory tests
First line testing
–FBC
–Peripheral smear
–Prothrombin time (PT)
–Partial thromboplastin time (PTT)
–Fibrinogen
–Thrombin time
–von Willebrand panel
•Factor 8 activity, vWF antigen, vWF activity
–PFA-100
10. Subsequent testing-repeat all abnormal tests
–Factor XIII test
–PTT abnormal
•PTT mixing study
•Factor 8, 9, 11, 12 levels
•Lupus anticoagulant, Anti phospholipid testing
–PT abnormal
•PT mixing study
•Factor 7
•Protein C and S activity
–vWF panel abnormal
•Repeat testing
•vWF multimers
11. PT PTT Plt DDx Follow-up tests
N ↑ N PTT inhibitor PTT mixing study, lupus anticoagulant, cardiolipin Ab’s
von Willebrand
disease
von Willebrand panel including multimers
Hemophilia A or B Factor VIII and IX activity
Factor XI Deficiency Factor XI activity
Heparin contamination Thrombin time
PT PTT Plt DDX Follow-up tests
N N N von Willebrand disease PFA-100
von Willebrand panel, including multimers
Platelet function disorder Platelet aggregation studies
Factor XIII deficiency Ureaclot lysis test
12. PT PT Plt DDX Follow-up Tests
↑ N N PT inhibitor
Vitamin K deficiency Factors II, VII, IX, X, protein C and proteinS
Warfarin
Factor VII deficiency Factor VII activity
13. PT PTT Plt DDX Follow-up Tests
↑ ↑ Circulating inhibitor Mixing studies, lupus anti coagulant,cardiolipin Ab’s
Liver dysfunction Liver enzymes, thrombintime, reptilase time
Vitamin K deficiency Factors II, VII, IX, X,protein C and protein S
FactorII, V, and X deficiency Factor activity assay
DIC DIC screen, assess and treat for underlying cause
14. Physiology of Lab Parameters
Platelet count
Normal (140,000 to 400,000/mm3)
Thrombocytopenia : <140,000/mm3
Clinical bleeding problem : <50,000/mm3
Spontaneous bleeding with life threatening :<20,000/mm3
APTT
The APTT is a test of the integrity of the intrinsic and common pathways of coagulation.
The in vitro clotting time is measured after addition to plasma of calcium and the APTT reagent, which
contains phospholipid (a platelet substitute, also called ‘partial thromboplastin’ as it lacks tissue factor),
and an intrinsic pathway activator e.g. kaolin.
The APTT should be designed to detect bleeding disorders due to deficiencies of factors VIII, IX, and XI
and inhibitors of the intrinsic and common pathway factors (including lupus anticoagulant and therapeutic
anticoagulants).
Inevitably, it also detects deficiency of factor XII.
15. Activated PTT (aPTT)
Activated by contact activator (kaolin)
Tests intrinsic and common pathway
Normal ( 25-35 sec )
Heparin therapy- PTT in 50-65 sec range by promote AT III
PT
The PT assesses the integrity of the extrinsic and common pathways.
The in vitro clotting time is measured after addition of the PT reagent, which
contains thromboplastin (phospholipids with tissue factor) and calcium to citrated
plasma.
PT prolongation should detect important deficiencies (or rarely inhibitors) of
factors II, V, VII and X.
Its main use is for anticoagulant monitoring and detection of acquired bleeding
disorders (especially disseminated intravascular coagulation, liver disease and
vitamin K deficiency).
16. PT (Prothrombin Time)
Activated by tissue thromboplastin, tests extrinsic ( factor VII ) and common ( I,II,V,X ) pathways
Normall ( 11-15 sec )
Coumarin therapy- PT at 1.5 to 2.5 time
International normalized ratio (INR): the ratio of a patient's prothrombin time to a normal (control)
sample, raised to the power of the ISI value for the analytical system used.
TT (Thrombin Time)
Activated by thrombin
Tests ability to form initial clot from fibrinogen
Normall ( 9 to 13 seconds )
Skin bleeding time
This is the only in vivo hemostasis test available..
It is used to test for defects of platelet-vessel wall interaction and should detect inherited or
acquired disorders of platelet function, von Willebrand disease (VWD) and abnormalities of vessel
wall integrity
17. Thrombocytopaenia
There are 3 major mechanisms of thrombocytopenia:
impaired production, increased destruction and abnormal sequestration or dilution.
Impaired platelet production can be due to congenital disorders (amegakaryocytic
thrombocytopenia, May-Hegglin anomaly), viral infection, alcohol, B12 or folate
deficiency, bone marrow infiltration (leukemia, myelofibrosis, metastatic cancer),
chemotherapy or radiation, paroxysmal nocturnal haemoglobinuria, or
myelodysplasia.
The peripheral smear may provide clues to the diagnosis. E.g. a leukoerythroblastic
smear (teardrop cells, nucleated RBCs, and early myeloid precursors) suggests an
infiltrative process, whereas oval macrocytes and hypersegmented neutrophils
suggest a B12 or folate deficiency.
Disorders associated with increased platelet destruction include immune
thrombocytopenic purpura (ITP), thrombotic thrombocytopenic purpura,
disseminated intravascular coagulation (DIC), infection, sepsis, antiphospholipid
antibody syndrome, drugs, heparin-induced thrombocytopenia (HIT), and
cardiopulmonary bypass.
18. ITP is characterized by autoantibody-mediated platelet destruction, with the majority of platelet autoantibodies
directed against platelet GpIIb/IIIa or GpIb/IX complexes on the platelet surface.
ITP is a diagnosis of exclusion, and tests for antiplatelet antibodies are not useful for diagnosis or for
guiding therapy.
Thrombotic thrombocytopenic purpura is associated with thrombocytopenia, microangiopathic haemolytic
anemia, and often fever or renal or neurologic abnormalities. The pathophysiology involves both endothelial
damage with release of ultralarge multimers of von Willebrand factor (vWF) and a deficiency of a plasma vWF-
cleaving protease.
The diagnosis is suggested by the combination of unexplained thrombocytopenia, anemia with a high
lactate dehydrogenase level, and RBC fragmentation on the peripheral smear. Assays for the vWF-cleaving
protease are performed in some research laboratories but are not yet routinely available.
Sepsis is one of the most common causes of thrombocytopenia in patients in intensive care units. Recent
evidence suggests that haemophagocytosis by activated monocytes and macrophages may be a major
mechanism of platelet destruction.
Drugs most commonly implicated in thrombocytopaenia include quinidine or quinine, rifampin, and
trimethoprim/sulfamethoxazole.
HIT is a special type of drug-mediated thrombocytopenia. The mechanism involves the formation of
autoantibodies directed against heparin bound to platelet factor 4 (PF4) released from platelet granules.
The resulting antibody/heparin/PF4 immune complexes bind to platelet Fc receptors, triggering platelet
activation and clumping. There are several platelet aggregation assays available that detect the HIT
antibody.
Thrombocytopenia can also result from abnormal sequestration or dilution.
Massive transfusion with RBC products alone (more than 15-20 units in a 24- hour period) can result in a
dilutional thrombocytopenia.
19. Platelet Function Disorders
Inherited platelet function disorders include Glanzmann thrombasthenia, Bernard-Soulier syndrome, and
storage pool disorders.
Acquired causes of platelet dysfunction include drugs (aspirin, nonsteroidal antiinflammatory drugs, beta-
lactam antibiotics), uremia, myeloproliferative disorders, myelodysplasia, paraproteins, and
cardiopulmonary bypass. The diagnosis of a platelet function defect is suggested by the combination of a
prolonged bleeding time or abnormal platelet function analysis and a normal platelet count. Platelet
aggregation studies test the aggregation response of the patient’s platelets to a series of agonists. The
pattern of aggregation responses may be diagnostic of specific platelet function defects.
• von Willebrand Disease
von Willebrand disease (vWD) is the most common inherited bleeding disorder, found in 1% of the general
population and affecting all racial and ethnic groups. It results from either a deficiency or defect in vWF,
the large multimeric protein that mediates platelet adhesion and serves as a carrier protein for FVIII [F2].
Patients with vWD present with superficial or mucosal bleeding, reflecting the defect in platelet adhesion.
The diagnosis of vWD is often suggested by abnormal screening test results, but specific assays of vWF are
required to confirm the diagnosis.
The aPTT may be normal or slightly prolonged if the FVIII level is low (<40%). The bleeding time is usually
prolonged in severe cases but is often normal in mild cases. Platelet function analysis will be abnormal in
at least 95%.
The diagnosis is confirmed by a panel of 3 tests: the vWF antigen level, the vWF activity level, and the FVIII
activity.
If vWF levels are low, analysis of vWF multimers is required to determine the specific vWD subtype. The
different subtypes of vWD are distinguished based on the results of the von Willebrand panel and
multimer analysis [T3]. Various factors (trauma, surgery, estrogens, inflammation, blood group) can affect
vWF levels and complicate or confound the diagnosis. vWF levels also vary significantly over time in an
individual patient. Thus, a normal vWF panel on one occasion does not rule out vWD, and repeated testing
is often necessary to confirm or exclude the diagnosis.
20. Coagulation Disorders
Coagulation disorders occur in inherited and acquired forms, but all result in a defect in the formation of a
fibrin clot.
The term hemophilia refers to either of 2 clinically indistinguishable inherited clotting factor deficiencies.
Hemophilia A (FVIII deficiency) is more common, affecting 1 in 10,000 males. Hemophilia B (FIX deficiency)
affects approximately 1 in 50,000 males. Hemophilia is characterized by bleeding into joints, muscles, and
deep tissues, in contrast to the mucocutaneous pattern of bleeding characteristic of vWD and platelet
disorders. Hemophilia patients are broadly classified as having mild (>5%), moderate (1%-5%), or severe
(<1%) hemophilia based on the FVIII or FIX level.
Severe hemophilia is usually diagnosed in early childhood, but mild hemophilia may escape detection until
adulthood, since these patients have a mild clinical course and usually bleed only with trauma or surgery.
The 4 major acquired coagulation disorders include vitamin K deficiency, liver disease, DIC, and acquired
clotting factor inhibitors.
Deficiencies of the 4 vitamin K–dependent clotting factors (FII, FVII, FIX, FX) may result from poor nutrition,
obstructive jaundice, betalactam antibiotics, oral anticoagulants, or the ingestion of rodenticides. The
PT/INR and aPTT are both prolonged, but in the absence of other hemostatic defects, the thrombin time,
fibrinogen level, and platelet count are normal. The diagnosis is usually confirmed by correction of the
prolonged clotting times after vitamin K replacement.
End-stage liver disease results in a multifactorial and occasionally profound failure of hemostasis due to
defects in 1 or more components of hemostasis. The PT/INR and aPTT are usually both prolonged in
advanced liver disease, reflecting the defect in clotting factor synthesis. Thrombocytopenia may be due to
splenic sequestration and impaired hepatic production of thrombopoietin.
21. DIC is a complex derangement of the hemostatic system in which generalized activation
of coagulation causes widespread intravascular fibrin formation and subsequent
secondary fibrinolysis. Hemostatic defects predisposing to bleeding in DIC include
consumption and depletion of clotting factors, thrombocytopenia, excessive fibrinolysis,
and generation of fibrin degradation products (measured as D dimers) that interfere
with fibrin polymerization and impair platelet function.
The laboratory findings in DIC reflect the intensity of the inciting stimulus and the
patient’s ability to compensate by synthesizing new clotting factors and platelets. In
severe DIC, the PT/INR and aPTT are usually both prolonged, the fibrinogen level and
platelet count are low, and the D-dimer level is elevated.
Acquired FVIII inhibitors are autoantibodies against FVIII that develop spontaneously in
patients with no history of hemophilia or a bleeding disorder. The autoantibodies
(usually IgG) inactivate FVIII coagulant activity resulting in an acquired FVIII deficiency
and a severe bleeding disorder. The diagnosis should be suspected in an elderly patient
with no bleeding history who develops spontaneous bruising and soft tissue bleeding.
FVIII inhibitors are identified by an isolated prolonged aPTT, which does not correct in a
mixing study. Incubation of the mixing study at 37°C for 1 hour is required to detect
some inhibitors with slow kinetics. The FVIII level is low, and a Bethesda assay confirms
and quantifies the inhibitor.
23. Approach To Management
Treatment is both supportive and therapeutic
Treat the underlying and give blood products if necessary life threatening circumstances
ITP
Aspirin and other medications that compromise platelet function should be avoided.
Bleeding precautions (eg, restriction from physical contact activities and use of helmets) should be
observed.
Platelet transfusion should be avoided except in circumstances of life-threatening bleeding, in which case
emergent splenectomy is to be pursued. In this setting, administration of corticosteroids and IVIG is also
advisable. Corticosteroids Patients with clinically significant but non–life-threatening bleeding (ie, epistaxis,
hematuria, and hematochezia) and those with a platelet count of less than 10,000/μL may benefit from
prednisone at 2–4 mg/kg orally per day for 3–5 days, decreasing to 1–2 mg/kg//d for a total of 14 days.
The dosage is then tapered and stopped.
No further prednisone is given regardless of the platelet count unless significant bleeding recurs, at which
time prednisone is administered in the smallest dose that achieves resolution of bleeding episodes (usually
2.5–5 mg twice daily). Follow-up continues until the steroid can again be discontinued, spontaneous
remission.
Intravenous Immunoglobulin (IVIG) IVIG is the treatment of choice for severe, acute bleeding, and may
also be used as an alternative or adjunct to corticosteroid treatment in both acute and chronic ITP of
childhood. IVIG may be effective even when the patient is resistant to corticosteroids; responses are
prompt and may last for several weeks
24. Most patients receive 1 g/kg/d for 1–3 days. Infusion time is typically 4–6 hours. Platelets may be
given simultaneously during life-threatening hemorrhage but are rapidly destroyed.
Up to 70% of patients spontaneously recover with a platelet count greater than 100,000//μL within
1 year. For the remainder, corticosteroids, IVIG, and anti-D immunoglobulin are typically effective
Splenectomy produces a response in 70–90%, but it should be considered only after persistence of
significant thrombocytopenia for at least 1 year.
TTP
Plasma exchange with fresh frozen plasma is the therapy of choice for TTP. Octaplas is a pooled plasma
(human) that has been treated with a solvent detergent process. This blood product provides a viable
alternative to single-donor fresh-frozen plasma and provides a reduced risk of certain viral
transmissions. Replacement with normal saline and albumin is not adequate. When immediate plasma
exchange is not available, simple plasma infusion can be performed until the patient can be transferred
to a facility that performs plasma exchange.
Usually, at least five plasma exchanges are performed in the first 10 days.
25. DIC
Treatment should primarily focus on addressing the underlying disorder. DIC can result
from numerous clinical conditions, including sepsis, trauma, obstetric emergencies,
and malignancy. Surgical management is limited to primary treatment of certain
underlying disorders.
Management of the DIC itself has the following basic features:
• Monitor vital signs
• Assess and document the extent of hemorrhage and thrombosis
• Correct hypovolemia
• Administer basic hemostatic procedures when indicated
Platelet and factor replacement should be directed not at simply correcting laboratory
abnormalities but at addressing clinically relevant bleeding or meeting procedural
needs. Heparin should be provided to those patients who demonstrate extensive fibrin
deposition without evidence of substantial hemorrhage; it is usually reserved for cases
of chronic DIC.
26. Haemophilia A
The treatment of hemophilia may involve prophylaxis, management of bleeding episodes,
treatment of factor VIII (FVIII) inhibitors, and treatment and rehabilitation of hemophilia
synovitis. Use of factor replacement products and other medications, including pain
medications, is typically required.
Dose calculations are directed toward achieving an FVIII activity level of 30-40% for most
mild hemorrhages, of at least 50% for severe bleeds (eg, from trauma) or prophylaxis of
major dental surgery or major surgery, and 80-100% in life-threatening hemorrhage
Desmopressin vasopressin analog, or 1-deamino-8-D-arginine vasopressin (DDAVP), is
considered the treatment of choice for mild and moderate hemophilia A. It is not effective
in the treatment of severe hemophilia. DDAVP stimulates a transient increase in plasma
FVIII levels.
Approaches to treating patients with FVIII inhibitors include the following:
• Porcine FVIII, which has low cross-reactivity with human FVIII antibody
• Activated prothrombin complex concentrate (PCC)
• Activated FVII
• Desensitization
• Immune tolerance induction (ITI)
• Monoclonal antibodies that bridge FIXa and FX (eg, emicizumab)
27. Indication or Site of Bleeding Factor level Desired, % FVIII Dose, IU/kg Comment
Severe epistaxis; mouth, lip,
tongue, or dental work
20-50 10-25
Joint (hip or groin) 40 20 Repeat transfusion in 24-48
Soft tissue or muscle 20-40 10-20 No therapy if site small and
not enlarging (transfuse if
enlarging)
Muscle (calf and forearm) 30-40 15-20 None
Neck or throat 50-80 25-40 None
Hematuria 40 20 Transfuse to 40% then rest
and hydration
Laceration 40 20 Transfuse until wound healed
GI or retroperitoneal
bleeding
60-80 30-40 None
Head trauma (no evidence
CNS bleeding
50 25 None
Head trauma (probable or
definite CNS bleeding, eg,
headache, vomiting,
neurologic signs)
100 50 Maintain peak and trough
factor levels at 100% and
50% for 14 d if CNS bleeding
documented†