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Critical Care Haematology
The document discusses complex clinical cases involving coagulopathy, specifically DIC, thrombotic microangiopathies, and their associations with severe illness in ICU patients. It emphasizes the multifactorial nature of thrombocytopenia and the importance of proper diagnosis and management of conditions like TTP and HIT. Key laboratory findings and treatment strategies are highlighted, addressing the urgency of intervention in these life-threatening scenarios.
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Critical Care Haematology
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- 2. –“Bad Blood “Taylor Swift “Now we got problems, and I don't think we can solve them.”
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- 6. In the ICUthere is a 32 y.o. man… Type 1 DM Septic shock, pneumonia hypotensive, lactate 5.5 mmol/l High dose vasopressor and inotrope Progressive symmetrical duskiness of all limbs- necrosis of fingers and distal feet
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- 8. FBE Hb 138 WCC 1.07 Plats7 Marked red cell crenation, L shifted toxic neutrophils Severe thombocytopenia
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- 12. Production 13-60% Of prognostic significance Destruction Marrowfailure primary or secondary (suppression) Idiopathic aplastic anemia Malnutrition Sepsis Drugs Mechanical IABP, ECMO, CRRT Microangiopathic TTP, DIC, SBE, vasculitis Drugs splenic pooling Passive Splenomegaly Cell mediated Haemophagocytosis
- 13. Platelets in sepsis Rapidlylocalise to site of infection, and migrate to liver, lungs Cell-cell contact- adhesion molecules Antimicrobial proteins bind bateria and viruses Toll like receptors - PAMPS
- 14. NET(osis) Many mechanisms bywhich platelets in sepsis contribute to inflammation NETs Neutrophil Extracellular Traps Novel pathway by which bacteria trapped in the vasculature
- 15. Slide courtesy ofDr Rob Andrews, Australian Centre Blood Diseases, Monash Uni
- 16. COAGs.. INR 4.2 PT 40 aPTT80 Fib 3.8 D Dimers 16.97 TCT normal (= no heparin)
- 17. INR 4.2 PT 40 aPTT80 Fib 3.8 D Dimers 16.97
- 18. INR 4.2 PT 40 aPTT80 Fib 3.8 D Dimers 16.97 Fibrinogen is an acute phase protein- high fibrinogen does not rule out fibrinolysis
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- 21. DIC Clinico-pathological diagnosis (likesepsis- not a distinct entity) Fibrin deposition in organs- organ failure Coagulopathy Several scoring systems Levi et al BJH 2009 145:24-33. Guidelines for the diagnosis and management of DIC
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- 23. D.I.C. Presence of DICassociated with mortality Increasing score Repeated score clinically useful
- 24. Wada et alJ Intensive Care 2014 NETS can cause this
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- 26. Treatment ?Activated protein C ?Tissuefactor pathway inhibitor Avoid prothrombotics- tranexamic acid, prothrombinex -FFP safe- balanced ? heparin Other? ? AT replacement No reduction in death inc bleeding
- 27. A 52 y.o.female presents to the Emergency Deparment.. presented with confusion, nausea, abdominal pain and vomiting in ED found to have renal impairment and abnormal labs
- 28. Labs Hb 100 Hct 0.29 WCC11.6 Plats 9 INR 1.1 PT 14.3 aPTT 29.2 Fib 4.4 haptoglobin <0.08 urea 27.8 creat 246 LDH 1635 u/l (n 120-250)
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- 31. Fragmentation-schistocytes ++- helmet cells,triangular cells . Polychromasia. Nucleated red cells MAHA microangiopathic haemolytic anaemia
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- 33. What are TMAs? Thrombotic microangiopathies Primary TTP HUS Complement mediatedTMAs DITMAs Hereditary forms Secondary Severe hypertension Preeclampsia/ HELLP
- 34. DITMAS Drug induced thrombotic micro- angiopathies e.g. CNIs Cocaine CTZ Quinine(may be abrupt onset)
- 35. Diagnostic test ADAMTS 13.. ADisintegrin And Metalloprotease with a ThrombSpondin Type 1 motif, member 13
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- 37. Moake, Sem inHematol, 2004 Moake, Sem in Hematol, 2004 Moake, Sem in Hematol, 2004
- 38. additional tests.. Stool microscopy: no EHEC Shiga toxin negative No recent drugs
- 39. Dx TTP Urgent PlasmaExchange (mortality 90% untreated) Rationale for treatment Steroids
- 40. Meanwhile in ICU… Theintensivist on duty is worried about a patient on VA ECMO for acute myocarditis The patient has just clotted their ECMO pump..
- 41. Pump Thrombosis Noisy pump intravascularhaemolysis… renal failure
- 42. FBE FBE Day 1Day 2 Day 3 Day 4 Day 5 Hb 110 108 105 96 92 WCC 6.4 7.5 4.8 5.6 4.9 Plats 289 267 205 199 98
- 43. HIT Rare, difficult todiagnose, heparin dependant pro- thrombotic disorder Antibody to platelet factor 4
- 46. The HIT Iceberg Assfalget al. 2016. World Journal of Transplantation. HIT in solid organ transplant recipients.
- 47. Pre-test probability 4T score6- intermediate probability Heparin stopped and bivalirudin commenced Shortly after commencement of bivalirudin patient complained of severe abdo pain and lactic acidosis.
- 48. Takeaways DIC is aclinico-pathological syndrome with different clinical phenotypes (bleeding, massive bleeding, thrombotic) Low platelets are common in critically ill and multifactorial TTP, HIT are very uncommon disorders but should be considered in the right clinical setting as they can both frequently be fatal