PGI Roselada, Benjune S.

ARMMC Department of Anesthesiology

DLR: Chapter 17 Hemostasis and Transfusion Medicine February 21, 2023

Hemostasis and Coagulation

● Primary Hemostasis
○ In addition to maintaining blood as a fluid in circulation, blood must also be
capable of forming a solid clot to stanch leaks in vascular walls, and then
dismantling the clot when no longer required.
■ To form a platelet plug, platelets adhere to sites of endothelial
disruption, recruit more platelets, and amplify the platelet response
through activation and cross-linking with fibrin, an end product of the
plasma clotting factor cascade.
○ Adherence
■ Platelets attach to collagen via surface integrin receptors, glycoproteins
(GP) Ia/IIa and GP VI, when the endothelial lining is disrupted to
expose the underlying matrix
■ Von Willebrand factor (vWF) from endothelial cells and pre-existing
clots binds to integrin Ib/IX, another major adherence anchor, in
high-shear arterial blood flow
■ Platelets are pushed to the periphery of capillary blood flow by red
blood cells (RBCs), so anemia reduces platelet contact and function
○ Activation
■ There are a number of signaling pathways from the platelet surface that
can activate platelets
■ Ca2+ is released from storage tubules through
inositol-1,4,5-triphosphate (IP3). Calcium ions then catalyze the
release of dense granules at the platelet surface, which contain ADP,
serotonin, and more Ca2+.
■ It contains numerous proteins such as factor V, fibrinogen, and platelet
factor 4 (PF4), which neutralizes heparin-like compounds and heparin
to promote clotting.
○ Stabilization
■ Through diacylglycerol (DAG) and protein kinase C, an activated PLC
initiates "inside-out" signaling of GP IIb/IIIa
 ■ This changes the shape of GP IIb/IIIa, which permits it to better bind
fibrin and vWF.
■ The fibrin binding can also enmesh the platelets, contributing to the
formation of the platelet plug during the convergence of the platelet
and clotting factor systems.
○ Inhibition
■ In order to maintain hemostatic balance, platelets are naturally
inhibited by their endothelial environment. Endothelial cells secrete
prostaglandin I2 (PGI2), which binds to a receptor on the surface to
increase cyclic adenosine monophosphate (cAMP). Protein kinase A
(PKA) is activated by elevated cAMP, inhibiting vWF adhesion, TxA2
activation, and internal signaling in the PLC.
○ Mechanisms of Antiplatelet Medications
■ Aspirin and triflusal dampen the secretion of TxA2 by inhibiting
COX-1, the enzyme which converts AA into TxA2
■ Absciximab, eptifibatide, and tirofiban block the formation and
stabilization of platelet plugs.
■ Finally, the major inhibitory pathway mediated by endothelial PGI2 is
upregulated by dipyridamole and cilostazol
● Secondary Hemostasis
○ After endothelial injury, plasma clotting factors assemble into enzymatic
complexes to activate thrombin. This initiates secondary hemostasis.
○ A thrombin burst occurs when thrombin activates more efficient enzymes to
increase its own production.
○ A platelet plug is formed when fibrinogen is converted into fibrin by
thrombin.
○ Extrinsic Pathway
■ TF binds to both VII and VIIa, which circulate at low levels, and is a
cofactor for the activation of factor VII after endothelial disruption
exposes tissue factor (TF) on underlying cell membranes. A
low-efficiency extrinsic-pathway “tenase” complex forms when VIIa
enzyme, TF cofactor, cell membrane phospholipid, and Ca2+ are
combined. that activates factor X and factor IX. Then Xa enzyme, its
 cofactor Va (derived in large part from factor V released from activated
platelet α-granules), phospholipid, and Ca2+ assemble to form the
second complex, a “prothrombinase,” which converts prothrombin (II)
to thrombin (IIa).
○ Intrinsic Pathway
■ Thrombin has several central functions. It activates platelets via
surface receptors PAR-1 and PAR-4, cleaves more V to Va, and
initiates the "intrinsic" coagulation pathway by cleaving factor XI to
XIa. XIa cleaves more IX to IXa. As a result of thrombin, VIII is also
activated to VIIIa. IXa enzyme, VIIIa cofactor, calcium, phospholipid,
and a third complex is formed: IXa enzyme, VIIIa cofactor,
phospholipid, and calcium. This is a high-efficiency intrinsic-pathway
“tenase,” which provides many times more Xa for more
prothrombinase complexes. As thrombin cuts fibrinogen into fibrin
monomers, they polymerize extensively. In order for fibrin to form a
stable clot, factor XIIIa (also activated by thrombin) crosslinks fibrin
polymers with activated platelets via their GP IIb/IIIa receptors.
○ The liver produces all of these clotting factors, except for VIII, which is also
produced by endothelial cells in liver disease.
○ Inhibition of Clotting Factors
■ Heparin stimulates the release of TFPI and increases its inhibitory
efficiency by binding to the VIIa protease and its Xa product. TFPI
inhibits the external tenase complex by binding to the VIIa protease
and its Xa product.
■ A serpin is a serine protease inhibitor. Serpins disrupt the active sites
of proteases and increase their clearance. All clotting pathways are
inhibited by AT-III, including extrinsic tenase VIIa and prothrombinase
Xa, intrinsic tenase XIa and IXa, as well as thrombin. AT-III is
significantly more inhibited when bound to heparin.
■ The protein C-ase complex is composed of an enzyme, thrombin,
thrombomodulin, phospholipids, and calcium. It has the same four-part
structure as the coagulation complexes. The protein C-ase complex
cleaves protein C and activates it. Thrombomodulin is expressed on
endothelial cell membranes. C (APC) brakes clotting by cleaving VIIIa
 and Va, the cofactors for the external tenase and the prothrombinase
complexes. Protein C has a short half-life of 6 hours. Protein S is
thought to be a cofactor for protein C; both are vitamin K–dependent
● Fibrinolysis
○ Fibrin clots must be broken down after their job is done (fibrinolysis), and is a
complex process with checks and balances.
○ Plasminogen is activated to plasmin, which breaks down fibrin polymers
○ The major activator of plasminogen in the blood is tissue plasminogen
activator (tPA), which is secreted from endothelial cells and platelets. Both
plasminogen and tPA bind to lysine sites on fibrin. When associated with
cross-linked fibrin, tPA becomes much more efficient. Once some plasmin is
formed, it cleaves tPA to a more active form. tPA also directly cleaves fibrin
polymers.
○ Endothelium, monocytes, macrophages, and urinary epithelium secrete
urokinase, which is a major plasminogen activator in tissues. In addition to
binding plasminogen with two receptors, annexin A2 and urokinase receptors,
these cells also activate urokinase to a more active form, which facilitates its
conversion into plasmin. As medications to lyse thrombi, urokinase and tPA
can be administered.
○ Inhibition of Fibrinolysis
■ Plasminogen activation inhibitor-1 (PAI-1) is a serpin that binds to tPA
and urokinase and accelerates their clearance from plasma
■ Activated platelets release PAI-1 from α-granules. PAI-2, which acts
similarly to PAI-1, is secreted by the placenta and is prominent in
pregnancy.
■ The thrombin–thrombomodulin complex activates thrombin-activated
fibrinolysis inhibitor (TAFI), which is secreted by endothelial cells. In
addition to inhibiting tPA action, TAFI also inhibits plasmin action on
fibrin by cleaving fibrin and fibrin polymers.
■ Epsilon-aminocaproic acid (EACA) and tranexamic acid (TXA) inhibit
fibrinolysis pharmacologically. These drugs act by blocking the
lysine-binding sites of plasminogen, preventing it from acting on
fibrin.
Laboratory Evaluation of Hemostasis
● The first screening test for hemostatic problems should always be the patient’s
medical history
○ Hemarthroses or soft tissue bleeding suggest deficiency of factors,
whereas dermal or mucosal bleeding may indicate platelet dysfunction.
● Laboratory Evaluation of Primary Hemostasis
○ The normal automated platelet count in adults is approximately
150,000 to 400,000/μL.
○ Microscopic review of peripheral blood smears may reveal clotted
specimens, artifactual platelet clumping in vitro, or abnormal platelet
morphology in specimens with abnormal platelet counts.
○ The template bleeding time was one of the first platelet function tests
(PFTs), in which a small cut is made on the forearm of the subject and
the bleeding duration is measured. However, this test is invasive,
labor-intensive, impractical to repeat frequently, poorly reproducible,
and only modestly predictive of bleeding problems.
● Laboratory Evaluation of Secondary Hemostasis and Coagulation
○ A general assessment of plasma clotting factor activity is conducted
with the prothrombin time (PT) for the extrinsic (tissue) pathway and
the aPTT for the intrinsic (contact) pathway, with both tests relevant to
the common pathway.
● Monitoring Anticoagulation Therapeutic Agents
○ Warfarin Anticoagulation
■ To prevent under- or overcoagulation, warfarin therapy must be
monitored by the PT and its analogue, the international
normalized ratio (INR).
■ In the warfarin-dependent factors II, VII, IX, and X, the INR
represents a normalized value for comparing results across
laboratories.
■ There are genetic variations associated with Warfarin's
pharmacology and its counterbalancing vitamin K (vitamin K
epoxide reductase complex subunit 1, VKORC1).
○ Heparin Anticoagulation Testing
 ■ Heparin anticoagulation is assessed using the aPTT. Each
laboratory defines a therapeutic target range of 1.5 to 2.5 times
the normal mean value for heparin anticoagulation.
Blood Products and Transfusion Thresholds
● Compatibility Testing
○ ABO and RhD typing, antibody screening for non-ABO antibodies, and RBC
crossmatching are routine RBC compatibility tests
○ Patients who are RhD-negative should receive D-negative RBCs in order to
avoid anti-D alloimmunization. RBCs must be compatible with ABO in order
to prevent intravascular hemolysis.
○ A RBC compatibility test normally takes 45 to 60 minutes, but if antibodies
are discovered, it may take longer. The risk of non-ABO antibody
incompatibility is heightened in emergencies when uncross-matched group O
RBCs are given, even if they are not cross-matched. Since Group AB is a
universal donor plasma, it avoids transfusing anti-A or anti-B against the
patient's RBCs.
○ Physiologic Compensation for Anemia
■ Increased CO
● First, the heart rate increases secondary to a sympathetic surge
initiated by anemia and hypoxia.
● Further, a higher stroke volume is caused by an increase in
preload due to a decrease in both systemic vascular resistance
and afterload.
■ Altered microcirculatory blood flow
● As a result of isovolemic hemodilution and chronic anemia,
blood flow through the microcirculation is improved due to a
lower shear force in capillaries.
■ Increased tissue oxygen extraction.
● Anemia causes the oxyhemoglobin
● disassociation curve to shift to the right secondary to increased
levels of 2,3-DPG in RBCs.
Source: Barash, P. G., Cullen, B. F., Stoelting, R. K., Cahalan, M. K., Stock, M. C., Ortega,
R. A., Sharar, S. R., & Holt, N. F. (2017). Clinical anesthesia. Wolters Kluwer.
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It is the responsibility of anesthesiologists to manage patients before, during, and after
surgical procedures. During surgery, ensuring that patients do not experience excessive
bleeding or develop blood clots is one of the most important aspects of anesthesia
management. In hemostasis, blood clots stop bleeding, while transfusion medicine uses blood
products to stop bleeding, including red blood cells, platelets, and plasma.
To identify patients at risk of bleeding and to effectively manage bleeding during and
after surgery, anesthesiologists need to understand hemostasis and transfusion medicine.
Additionally, they need to know how to interpret laboratory and point-of-care coagulation
tests, as well as how to assess a patient's coagulation status. In order to prevent and manage
bleeding complications that can be life-threatening, such as massive hemorrhage, this
knowledge is crucial.
Furthermore, transfusion medicine is vital for treating patients with preexisting
anemia or who have lost significant amounts of blood during surgery. Anesthesiologists need
to know when to initiate blood transfusion and how to choose appropriate blood products
based on the patient's coagulation status, blood type, and other clinical factors.
In conclusion, anesthesiologists must be knowledgeable about hemostasis and
transfusion medicine in order to provide safe and effective anesthesia. To optimize patient
outcomes, anesthesiologists should stay up-to-date with current transfusion medicine
practices and collaborate with hematologists and transfusion medicine specialists.