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By Group two 3rd year anesthesia student
December/ 25 / 2023

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Group member
1 Bosona Derso AnesR/0007/12
2 Cherenet Chirato AnesR/0008/12
3 Meheret Nuriye TNaScR/0051/11
4 Markos Mekuriya AnesR/0010/12
5 Mekdes Mulugeta AnesR/0011/12
6 Yordanos Alemayehu AnesR/0024/12

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Outline of Presentation
 The Basics of Coagulation and Clot Breakdown
 Evaluating Abnormal Coagulation Tests
Approach to the Evaluation of the Bleeding Patient
Diagnosis and Emergency Management of Common
Bleeding Disorders
VTE

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course objectives
At the end of this presentation we must be able to ;
Describe major coagulation disorders
Know how to evaluate coagulation abnormalities
preoperatively
Remind pre , intra and post operative anesthesia
considerations

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introduction
 Coagulation is the process by which soluble
fibrinogen is convert into insoluble fibrin strand .
 It is the property of plasma which means it doesn’t
require mandatorily platelets, red blood cells and
WBS.
 Coagulation disorders are conditions that affect the
bloods clotting activities.

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The basics of coagulation
 Haemostasis is a complex process in which multiple
components of blood clotting system are activated
in response to vessel injury to control bleeding.

 Haemostasis is composed of four major events

 Primary haemostasis
 Secondary haemostasis
 Fibrin clot formation and stabilization
 Inhibition of coagulation

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1.Primary homeostasis
 Includes vasoconstriction and platelet plug formation
 Triggered by injury to the vessel wall ,exposing sub
endothelial collagen
 Vasoconstriction occur at the site of injury to reduce
blood flow
 Platelets plug formation includes
- Activation
-Adhesions
- Aggregations

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2. Secondary hemostasis
 Activation of coagulation factors and generation of
thrombin
 Three phases
1.Initation of coagulation
2.Amplifiction phase
3.Propagation phase

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3.Fibrin clot formation and stabilization

 Thrombin converts fibrinogen to fibrin monomer which

polymerize to form a soluble clot
 Thrombin then activates factor XIII which crosslink with
fibrin monomers and stabilizes the clot

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4.Inhibition of coagulation = inhibition of thrombin
generation and fibrin
clot breakdown (fibrinolysis)

Inhibition of thrombin generation

 At the same time that a clot is being formed, the clotting
process also starts to shut itself off to limit the extent of
the thrombus formed.
 Thrombin binds to the membrane receptor
thrombomodulin and activates Protein C to Activated
Protein C (APC).

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ROUTINE COAGULATION TESTS

 In the coagulation laboratory, the coagulation

factors are divided into:
• Extrinsic pathway factors (Factor VII)
• Intrinsic pathway factors (Factors XII, XI, IX, VIII)
• Common Pathway factors (Factors X, V, II,
Fibrinogen)

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generalizations

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EVALUATING ABNORMAL COAGULATION
TESTS
 Prolonged PT / INR with normal APTT
 Prolonged APTT with normal PT / INR
 Prolonged APTT and PT / INR
 Prolonged Thrombin time (TT) with normal or
prolonged APTT and PT / INR

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investigations
 Initial investigations should be directed by the history
and include:
 CBC and peripheral blood film
 PT / INR and APTT
 + / - Thrombin time
 + / - Fibrinogen
 + / - Hepatic, renal function
 + / - Ferritin

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 The initial investigations may be normal in both VWD and
PFD.
 Subsequent investigations will depend on the clinical
history and initial test results and may include:
- von Willebrand screen
- Testing of specific coagulation factors
- Platelet function testing

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Clinical manifestations
bleeding disorders
 Divided in to two
- primary hemostasis disorder
platelet disorder and vessel wall disorders
- disorders of coagulations

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Primary hemostatic
disorders
 Mucosal and cutaneous bleeding
mucosal bleeding includes epistaxsis ,gum bleeding
and large bullos hemorrhage on the bucal mucosa
 Bleeding in to the skin ; petechia and superficial
ecchymosis
 Immediate bleeding after trauma ,Petechiae ,
Purpura ,Echymoses , Telangectasia and Menoragia.

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Coagulation disorders
 Large palpable echymosis
 Large spreading deep soft tissu hematoma
 Hemarthrosis
 Delayed bleedings

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Primary Hemostatic
Disorders
 Disorders related to the platelet number and function.
 Clinical feature of bleeding
 Immediate
 Mucocutaneous
 Prototype conditions
 Thrombocytopenias
 Platelet Functional Abnormalities
 Von Willbrand Disease (vWD)

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 BLEEDING DISORDER

Clinical Platelet Defect Clot Factor Deficiency

Characteristics
Site of Bleeding Skin. Mucous Deep in soft tissue
Membrane
Bleeding after Yes Not usual
minor cuts
Petechiae Present Absent

Ecchymosis Small & Superficial Large & Palpable

Hemarthrosis, Rare Common

Hematomas
Bleeding after Immediate & Mild Delayed & Severe
surgery 21
Secondary Hemostatic
Disorders
 Bleeding disorders related to acquired or inherited
deficiency or dysfunction of the coagulation proteins

 Clinical feature of bleeding

 Deep bleeding ( joints, viscera, muscle...)
 Delayed

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 Conditions/diseases
 Hemophilia
 Disseminated Intravascular coagulation (DIC)
 Liver Disease
 Vitamin K deficiency & warfarin overdose
 Other rare inherited bleeding disorders

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VTE

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• VTE includes DVT and PE.
80% of VTE has identifiable
causes, mostly multiple
• Major theory about
pathogenesis
• Virchow’s Triad
– Stasis
– Vascular Injury
– Hypercoagulable/
thrombophilic state
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 CAUSES OF VTE
Inherited thrombophilia
 Factor V Leiden
 Prothrombin Gene Mutation
 Protein C Deficiency
 Protein S Deficiency
 Antithrombin Deficiency
 Rare
 Dysfibrinogenemia

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Acquired causes
• Malignancy • Inflammatory Bowel
• Surgery Disease
• Trauma • Nephrotic Syndrome
• Pregnancy • Myeloproliferative
• OCP disorders
• Immobilization – ET
• Central Catheters – PV
• Drugs • Antiphospholipid Syndrome
• Congestive Heart • Paroxysmal Nocturnal
Failure Hemoglobinuria

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 Diagnosis of dvt
pre test probability
WELL’S SCORE

 Scoring system based on patients risk factors and

clinical findings
 Groups the patient in to three pretest probability
- low , Moderate or high
 Helps to decide which further test to undergo
Patient with low probability and negative D-dimer
test
- no further test , reliabely rules out DVT
• Patients with low probability and positive D-dimer,
moderate and high probability score needs imaging
study
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• Non invasive
– D-dimer
– Compressive ultrasonography
• Invasive
– Contrast venography
• Screening for inherited thrombophilia

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Treatment of VTE
 Anticoagulation
 Thrombolytic
 Thromebectomy
 IVC filtration

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Anaesthesia consideration
A detailed history about the type of haemophilia and VWD
and its severity must be obtained and a detailed
coagulation screen must be done to evaluate the diagnosis
and to monitor treatment as patients are on
anticoagulation.
All patients must be evaluated for the presence of
transfusion related infections such as HIV and hepatitis B
and C.
Perioperative avoidance of mucosal trauma, im injection,
maintenance of normothermia and pressure point care.

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 Examination for the presence of joint deformities
contractures and athorough airway assessment.
 Avoidance of tachycardia and hypertension
 Risk-benefit for neuraxial block and regional blocks
need to be assessed indivitually and in general
avoided.
 Early mobilization consider mechanical deep venous
thrombosis prophylaxis
 Multimodal pain management avoid NSAID drugs

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 In high-risk patients warfarin must be converted to
heparin before surgery with monitoring of
coagulation.
 Patients with haemophilia need 80-100% correction
of their factor 8 before any major surgical procedure
and this must be confirmed before surgery
 Postopratively level should be maintained for upto 6
weeks after orthopedic procedures and 1-2 weeks
for the other procedures.

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Summary
 Patients with inherited coagulation disorders can
have the same perioperative outcome as a normal
patient if care is taken to maintain the deficient
factor levels in bleeding disorders or time
anticoagulation in clooting disorder s in the
perioperative period.also the availibility of
recombinant f8a has revolutionized treatment in
complicated hemophilia patients with inhibitors.

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 Reference
• Douketis J, Spyropolous AC, Kaatz S, Becker RC,
Caprini JA, Dunn AS, et al.
Perioperative Bridging Anticoagulation in Patients
with Atrial Fibrillation. The New England Journal
of Medicine
Morgan 7th edition
Miller 9th edition
Brash 8th edition

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