COAGULATION
COAGULATION
9/9/95: kaufmannm@ubaclu.unibas.ch
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02/16/96 kaufmannm@ubaclu.unibas.ch
Laboratory
PTT (Partial Thromboplastin Time):
Quick / PT (Prothrombin Time):
ACT (activated clotting time):
Bleeding Time:
TT
Fibrinogen:
Norm 1.5 - 4.5 g/l,
Fibrinspaltproduct
Reptilase time
Screening
1. Anamnesis 2. Laboratory checks if positive Anamnesis : . PTT Q No. Thromb. Bleeding Time Liver Disease +/= - -/= = Warfarin = - = = Thrombocytopenia = = - + Aspirin = = = + Heparin + -/= = = Hämophilia + = = = v. Willebrand's disease + = = + DIC +/= -/= - + Massive transfusion + - - +
Drugs
Full Liqueminisierung: 5'000 IU bolus, women 300 (men 400) IU/kg KG/24 hrs.
In vascular surgery, subtherapeutic postoperatively: depending on type of OP, ca. 10'000 IU/24 hrs., TZ 30-50''.
For HLM 300 IU/kg KG as bolus
Antidote: Protamin IU = 1.5 x dose IU Heparin, as short infusion.
Side Effects:
1. Allergic to Type I
2. Fall in blood pressure (Myocardial depression)
3. pulmonal-arterial Hypertonia
Therefore inject Tavegyl as antihistamine beforehand
Warfarin (Vit K Antagonist)
Blocks formation of Factors II, VII, IX, X
Antidote : Vit K = Phytomenadione, required min. 3-6 hrs.; FFP
Acetylsalicylacid
Irreversible inhibitor of cyclo-oxygenase; thrombocyte-lifespan 7 days
Monitoring:
Bleeding time :
2 days after withdrawal, signigicant improvement,
4 days after withdrawal, baseline reached.
Aggregation ability:
4 days after withdrawal, normal at 100 mg/die
7 days after withdrawal, normal at 300 mg/die
Anvitoff
Tranexamic Acid
Inhibits the plasminogen activity
Necessary activity level 5 - 10 g/ml
Dose: 10g (= 20 Ampules à 0.5 g) Tranexamic acid in 250 ml NaCl in the middle of infusion for ca. 30 mins. (Typ. heart operation)
Time: Begin 20 min before start of operation.
By limited kidney function : check Physicians Desk Reference (PDR).
Until now, there has been no observed interference of the ACT test.
Aprotinin (Trasylol)
By still partly unknown mechanisms (Thrombin and Plasmin inhibition), Aprotinin with its connection to the ECC original clotting disorder can reduce blood loss, respectively, the need for a blood transfusion .
Dosage : (For a Heart-OP)
Initial : 2 Mio E Aprotinin (= 280 mg ) during the opening of the thorax for 20 min.
Then : until the end of operation 500 000 E/h Aprotinin
In addition, administer Zusätzlich verabreicht der Kardiotechniker im Prime der HLM 2 Mio E Aprotinin.
Attention: Control of the Heparin action with mean ACT values during Aprotinin is unreliable! Aprotinin works synergisticly with Heparin but can also cause Heparin resistance. During a bypass, the ACT value should be at least 750 seconds.
Antithrombin III
In accordance with Coagulation Consultation (available 24 h/d)
Adults : Begin with 2'500 IU Atenativ®
FFP pro bag Quick increase 5 % (1 IU/kg KG Quick increases 2% and Factors 1%)
Coagulation Factor increases 2-3 %
Volume : 250 +/- 50 ml. Attention : Waterbath not above 38ºC.
Fibrinogen Fibrinogen S-TIM Immuno
Pooled Fibrinogen Concentrate, 1 Bottle = 1g ( in 50 ml : 20 mg/ml)
HBs-Ag and Anti-HIV negative
To increase level to 1 g/l : 3 - 4 g Fibrinogen
Factor VII Factor-VII Concentrate S-TIM 4
Dose (in accordance with Consulation), begin with 600 IU
Factor-VIII-Complex SRK : 200 or 500 IU per bottle
Dosage for Hemophiliac A (iv, max 4 ml/min in a short infusion) :
Dose in IU = kg KG x required factor increase in % x 0.5 or :
Bleeding, Operation Dose Length
IU/kg
Light : 10 - 15 Once often enough
Spontaneous hemorrhage of joints
Light nose bleeding
Bleeding of soft parts
Medium : 15 - 35 Repeat giving half initial
Complete Hemarthrosis dose every 8-12 h
Distinct bleeding in forearm/ for 3 -4 days
calf
Bleeding of the psoas
Tooth extraction
Severe : 35 - 50 Repeat giving half initial
Bleeding from an injury dose every 8 - 12 h.
Preparation for an OP Consult
Intracranial bleeding
GI-bleeding (including throat
and tongue)
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Factor IX-Complex SRK
including F. II, VII, IX, X. 200/500/1000 IU per bottle
Dosage for Hemophiliac B:
Dose in IU = kg KG x required factor increase in %, or
Bleeding, Operation Dose Length
IU/kg
Light : 10 - 25 Once often enough
Spontaneous hemorrhage of joints
Light Nose Bleeding
Bleeding of soft parts
Medium : 15 - 35 Repeat giving half initial
Complete Hemarthrosis dose every 12 - 24 h
Distinct bleeding in forearm/calf until wound healed
Bleeding of the psoas, Tooth extraction
Severe : Consult Consult
Bleeding from an injury
Preparation for an OP
Intracranial bleeding
GI-bleeding (incl. throat
and tongue)
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Thrombocyte
General : only apply with special filters (normally included with supplies); pore size is the same as in other filters but volume setting is bigger !
Preparation can be kept for upto 5 days after receipt.
Preparation should be continuously shaken, and kept not in the refrigerator but in a "Hosensack".
A single pack = 1 bag Tc from 1 whole blood donation (= 1 unit).
Begin with 6 units or :
Pooled Tc (= 6 units from open units)
Keep for no more than 6 hours because of danger of bacterial contamination
If DIC, 3 units ca. every 3 - 4 hours, and control haemostasis.