Coagulopathy (main)

Liver Disease

Background

• PT prolongation
  • Decreased synthesis of vitamin K-dependent factors (II, VII, IX, X)
• Thrombocytopenia
  • Portal hypertension -> congestive hypersplenism -> splenic sequestration
• Fibrinolysis increased
  • Due to decreased synthesis of alpha2 plasmin inhibitor
  • Low fibrinogen level, mild elevation of FDP and D-dimer

Treatment

1. Lab abnormalities only (w/o significant bleeding)
   1. Observation
2. Significant bleeding
   1. Vitamin K PO or IV
   2. Desmopressin
      1. Effective w/ minimal side effects
      2. 0.3 mg/kg IV (preferred) or SC (max 20mg)
      3. Onset of action ~1hr, duration of action ~4-24hr
   3. Cryoprecipitate
      1. May be used to replace fibrinogen in pts w/ fibrinogen levels <100
      2. 1 bag per 10kg of body weight
   4. Plts
      1. Aim for >50K for moderate risk procedures; >100K for high risk procedures
   5. FFP
      1. Use w/ caution; requires large volume of FFP to make a significant difference
   6. PPI/pepcid/octreotide (variceal bleed)

Renal Disease

Background

• Uremic toxins inhibit platelet aggregation
• Dialysis filter may cause thrombocytopenia

Treatment

1. Acute dialysis
   1. pRBCs
      1. Raising hct to above 25-30% improves bleeding time
   2. Desmopressin
      1. Simplest and least toxic acute treatment
      2. Increases release of factor VIII:von Willebrand factor multimers
      3. 0.3 mg/kg IV (preferred) or SC (max 20mg)
      4. Onset of action ~1hr, duration of action ~4-24hr
2. Estrogen
   1. Unclear mechanism of action
   2. Onset of action within 1d
   3. Options
      1. Conjugated estrogen 0.6mg/kg IV or 2.5-25mg PO daily
3. Cryoprecipitate
   1. Only indicated for life-threatening bleeding resistant to DDAVP and blood tranfusion
4. Plt transfusion
   1. Minimally effective b/c infused plts quickly acquire the uremic defect

See Also

• Bleeding Treatment
• Hemophilia

Source

• Tintinalli
• UpToDate