Coagulopathy (main)

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DDX

Factor VIII Inhibitor

  1. (PTT does not correct after mixing)
  2. high dose Factor VII, prothrombin, or recombinant factor VIIa

Lupus Anticoagulant

  1. (rare)
  2. warfarin or ASA

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

Managment

See Also

Source

  • Tintinalli
  • UpToDate