Bleeding & Coagulation
Bleeding & Coagulation
Bleeding & Coagulation
Anticoagulation
Dr A.J. Crighton
Anaemia
reduction in HAEMOGLOBIN in the
blood - not necessarily RED CELLS
causes:
reduced PRODUCTION
increased LOSSES
increased DEMAND
Anaemia – Production Failure
reduced normal red cells
marrow failure
Management
Blood transfusions
Prevent iron overload
Sickle Cell Anaemia
tachycardia dizzy
SOB
rarely palpitations
enlarged liver
enlarged spleen
Anaemia - investigations
HISTORY
FBC (Ferritin & RC Folate/vit B12 )
FOB (Faecal Occult Blood)
Endoscopy/Colonoscopy
Renal Function
Cellular component
platelets number and function
Coagulation component
adequate clotting
adequate clot lysis
Cellular component
platelet number – FBC
Throbocythaemia
‘myeloproliferative’ abnormal cells
poor function
Coagulation component
adequate amount of clotting factors
synthesis, consumption
Normal
Clot lysis
Clot formation
Inherited Malfunction of Clotting
Hypofunction
haemophilia A
haemophilia B (Christmas disease)
haemophilia C (von Willebrand disease)
other factor deficiencies (rare)
Hyperfunction
thrombophilia
Coagulation
Normal
Haemophilia
Thrombophilia
Clot lysis
Clot formation
Haemophilia - Management
Seek Specialist advice
Individually tailored treatment plan
Depends on patient’s clotting factor activity
REMEMBER INHIBITORS!
Thrombophilia
Patients with congenital deficiencies
antithrombin deficiency
Protein C deficiency
Protein S deficiency
APCR - Factor V Leiden variant
Heparins
unfractionated
low molecular weight
heparinoid - danaparoid
hirudins –lepirudin
Warfarin
Antiplatelet drugs - action
Aspirin
inhibit platelet production of thromboxane A2
effect lasts until platelets replaced - 1 week
Dipyridamole
inhibits platelet phosphodiesterase
Clopidogrel
Inhibits ADP dependent platelet aggregation
Antiplatelet Drugs - Treatment
minimal effect of normal clotting
CARDIOVASCULAR RISK
Drug interactions
none significant
Heparin Drugs
unfractionated heparin (1hr half life)
iv infusion (pump)
Sub cut. MINIHEP prophylaxis
Monitor with APPT
unstable angina
acute MI
Recurrent DVT waiting for INR
Disseminated Intravascular Coagulation
Surgical cover for warfarinised patients
Heparins - Action
Mast cell produced glycosaminoglycan
inhibits Factor Xa
unfractionated by:
syringe pump - therapeutic anticoagulation
subcutaneous injection – prophylaxis
Erythromycin
Metronidazole
Azole antifungals
TOPICAL and Systemic
MICONAZOLE - all preparations
fluconazole, itraconazole
Warfarinised patients
Check INR
if - in therapeutic range (<3.5)
if - for 1-4 teeth
perform treatment - local haemostatic measures
optional tranexamic acid rinse
Major Procedures
transfer to heparin (1-3 days prior to
treatment)
in patient if unfractionated
outpatient if LMW heparin
perform procedure
all local haemostatic measures used
restart warfarin
Protamine IV (heparin)
instant reversal - displaced from AT3 binding
Atraumatic surgery
experienced operator
planned surgical removal
Practical Patient Management
Extractions
immediate haemostasis
late bleeding
Gingival surgery
Drug interactions
Local haemostatic measures
socket compression
local anaesthetic/vasoconstrictor
Sutures
clot activators
surgicel, gelatin sponge
Tranaxemic acid
Tranaxemic acid
Prevents plasmin binding to fibrin
prevents fibrin breakdown
Fluid overload
Heart failure
Transmission of infection
Blood borne viruses
CMV, Hepatitis B, Hepatitis C, HIV, TT virus
Prion Disease
vCJD
Bacterial Infections
Syphilis
Transfusion Protocol
Filter the blood to remove any clots