Location via proxy:   [ UP ]  
[Report a bug]   [Manage cookies]                

Bleeding & Coagulation

Download as ppt, pdf, or txt
Download as ppt, pdf, or txt
You are on page 1of 72

Anaemia, Haemostasis and

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

 normal red cells, reduced Hb


 deficiency states - Fe, Folate, Vit B12
 abnormal globin chains
 Thalassaemia
 Sickle Cell
 chronic inflammatory disease
Aplastic Anaemia
Aplastic Marrow Normal Marrow
Anaemia - Production
 reduced normal red cells
 marrow failure

 normal red cells, reduced Hb


 deficiency states - Fe, Folate, Vit B12
 abnormal globin chains
 Thalassaemia
 Sickle Cell
 chronic inflammatory disease
Thalassaemia
Thalassaemia
 Normal Haem production

 Genetic mutation of globin chains


 Alpha chains (alpha thalassaemia)
 Asians
 Beta chains (beta thalassaemia)
 Mediterraneans
Thalassaemia
 Clinical Effects
 Chronic anaemia
 Marrow hyperplasia (skeletal deformities)
 Splenomegaly
 Cirrhosis
 Gallstones

 Management
 Blood transfusions
 Prevent iron overload
Sickle Cell Anaemia

Sickled Red Cells Normal Red Cells


Anaemia - Losses (RCC & HCT)
 normal red cells – bleeding

 abnormal red cells


 autoimmune
 hereditary - SICKLE, G6PD,
spherocytosis
Anaemia - Increased Demand
 pregnancy
 malignant disease
Anaemia cell terminology
(MCV)
 microcytic
 small RBC - Fe def., Thalassaemia
 macrocytic
 large RBC - B12/folate def., Retics
 normocytic
 normal RBC - bleed, renal, chronic
diseasel

 HYPOTHYROIDISM may mimic any!


Reticulocytes
Anaemia Diagnosis
 what is the Hb?
 degree of anaemia

 what are the RCC and HCT?


 Red cell deficiency or Hb formation deficiency

 What is the MCV?


 Is there a deficiency picture?
 What is the likely deficiency?
Pale mucosa
Smooth Tongue - Iron
‘Beefy’ tongue – Vit B12
Anaemia
Signs and Symptoms
Signs Symptoms
 pale  tired & weak

 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

 Bone Marrow examination


Anaemia - treatment
 treat cause!
 Replace haematinics
 FeSO4 200mg tds for 3months
 1mg IM vit B12 x 6 then 1mg/2 months
 5mg Folic acid daily

 Transfusions - production failure

 erythropoeitin - production failure


Anaemia - pointers for exams
 know how to differentiate deficiency from
bleeding (RCC, HCT & MCV)

 know how to tell what type of an anaemia


(MCV)

 know normal values for Hb, RCC, WCC,


MCV, HCT, PLT (g/dL or cellsx106/L)
Anaemia - pointers for exams
 know about iron deficiency anaemia
 ferritin estimation

 know about Folate/ B12 deficiency


 red cell folate, vit B12

 know common causes of blood loss


 young - male and female
 elderly
Haemostasis
Clinical Aspects
 ALWAYS ask about bleeding
problems!

 ALWAYS LOOK for bleeding problems!


 skin - red spots or purpura
 mucosa - purpura or blood blisters

 If in doubt TEST first


 FBC (Platelets), INR, APPT
Haemostatic disorders
 Vascular component
 retraction of vessel (collagen disorder)

 Cellular component
 platelets number and function

 Coagulation component
 adequate clotting
 adequate clot lysis
Cellular component
 platelet number – FBC

 platelet function - ‘bleeding time’

 REMEMBER ASPIRIN & NSAIDS


 permanent effect on platelets
 7-10 days to form new platelets
Bleeding disorders
Useful tests:- FBC, bleeding time
 ITP
 shortage of numbers
 50x106/L min for extractions
 can boost with steroids

 Throbocythaemia
 ‘myeloproliferative’ abnormal cells
 poor function
Coagulation component
 adequate amount of clotting factors
 synthesis, consumption

 adequate range of clotting factors


 hereditary deficiency - VIII, IX

 proper balance between thrombotic


and thrombolytic systems
Coagulation Cascade
Coagulation Cascade
Disseminated Intravascular
Coagulation (DIC)
Coagulation

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

 Tranaxemic acid (systemic)


 DDAVP
 Replacement clotting factor concentrate

 REMEMBER INHIBITORS!
Thrombophilia
 Patients with congenital deficiencies
 antithrombin deficiency
 Protein C deficiency
 Protein S deficiency
 APCR - Factor V Leiden variant

 Patients with antiphospholipid syndrome

 Patients with nephrotic syndrome


Thrombophilia

Crean et al, Dental Update 2000;27(6):302-5


Anticoagulation
Risk groups
Known risk groups Relative risk
 Certain cardiac  Smokers!
conditions  Oral contraceptive
 REMEMBER
 Pregnancy
antibiotic
prophylaxis!  Immobility
 Trauma/surgery
 Malignant disease
 Myelodysplasia
Anticoagulated Patients
 Stroke & MI Prevention

 Atrial fibrillation (2.5)


 Prosthetic heart valves (3.5)
 Cardiomyopathy (2.5)
 Hypokinetic myocardial segment (2.5)
 Recurrent pulmonary embolism (2.0-3.5)
Drugs used in anticoagulation
 Anti platelet drugs
 aspirin
 dipyrimadole
 Clopidogrel

 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

 no alteration of regime necessary


 ? for aspirin & Clopidogrel combination

 CARDIOVASCULAR RISK

 Drug interactions
 none significant
Heparin Drugs
 unfractionated heparin (1hr half life)
 iv infusion (pump)
 Sub cut. MINIHEP prophylaxis
Monitor with APPT

 LMW heparins (3-6hrs half life)


 tinzaparin
 dalteparin
 enoxaparin*
 certoparin
not monitored
Heparin - indications
 DVT prophylaxis (minihep)

 unstable angina
 acute MI
 Recurrent DVT waiting for INR
 Disseminated Intravascular Coagulation
 Surgical cover for warfarinised patients
Heparins - Action
Mast cell produced glycosaminoglycan

 enhances Antithrombin III

 inhibits Factor Xa

 inhibits platelet function


 aggregation
 activation by thrombin (with
AT3)

 LMW heparin mainly by Xa


Heparin - Interactions
 enhanced by concomitant use of
antiplatelet drugs
 aspirin
 Other NSAIDs
Heparin - Treatment
 rapid alteration in anticoagulation possible
(APPT)

 unfractionated by:
 syringe pump - therapeutic anticoagulation
 subcutaneous injection – prophylaxis

 LMW Heparin by:


 subcutaneous injection by patient - once/twice
daily
 no ‘routine’ monitoring used

 routine OS/extractions DO NOT STOP


Warfarin
 monitor with International Normalised Ratio

 inhibits synthesis of II, V, IX, X


 slow - 2-3 days
 Anticoagulates

 inhibits synthesis of Protein C & S


 quick
 enhances coagulation
Warfarin Interactions

Assume ALL drugs interact


with Warfarin
Warfarin - Significant Interactions
 NSAIDs

 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

 discontinue heparin when INR therapeutic


Post procedure bleeding
 CONTACT HAEMATOLOGIST!

 Vitamin K - 0.5mg IV for warfarin


 delay due to time for factor synthesis

 Fresh frozen plasma (FFP) warfarin/heparin

 Protamine IV (heparin)
 instant reversal - displaced from AT3 binding

DO NOT GIVE SYSTEMIC TRANEXEMIC ACID


General Principles
 Treatment planning
 avoid bleeding prone procedures?
 Avoid known drug interactions

 Atraumatic surgery
 experienced operator
 planned surgical removal
Practical Patient Management
 Extractions
 immediate haemostasis
 late bleeding

 Regional block anaesthesia

 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

 supplied as 5ml 10% solution

 use TOPICALLY ONLY

 dilute with 5ml water - 5% solution


 on gauze swab - bite pack
 oral rinse - 4 x daily for 1 week (RINSE & SPIT)
Blood transfusion
 Where one or more components of
the blood has to be replaced quickly
 Red cells, platelets
 Clotting factors (fresh frozen plasma)

 Where the bone marrow cannot


produce blood cells
 Red cells
 platelets
Ethical Issues
Where does it come from?
Blood antigens
 ABO system
 A
 B
 O
 AB
 D system (rhesus)
 + or -
Population Variations
Blood transfusion - indications
 Blood loss
 Specific production problems
 RBC, Platelets
 Plasma proteins
 clotting factors, albumin, gamma globulins

 In general AVOID if at all possible!


Blood transfusion - process
 Sample taken from patient
 Tested against known blood types
 Basic ABO compatibility
 Rhesus compatibility
 Does not always detect irregular
antibodies

 Tested against donated sample


 Matched blood given to patient
Cross Matching
Cross-matching
Cross-matching
Transfusion Complications
 Incompatible blood
 RBC lysis
 Fever, jaundice, death!

 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

 Monitor temperature, pulse & BP


every 15mins during transfusion

 STOP transfusion if a significant


change
 Small increase in temperature common

You might also like