Approach to bleeding disorders in ICU

Approach to bleeding disorders in ICU:

Approach to bleeding disorders in ICU Dr Bikram Gupta MD Anaesthesia PDCC in Critical care

Key elements:

Key elements History Physical examination Lab investigations

Slide 5:

Tooth extraction Menses Circumcision delivery

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Tooth extraction Menses Circumcision Delivery Easy bruising Lower limb pain Abdominal pathology Immobilisation

WHO:

WHO Age Sex Family history (AR or AD/x linked)

WHEN:

WHEN Underlying Disease Trauma Surgery Drug ingestion

Diagnostic clues:

Diagnostic clues Cardiac surgery Sepsis Pulmonary failure Seizure Renal failure Cardiac failure Liver failure pregnancy HIT Dilutional

Diagnostic clues:

Diagnostic clues Cardiac surgery Sepsis Pulmonary failure Seizure Renal failure Cardiac failure Liver failure pregnancy Mechanical ventilation CVP line Drug induced DIC hemophagocytosis

Diagnostic clues:

Diagnostic clues Cardiac surgery Sepsis Pulmonary failure Seizure Renal failure Cardiac failure Liver failure pregnancy Mechanical ventilation CVP line DIC Hanta virus

Diagnostic clues:

Diagnostic clues Cardiac surgery Sepsis Pulmonary failure Seizure Renal failure Cardiac failure Liver failure pregnancy TTP

Diagnostic clues:

Diagnostic clues Cardiac surgery Sepsis Pulmonary failure Seizure Renal failure Cardiac failure Liver failure pregnancy TTP Dengue HIT DIC

Diagnostic clues:

Diagnostic clues Cardiac surgery Sepsis Pulmonary failure Seizure Renal failure Cardiac failure Liver failure pregnancy HIT Drug induced

Diagnostic clues:

Diagnostic clues Cardiac surgery Sepsis Pulmonary failure Seizure Renal failure Cardiac failure Liver failure pregnancy Splenic sequestration Drug induced DIC HIT

Diagnostic clues:

Diagnostic clues Cardiac surgery Sepsis Pulmonary failure Seizure Renal failure Cardiac failure Liver failure pregnancy HELLP syndrome Fatty liver TTP

Drugs :

Drugs Antiarrhythmic chemotherepy gpIIb/IIIa inhib Amp b/ rifampin / vancomycin/ ceftriaxone/ penicillin H2 blockers NSAIDS Heparin Thiazide, ACE inhibitors Quinine / carbamazepine

Where:

Where Site Skin Mucous membrane GIT Genitourinary tract Retroperitoneal Joint- muscle Intracranial bleed Platelet defect Plasma protien defect

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Hemophilia

Lab investigation:

Lab investigation Hematocrit with CBC Peripheral smear (fragmented RBC) BT PT aPTT TT

Plat. Counts:

Plat. Counts 50,000-1 lakh TTP HIT DIC Hemophagocytosis <20,000 Drug induced Post transfusion Immune

BT -cut are made (1mmx6mm):

BT -cut are made (1mmx6mm) Normal range 2-10mts Prolonged in Platelet Disorder Bernard Soulier Glanzmann Scott Insensitive Severe anaemia Subcut edema NSAIDS collagen vascular disease Marrow failure Uremia

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MILD Heparin Liver disease SEVERE Hemophilia VWD

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MILD Heparin Liver disease SEVERE Hemophilia VWD Anticoagulant Postpartum Drug Antiphospholipid

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warfarin Liver disease Vit k defi

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warfarin Liver disease Vit k defi Lupus anticoagulant Postpartum Drug Antiphospholpid Elderly

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Thrombin time:

Thrombin time Normal< 22 sec Elevated in Dysfibrogenemia Heparin

Other :

Other PFA 100 detects qualitative platelet defects Cannot predict bleeding risk and cant monitor antiplatelet agents

Other :

Other Invitro platelet aggregation test VWF antigen Electrophoresis VWF activity: ristocetin Urea clot stability (for XIII) Fibrinogen conc.

HIT:

HIT Drop >50% (Auto Ab to PF4) 5-14 day after start Confirm – platelet aggregation essay (after 24hr)/ELISA Doppler of lower extremity stop all heparin, add argatroban/lepirudin/fondaparinux Bleed rare Thrombosis in 50% case

Posttransfusion purpura:

Posttransfusion purpura Thrombocytopenia <20,000 Within 7-10 day Tt- IVIg, plasmapheresis

Liver disease:

Liver disease Factor defi / enhanced fibrinolysis / delayed clearance of plasmin In hypo fn- vit k ineffective (mild indic) Attempt to normalise INR volume overload portal pressure further bleed FFP – limit INR 1.5 Antifibrinolytic therapy (tranexa)

Uremia :

Uremia Aggressive hemodialysis Desmopressin 0.3 micg/kg IV Cryoprecipitate 10 units

TTP (drug,preg]:

TTP (drug,preg] Thrombocytopenia, microangiopathic hemolytic anemia with end organ damage Think of TTP in a pt with renal failure, fluctuating neuro deficit and fever LDH raised, schistocyte with normal coagulation studies Tt- 1.5 plasma exchange/day – 5 days prednisolone 60-120 mg/day plt transfusion contraindicated until spont bleed +nt splenectomy may be tried Misdiagnosed as sepsis, DIC

DIC:

DIC Cause –obstetric, neoplasm, embolism, infections, acute glomerulonephritis Lab- intravasc hemolysis, low fibrinogen, prolonged time, high FDP Tt Correct cause Control bleed (FFP, croprecipitate,platelet) Use of heparin controversial ( reserved for patients who continue to bleed despite tt or are at risk of thrombosis)

Mx of platelet refractory pt:

Mx of platelet refractory pt Stop possible cause Check platelet count after starting infusion If rise <5000, check HLA Ab Give HLA matched platelet If complete refractory 1 plt transfusion/day Trenaxa 10mg/kg 8hrly EACA 1g/hr IV Cause :drug

Thanks for ur patience:

Thanks for ur patience