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Anaesthesiology
Hemostasis and Transfusion Medicine
Built from Barash Clinical Anesthesia, 9th Edition
What’s inside
16 sections · 199 slides
Overview
- Scope of hemostasis and transfusion medicine
- Structure of this topic
Normal hemostasis
- Balance between bleeding and clotting
- Three steps of platelet plug formation
- Platelet adherence to damaged endothelium
- Outside-in platelet activation signaling
- Stabilization through GP IIb/IIIa
- Endothelial inhibition of platelets
- Platelet adherence, activation, stabilization and inhibition
- Reading the platelet pathway map
- Sites of action of antiplatelet medications
Secondary hemostasis
- Definition of secondary hemostasis
- Sequence of thrombin generation
- Four-part structure of a clotting complex
- Extrinsic pathway initiation
- Central functions of thrombin
- Intrinsic pathway and the intrinsic tenase
- Fibrin formation and cross-linking
- Extrinsic, intrinsic and common coagulation pathways
- Coagulation cascade diagram and factor production
- Vitamin K-dependent clotting factors
- Three natural inhibitors of clotting
- Three natural inhibitors of the clotting cascade
- Inhibitory control of the coagulation cascade
- Reading the coagulation inhibitor diagram
Fibrinolysis
- Plasminogen activators in fibrinolysis
- Inhibitors of fibrinolysis
- Fibrinolysis and antifibrinolysis pathways
- Reading the fibrinolysis diagram
Laboratory evaluation of hemostasis
- History as the first screening test
- Bleeding pattern points to the defect
- Platelet count and platelet function tests
- Inherited and acquired von Willebrand disease testing
- Clotting time tests and mixing studies
- Interpretation of a mixing study
- Factor assays and coagulation inhibitors
- Intraoperative whole blood clotting tests
- Principle and output of viscoelastic testing
- Parameters measured by TEG and ROTEM
- TEG and ROTEM parameters and test channels
- Risk factors for venous thromboembolism
- Congenital thrombophilias: factor V Leiden, protein C and S, antithrombin
- Antiphospholipid antibodies and hyperhomocysteinemia
Monitoring anticoagulant therapy
- INR monitoring and pharmacology of warfarin
- Monitoring heparin and recognising HIT
- Monitoring direct oral anticoagulants
- Testing direct thrombin inhibitors and the ecarin clotting time
Blood component production
- Blood donor screening and whole blood separation
- Blood components: volume and storage
- Apheresis collection
- Donor infectious disease testing and CMV precautions
- Directed and autologous predonation
- Leukoreduction, washing, irradiation and platelet storage
- Red cell preservatives and the storage lesion
- Plasma derivatives and factor concentrates
- Red cell substitutes and hemoglobin-based oxygen carriers
Blood products in practice
- Red cell compatibility testing and emergency release
- Shift toward restrictive red cell transfusion
- Society transfusion thresholds by clinical setting
- ASA definition of restrictive transfusion
- Landmark transfusion threshold trials
- Tolerance of anemia and determinants of oxygen delivery
- Equations for tissue oxygenation
- Three compensations for anemia
- Physiologic compensation for anemia
- Clinical indications of tissue hypoxia
- Applying the transfusion decision
- Platelet transfusion thresholds by setting
- Indications for platelet transfusion
- Platelet thresholds and qualitative dysfunction
- Causes of acquired platelet dysfunction
- Platelet dose and expected response
- Plasma preparations, compatibility and dosing
- Indications for the use of plasma products
- Plasma given prophylactically
- Damage control resuscitation and the ratio trials
- Cryoprecipitate: preparation, use and fibrinogen targets
- Indications for fibrinogen replacement
- Fibrinogen concentrate
- Low-titer group O whole blood and cold-stored platelets
Risks of blood product administration
- Overall transfusion risk and human error
- Bedside monitoring during transfusion
- Nucleic acid testing and residual infection risk
- Residual risk of transfusion-transmitted infections
- Residual risk of transfusion-transmitted infections (continued)
- Transfusion-transmitted viruses
- Emerging transfusion-transmitted pathogens
- Bacterial contamination and its control
Non-infectious transfusion reactions
- Non-infectious transfusion reactions
- Non-infectious transfusion reactions (continued)
- Non-infectious transfusion reactions (continued)
- Reading the non-infectious reaction table
- Febrile and allergic transfusion reactions
- Acute hemolytic transfusion reaction: cause and frequency
- Pathophysiology of acute hemolysis
- Acute and delayed hemolytic reactions compared
- Transfusion-related immunomodulation and its mechanisms
- Red cell and platelet alloimmunization
- Transfusion-associated dyspnea
- Transfusion-related acute lung injury
- Transfusion-associated graft-versus-host disease
- Post-transfusion purpura and its treatment
- Transfusion-associated circulatory overload and its prevention
- TRALI compared with circulatory overload
- Hyperkalemia and citrate toxicity in massive transfusion
- Hypothermia from transfusion and its prevention
- Iron overload: mechanism and chelation
Patient blood management
- Patient blood management and its effect
- Perioperative blood conservation strategies
- Preoperative anemia and the Frankfurt Consensus
- Oral versus intravenous iron and their safety
- Perioperative erythropoietin
- Autologous blood transfusion in principle
- Three routes to autologous transfusion
- Preoperative autologous donation: indications and limits
- Acute normovolemic hemodilution: technique and selection
- Cell salvage: technique, yield and contraindications
- Caring for Jehovah's Witness patients
Disorders of hemostasis
- Classification of hemostatic disorders
- Classification of hemostatic disorders
- Bleeding patterns in primary and secondary disorders
- Bernard-Soulier and Glanzmann receptor defects
- von Willebrand disease: prevalence and function of vWF
- Classification of inherited von Willebrand disease
- Types, diagnosis and treatment of von Willebrand disease
- Hemophilia: types, features and treatment
- Factor V Leiden and protein C and S deficiency
- Vitamin K deficiency: causes and treatment
- Hemostatic balance in chronic liver disease
- Definition of disseminated intravascular coagulation
- Common disorders associated with disseminated intravascular coagulation
- Reading the DIC associations table
- Pathophysiology of disseminated intravascular coagulation
- Mechanism and presentation of DIC
- Bleeding pattern and diagnosis of DIC
- Scoring algorithm for the diagnosis of disseminated intravascular coagulation
- Scoring algorithm for the diagnosis of disseminated intravascular coagulation (continued)
- Scoring and transfusion management of DIC
- Cryoprecipitate and anticoagulation in DIC
Antiplatelet and anticoagulant drugs
- Four classes of antiplatelet drug
- Cyclooxygenase inhibitors: aspirin, NSAIDs and COX-2 drugs
- Phosphodiesterase inhibitors as antiplatelet drugs
- P2Y12 antagonists and clopidogrel resistance
- GP IIb/IIIa antagonists and their pharmacokinetics
- Vorapaxar
- Warfarin: indications, mechanism and targets
- Warfarin reversal without major bleeding
- Escalating warfarin reversal
- Emergency warfarin reversal: PCC versus plasma
- Why rFVIIa is not used to reverse warfarin
- Practical difficulties with warfarin
- Direct oral anticoagulants: agents and advantages
- Comparison of oral anticoagulation medications
- Oral anticoagulant comparison and trial evidence
- Reversal of dabigatran and factor Xa inhibitors
- Timing of preoperative DOAC discontinuation
- Unfractionated and low molecular weight heparin
- Fondaparinux
- Heparin-induced thrombocytopenia: types, diagnosis, treatment
- Parenteral direct thrombin inhibitors
Prohemostatic drugs
- Recombinant activated factor VII: indications and risks
- Prothrombin complex concentrates: composition, use and risk
- Desmopressin: mechanism, dosing and evidence
- Antifibrinolytic agents: aprotinin and lysine analogs
Summary
- Key points on normal hemostasis
- Key points on laboratory testing
- Key points on transfusion practice
- Key points on transfusion risk
- Key points on bleeding disorders
- Key points on drug therapy
- Conclusions
- Perioperative responsibility of the anesthesia provider
References
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- References (continued)
- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition