1. Coagulopathy Bundarika Suwanawiboon M.D. Yingyong Chinthammitr M.D. Theera Ruchutrakool M.D. Division of Hematology Department of Medicine Faculty of medicine Siriraj Hospital Bangkok Thailand 10700

2. Coagulopathy Bundarika Suwanawiboon M.D. Yingyong Chinthammitr M.D. Theera Ruchutrakool M.D.

3. Coagulopathy Outline  Basic of Normal Hemostasis (35 minutes) Theera  Clinical and Laboratory Approach to Bleeding Patients (35 minutes) Bundarika  Management of Bleeding Patients (35 minutes) Yingyong  Question and answer (15minutes) All

4. Normal Hemostasis Normal hemostasis  Blood vessel  Platelet  Coagulation factors  Fibrinolytic system  Natural anticoagulants

5. Red blood cell Platelet

6. Red blood cell Platelet

7. Red blood cell Platelet Von Willebrand factor

8. Red blood cell Platelet Von Willebrand factor

9. Red blood cell Platelet Von Willebrand factor

10. Red blood cell Platelet Von Willebrand factor

11. Red blood cell Platelet Von Willebrand factor

12. Red blood cell Platelet Von Willebrand factor

13. Red blood cell Platelet Von Willebrand factor

14. Red blood cell Platelet Von Willebrand factor

15. Red blood cell Platelet Von Willebrand factor

16. Red blood cell Platelet Von Willebrand factor Fibrin polymer

17. Red blood cell Platelet Von Willebrand factor Fibrin polymer

18. Red blood cell Platelet Von Willebrand factor Fibrin polymer

19. Normal Hemostasis Normal hemostasis  Blood vessel  Platelet  Coagulation factors  Fibrinolytic system  Natural anticoagulants

20. Blood vessel  Endothelium  Connective tissue or collagen Normal Hemostasis

21. Blood vessel  Endothelium Normal Hemostasis Antithrombotic Effect  Thrombomodulin  Platelet derived relaxing factor (PDRF)  Prostacyclin (PGI2)  Tissue plasminogen activator Thrombogenesis  von Willebrand factor  Tissue thromboplastin  Endothelin

22. Blood vessel  Endothelium  Connective tissue or collagen Normal Hemostasis

23. Blood vessel  Endothelium  Connective tissue or collagen Normal Hemostasis  Collagen direct bind and activate platelet  Release von Willebrand factor to bind platelet

24. Normal Hemostasis Platelet  Adhesion  via glycoprotein (GP)  Shape change  from disc to ameboid form  Release  ADP, thromboxane A2, vWF  Aggregation  via glycoprotein (GP)

25. Normal Hemostasis Platelet ligandreceptor  adhesionvWFGP Ib/IX/V collagenGP Ia/IIa  aggregationfibrinogenGP IIb/IIIa

26. Normal Hemostasis Platelet Platelet plug formation and vasoconstriction Primary hemostatic plug formation which is enough to stop bleeding from small and shallow wound

27. Factor XII HMWK/PK Factor XIFactor XIa Factor IXFactor IXa Factor VIIa Factor VIIIa Tissue factor Factor XFactor Xa Factor X Factor Va Prothrombin Thrombin Fibrinogen Fibrin Normal Hemostasis Coagulation pathway

28. Factor XII HMWK/PK Factor XIFactor XIa Factor IXFactor IXa Factor VIIa Factor VIIIa Tissue factor Factor XFactor Xa Factor X Factor Va Prothrombin Thrombin Fibrinogen Fibrin Normal Hemostasis Common pathway Intrinsic pathway Extrinsic pathway

29. Factor XII HMWK/PK Factor XIFactor XIa Factor IXFactor IXa Factor VIIa Factor VIIIa Tissue factor Factor XFactor Xa Factor X Factor Va Prothrombin Thrombin Fibrinogen Fibrin Normal Hemostasis Coagulation pathway

30. Normal Hemostasis Factor XII HMWK/PK Factor XIFactor XIa Factor IXFactor IXa Factor VIIa Factor VIIIa Tissue factor Factor XFactor Xa Factor X Factor Va Prothrombin Thrombin Fibrinogen Fibrin heparin Activated proteinC ProteinC Protein S antithrombin Natural anticoagulant

31.  High Molecular Weight Kininogen (HMWK)  Prekallekrein (PK)  F.XII  Tissue plasminogen activator (t-PA)  Urokinase PlasminogenPlasmin Fibrin polymer Fibrin degradation products (FDP) Normal Hemostasis Fibrinolytic system Streptokinase

32. Normal Hemostasis “New concept !” Cell-based model of coagulation

33. 1. Initiation 3. Propagation IIa 2. Amplification Hemostasis occurs on two surfaces: TF- bearing cells and platelet Normal Hemostasis

34. TFVIIa TF-expressing cell TFVIIa Activated platelet platelet X VaVa XaXa prothrombin thrombin VIII/vWFVIIIa V XIXI XIa Va prothrombin thrombin X XaXa VaVa IXIX IX a VII Ia IXIX XI a Hoffman M et al. Blood Coagul Fibrinolysis. 1998; 9(suppl 1): S61-S65.

35. TFVIIa TF-expressing cell TFVIIa Activated platelet platelet X VaVa XaXa prothrombin thrombin VIII/vWFVIIIa V XIXI XIa Va prothrombinthrombin X XaXa VaVa IXIX IX a VII Ia IXIX XI a Hoffman M et al. Blood Coagul Fibrinolysis. 1998;9(suppl 1):S61- S65.

36. Cell-based model“Three overlapping phases”  Initiation phase “TF-bearing cell to generate F.Xa, F.IXa and (little amount of) thrombin”  Amplification phase “Gererate cofactor F.V and F.VIII by little amount of thrombin from initiation phase”  Propagation phase “Large amount of thrombin production (burst of thrombin) on activated platelet”

37. Approach to Hemostatic Disorders: Clinical and Laboratory Approach Bundarika Suwanawiboon, M.D. Division of Hematology Department of Medicine

38. What is the diagnosis?

39. Clinical Evaluation of Bleeding Patients “80% of correct diagnosis can be made by history taking and physical examination.”

40. History Taking Identify if the bleeding problem is due to Local vs. systemic defect Location: single vs. multiple sites Severity: Spontaneous? Appropriate to trauma? Hereditary vs. acquired disorder Onset Family history Underlying disease Medication Primary vs. secondary hemostatic disoder

41. Deep Deep ecchymosis, hematoma Rare Retroperitoneal hematoma, hemarthrosis Superficial Petechiae, superficial ecchymosis Common Rare Sites Skin Mucosal Others DelayedImmediate Onset Secondary HemostasisPrimary Hemostasis

42. Primary Hemostatic defectSecondary Hemostatic defect

43. Laboratory Investigation of Hemostatic Disorders

44. Assessment of Primary Hemostasis Platelet Complete blood count (CBC) Bleeding time/ PFA-100 Platelet aggregation study Blood vessel Bleeding time von Willebrand factor (vWF) Bleeding time vWF Antigen, vWF: RCO, vWF multimer, FVIII

45. Complete Blood Count (CBC) Platelet number Normal platelet count: 150,000 –400,000/uL > 100,000/uL Bleeding unlikely < 20,000/uL ↑ risk for spontaneous bleeding Must exclude pseudothrombocytopenia Assess for platelet morphology

46. Bernard-Soulier Syndrome Giant platelet Thrombocytopenia Pseudothrombocytopenia

47. Etiology of Thrombocytopenia Decreased Production Hypoproliferation Ineffective Thrombopoiesis Aplastic Anemia, Amegakaryocytic thrombocytopenia, infection, toxins, drugs Infiltrative marrow disease, TAR Megaloblastic anemia Increased Destruction Immune Non-immune Alloimmune, Autoimmune: ITP, SLE DIC, TTP, HUS Others Splenic sequestration Dilutional Hypersplenism Massive blood transfusion

48. Bleeding Time

49. Bleeding Time: Interpretation Normal value* : 1-9 min Prolonged bleeding time: Thrombocytopenia/ anemia (Hct < 20%) Hereditary platelet dysfunction von Willebrand disease Severe hypofibrinogenemia Blood vessels disorders Uremia Myeloproliferative disorders Medication: Aspirin, NSAIDs,other antiplatelet drugs

50. Platelet Aggregation Study

51. Normal Platelet Response Arterioscler Thromb Vasc Biol 2000 20:285

52. Epinephrine ADP Collagen Ristocetin Arachidonic acid Normal +++ +++ +++ +++ +++ Glanzmann’s - - - +++ - Thrombasthenia Bernard-Soulier +++ +++ +++ - +++ Syndrome Storage Pool + +* +* +++ ++ Disease (no secondary wave) Aspirin + ++ + ++ - Effect

53. von Willebrand Factor Synthesized in endothelial cells and megakaryocytes Two important functions: Carrier protein for plasma FVIII Ligand binding to platelet GPIb receptor to initiate platelet adhesion

54. Primary Hemostasis: vWF Arterioscler Thromb Vasc Biol 2000 20:285

55. von Willebrand Factor Panel vWF antigen vWF ristocetin cofactor activity vWF multimer analysis FVIII level

56. vWD Laboratory Diagnosis Test/Type 1 2A 2B 2M 2N 3 BT N or ↑ ↑ ↑ N or ↑ ↑ ↑ N ↑↑↑↑ vWF:Ag ↓ ↓ ↓ ↓ or N ↓ or N ↓↓↓↓ vWFR:Co ↓ ↓↓↓ ↓↓ ↓ ↓ or N ↓↓↓↓ LD-RIPA - - ↑ - - - FVIII N or ↓ N or ↓ N or ↓ N ↓↓↓ ↓↓↓ Multimer N but ↓ abnormal abnormal N but ↓ N but ↓ absent

57. vWF Multimer Analysis Hoffmann. 4 th Ed.Hematology Basic Principles and Practice

58. Assessment of Secondary Hemostasis Screening tests: PT aPTT Mixing study Additional Tests Fibrinogen Thrombin Time Reptilase time Coagulation factor assays D-dimer Fibrin Degradation Product Euglobulin lysis time

59. Accurate Sample Collection is the Key Always use 3.2% sodium citrate tube and sent to the lab immediately. Fill tube to the proper level. (anticoagulant to plasma ratio = 1:9) Modification may be required based on Hct Sodium citrate (ml) = (100 – Hct pt) x 0.5 / 55* * normal plasma vol.

60. XII XIIa XIXIa HMWK IXaIX VIIIa/PL Tenase Ca ++ XXa II IIa Va/PL Ca ++ Fibrinogen Fibrin X-linkedFibrin XIIIa Intrinsic Pathway Extrinsic Pathway Common Pathway XII XIIa XI HK/PK IXa/ IX VIIIa VIIa/TF VIIVIIa TF Ca ++ XXa II IIa Va/PL Ca ++ Fibrinogen Fibrin XIa

61. Prothrombin Time (PT) PT : test extrinsic and common pathway

62. Activated Partial Thromboplastin Time (aPTT) aPTT : test intrinsic and common pathway

63. Mixing Study + 0%100% 50% <35% Correctable Normal coagulation time Uncorrectable prolonged coagulation time Deficiency Inhibitor Prolonged PT or aPTT occurs when coagulation factor < 35-40%

64. Interpretation of Abnormal Coagulogram Isolated prolonged PT Isolated prolonaged aPTT Prolonged PT and aPTT

65. Isolated prolonged PT Mixing study Correctable Uncorrectable Deficiency Inhibitor Hereditary: FVII FVII (rare) Lupus anticoagulant Acquired: Early liver impairment Vitamin K antagonist Vitamin K deficiency

66. Isolated prolonged aPTT Bleeding No bleeding Mixing study Mixing study Correctable Uncorrectable Deficiency Inhibitor Factor VIII /vWD Factor VIII Factor XII Factor XII Factor IX Factor IX HMWK HMWK Factor XI Factor XI Prekallekrein Prekallekrein Heparin Lupus anticoagulant

67. Acquired FVIII inhibitor

68. Prolonged aPTT and PT Mixing study Correctable Uncorrectable - FII,FV or FX deficiency - FII, V, or X inhibitor - FV and VIII deficiency - Lupus anticoagulant - Liver disease - LAC + Factor inhibitor - Vitamin K antagonist - Vitamin K deficiency - DIC

69. Bleeding Disorders with Normal PT and aPTT Factor XIII deficiency Dysfibrinogenemia Mild isolated factor deficiency   -antiplasmin deficiency Elevated fibrin degradation products Platelet disorders Vascular disorders

70. Further Diagnostic Tests Specific coagulation factor assay Coagulation factor inhibitor assay Lupus anticoagulant panel

71. Other Tests for Secondary Hemostasis Fibrinogen D-dimer Fibrin(ogen) degradtion product Thrombin time Reptilase time Euglobulin lysis time

72. Fibrinogen Functional level (200-400 mg/dl) ↓ Fibrinogen(esp. < 100 ) DIC Fibrinolytic therapy Primary fibrinolytic state Congenital afibrinogenemia Acquired/congenital dysfibrinogenemia ↑ Fibrinogen Inflammatory states/acute illness May associated with shortened PT/aPTT

73. D-Dimer Measured cross-linked fibrin degradation product by plasmin More sensitive and specific for fibrinolysis than Fibrin(ogen) Degradatioin Product (FDP) ↑ D-dimer: DIC Acute thromboembolic episodes Post-trauma or surgery Malignancy

74. Fibrin(ogen) Degradation Product ↑ levels in Primary fibrinolytic syndromes DIC After lytic therapy Acute thromboembolic episodes After injury/surgery

75. Thrombin Time Thrombin Time (TT) Assess the ability to convert fibrinogen  fibrin by adding thrombin to plasma Prolonged TT: Inhibitor of thrombin: heparin, anti-thrombin antibody Hypofibrinogenemia or dysfibrinogenemia Inhibitor of fibrin polymerization: fibrin degradation product, paraprotein

76. Euglobulin Lysis Time Euglobulin fraction of plasma is precipitated by acetic acid and thrombin added. Lysis of clot is observed. Normal : > 120 min Shortened ELT: DIC Liver disease Primary fibrinogenolysis: malignancy, e.g. prostate carcinoma

78. Management of Bleeding Patients Yingyong Chinthammitr 27 June 2007

79. Objectives Efficient practice of replacement therapy Management of common bleeding problems

80. Goal of replacement Rx Treatment of bleeding Prevention of bleeding before procedure Not treat only lab. esp. in irreversible causes of coagulopathy

81. WB PRCPRP FFPPC CRPCryo WB = Whole blood PRC = Pack Red Cell PRP = Platelet-rich plasma FFP = Fresh frozen plasma PC = Platelet concentrates (other: apheresis PLT = 4-6 u) CRP = Cryo-removed plasma, FFP with cryo.-removed Cryo. = Cryoprecipitate (F VIII 100 u, vWF, Fibrinogen, F XIII) 1 unit

82. Other products Factor concentrates : VIII, IX Prothrombin complex concentrates (PCC) Activated PCC (APCC) DDAVP Vitamin K injection Recombinant F VIIa (novoseven) Tranexamic acid – antifibrinolysis Fibrin glue – two bottles: Fibrinogen & Thrombin

83. Recombinant Factor VIIa (Novoseven R ) EFFECTIVE+SAFE but VERY EXPENSIVE - Hemophilia with inhibitor (alloantibody) - Factor VIII inhibitor (autoantibody) - Uncontrolled bleeding from coagulopathy (liver failure) - Uncontrolled bleeding from thrombocytopenia - Uncontrolled bleeding from platelet dysfunction (uremia, congenital defect) - Severe surgical and traumatic hemorrhage

84. VIIa TFPI Activated Platelet TF Va XI a Xa IXa X II IIa IX Activated platelet Va VIIIa IIa VIII/vWF XI XIa Platelet Va V VIIIa + free vWF V TF Tissue factor--bearing cell TF TFTF VIIa Xa TF Va I X

85. TFPI Activated Platelet TF Va Xa X II IIa Activated platelet Va IIa VIII/vWF XI XIa Platelet Va V VIIIa + free vWF V TF Tissue factor--bearing cell TF TFTF VIIa Xa TF Va I X VIIa

86. Fibrin Glue - มี 2 ขวด คือ 1. Thrombin 2. Fibrinogen, F XIII (cryoprecipitate) Thrombin XIIIa Fibrinogen ------------->Fibrin ------> Cross-linked Fibrin เติม Calcium ใน Thrombin อาจเติม Tranexamic acid ใน Fibrinogen ใช้ อุปกรณ์ two syringes with one air-line

87. Tranexamic acid - anti-fibrinolysis - adjunctive Rx in areas with high fibrinolysis (Oral cavity, GI tract, GU tract) - Contraindication : DIC, Thrombosis, Renal bleeding (obstructive uropathy) - IV : 10 mg/kg/dose q 8 h - Oral : 25 mg/kg/dose q 8 hr - Oral wash in dental bleeding

88. Bleeding Thrombocytopenia Coagulopathy Combined

89. Platelet level & Bleeding > 100,000/mm3No bleeding tendency < 100,000/mm3Bleeding time prolongation < 50,000/mm3Bleeding after trauma, surgery < 10,000/mm3Spontaneous bleeding < 5,000/mm3High risk for spontaneous CNS bleeding

90. Platelet level Platelet function Anemia Local problem Coexisting coagulopathy Thrombocytopenia & Bleeding

91. Platelet transfusion Symptomatic Rx, not Rx cause Dose: 1 unit per 10 kg BW Indication –Bleeding associated with thrombocytopenia –Prophylaxis, before invasive procedure/surgery Contra-indication –TTP (Thrombotic thrombocytopenic purpura) /HUS (Hemolytic uremic syndrome), HIT (Heparin-induced thrombocytopenia)

92. Prophylaxis in thrombocytopenia ConditionThreshold Chronic stable thrombocytopenia (underproduction e.g. aplastic anemia) <5,000 or No Post-chemo stable patient<10,000 Unstable (fever or infection or coagulopathy or platelet dysfunction) <20,000 Invasive procedures, surgery<50,000 Neurosurgery, ocular Sx<100,000

93. Plasma derivatives: FFP, Cryo. No medications added Return to blood bank if not use within 30 min Most adverse transfusion reactions occur in the first 15 min. Time of transfusion – not exceed 4 hr Rate in adult (good cardiac condition) : 200 - 300 mL/hr NOT for: volume expansion, protein (alb, glob) nutrient

94. Cirrhosis FFP 10-15 ml/kg Vitamin K 10 mg IV Pitfalls –Uncorrected localized bleeding problem e.g. varice, mucosal lesion –Overdependence on PT Not –Goal: to correct or prevent bleeding, Not to achieve a normal PT –Timing of FFP therapy before an invasive procedure

95. - Vitamin K : fat-soluble vitamin - Vitamin K-dependent factors : II,VII,IX,X ; Protein C,S,Z - Vit.K : K1(green vegetables), K2(gut flora), K3(synthetic water-soluble) Vitamin K deficiency

96. * Neonatal : hemorrhagic disease of the newborn * Children & Adult : - low intake - absorption defect - cholestasis, fat malabsorption syndrome - broad-spectrum antibiotics (+low intake) Vitamin K deficiency

97. Vit. K 10 mg IV slowly, sc FFP Prothrombin complex concentrate (PCC)

98. HEMARTHROSIS AND HEMOPHILIC ARTHROPATHY

99. Hemophilia A Cryoprecipitate Factor VIII concentrates FFP DDAVP Hemophilia B FFP Cryo. Removed Plasma F IX concentrates vWD DDAVP Cryoprecipitate F VIII concentrates FFP

100. Rx of Bleeding episodes in Hemophilia SiteLevel (%)Rx Length Joint30-401 dose Muscle30-401-3 doses Hematuria30-401 dose Retroperitoneal505-7 d GI505-7 d Neck1007-10 d Intracranial10010-14 d

101. Hemophilia A with hemarthrosis 60 kg. Raise F VIII to 30 % 1 u/kg raise 2% F VIII half life = 12 hr –Raise 30% -> 15 u/kg = 15x60 = 900 u –Cryo. 9 bags ( cont.  ~5 bags q 12 hr)

102. Hemophilia B with hemarthrosis 60 kg. Raise F IX to 30 % 1 u/kg raise 1% F IX half life = 24 hr –Raise 30% -> 30 u/kg = 30x60 = 1800 u –FFP 1800 ml. ( cont.  900 ml. q 24 hr)

103. Warfarin-associated coagulopathy & bleeding Life-threatening Bleeding –withhold warfarin, FFP/PCCs, vit. K 5-10 mg. i.v., provide medical support (e.g. PRC) Major, non-life-threatening Bleeding –withhold warfarin, FFP/PCCs, vit. K 1-10 mg. i.v., provide medical support (e.g. PRC) J Thromb Haemost 2006;4:1853-63

104. No Warfarin-associated coagulopathy & No bleeding –Withhold warfarin –Vit. K 1 mg. –Reintroduce at a lower dose on the following day –Recheck INR in < 72 hr Beware of re-thrombosis from overcorrection –Withhold warfarin –Vit. K 1 mg. i.v. –Recheck INR in 24 hr –Withhold warfarin –Recheck INR in 24-48 hr INR 4.5-10 Identify and correct the cause of elevated INR INR >10 J Thromb Haemost 2006;4:1853-63

105. Heparin Unfractionated heparin (prolonged APTT) –Bleeding: hold heparin, protamine (1 mg/100 u heparin) –No bleeding: hold heparin (Hf. life 1 hr) LMWH (normal APTT) –Bleeding: protamine (neutralize all anti-IIa but 75% of anti-Xa)

106. DIC Rx cause Bleeding –FFP, PLT concentrate –Cryoprecipitate raise fibrinogen > 100 mg/dL :1 bag/5 kg BW raise fibrinogen 100 mg/dL

107. Treatment of DIC * Treat associated disease * Bleeding - Replacement therapy * Thrombosis - heparin : purpura fulminans, acral/dermal ischemia, retained dead fetus syndrome, giant hemangioma, aortic aneurysm without rupture, solid tumor * AT concentrate, APC

108. Massive blood transfusion > Total blood volume in 24 hour Dilution and/or consumption of PLT, Coag. Factors LAB: platelet, coagulogram, fibrinogen PLT > 50,000, PT 100 mg/dL : generally adequate for hemostasis

109. Platelet dysfunction Stop Antiplatelet agents before surgery –Aspirin : 7 days (irreversible inhibition) –NSAID : 1-4 days (reversible inhibition) –Clopidogrel : 10 days

110. Uremic bleeding TreatmentRegimenOnset Duration *PRC /LPBHct ~30% 1 h While Hct at this level *EPO 50-100 U/kg Hct 30% Same (~6 wk) *Cryoppt.10 units 1 h 24–36 h[Effective ~ 50%] *DDAVP 0.3-0.4 mcg/kg 1 h 4 – 8 h IV or SC 2-3 mcg/kg intranasal *Conjugated 0.6 mkd IV 6 h 14 d (IV) estrogen 50 mkd po 2 d 5 d (PO) x 5 days *Dialysis

111. Thank you for your attention Question…