leanna r. miller, rn, mn, ccrn-csc, pccn-cmc, cnrn, cen, np education specialist lrm consulting...
Post on 17-Dec-2015
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Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC, CNRN, CEN, NP
Education Specialist
LRM Consulting
Nashville, TN
ObjectivesIdentify the most likely type of
coagulopathy with regards to INR, aPTT, platelet numbers and function.
Discuss the four causes of thrombocytopenia.
Describe the priorities in the management of patients with life – threatening coagulopathies.
Admission Screening • identify defects in
hemostasis that can be corrected
• guide the management of hemostatic defects that cannot be corrected
• help manage the bleeding that cannot be prevented
Preoperative Screening • History & Physicalunlikely congenital or familial
coagulopathy– no personal or family history
of bleeding– no abnormal bleeding
associated with:• dental extractions• previous surgery• routine childhood trauma
Admission Screening • Assessment of Coagulopathy
– CBC with coagulation studies– check for and correct
hypothermia– review the history– review medications
Symptom INR aPTT Platelet # PlateletFunction
History Diagnosis
Major/minorbleeding
N N N Massive transfusion;
fluids
Dilutional thrombocytopenia
Major/minorbleeding
N Prolonged N N negative Drug induced - heparin
Major/minorbleeding
N N n/a Vitamin K deficiency
Liver disease, warfarin, antibiotics
Major bleeding
prolonged prolonged N DIC
Medical Causes of Bleeding • residual heparin effect• platelet consumption (CPB)• preoperative platelet
inactivation
Protamine Reactions • Type I
– benign reaction– Histamine release
systemic hypotension– administer protamine
slowly
Protamine Reactions • Type II
– anaphylactoid reaction– occurs within 10 to 20
minutes of administration– symptoms
• hypotension• flushing• edema• bronchospasm
Protamine Reactions • Type III
– catastrophic pulmonary vasoconstriction
• elevated pulmonary pressures• cardiopulmonary collapse• noncardiogenic pulmonary
edema
– reaction occurs between 10 to 20 minutes after start of administration
Differential diagnosis
• A platelet count fall that begins 5 to 10 days after cardiac surgery or that occurs abruptly after starting heparin in a patient previously exposed to heparin within the past 5 to 100 days, is very suggestive of HIT.
Definition•serious bleeding
disorder• thrombosis; then
hemorrhage
Disseminated Intravascular Coagulation
Etiology of DIC•Hemolytic/Immunologic
–anaphylaxis–hemolytic blood reaction–massive blood transfusion
Case Study• 62 – year old male• admitted to CVICU
post bypass • complications
postop (tamponade) – stabilized & on IABP
• required CPR several times
Case Study• 3 days later
diminished leg circulation – IABP removed
• pneumonia, groin infection, renal failure
• step – down develops sternal wound infection
Case StudyHgb/Hct 8.8 / 30%PT 38 secondsFibrinogen 102 mg/dLPlatelets 50,000/mm3
D – dimer > 2500 ng/dL
FSP 80 mcg/dL
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