A Case, and Something About It.

R1, SU HUNG CHANGR1, SU HUNG CHANG

• A patient with antithrombin III deficiency

• Preoperative evaluation of coagulation disorder

• 66 year-old female• antithrombin III deficiency with DVT

history• HTN, DM, CRF• Family History : DVT• Long-term oral anticoagulation

• 66 year-old female• antithrombin III deficiency with DVT

history• HTN, DM, CRF• Family History : DVT• Long-term oral anticoagulation

The CaseThe Case

• General weakness, malaise, soreness since late June

• Multiple migratory aching

• Fever

• General weakness, malaise, soreness since late June

• Multiple migratory aching

• Fever

Treating CourseTreating Course

• 6/25 : admitted to 淡水馬偕• Blood Culture : MRSA (+)• Image : abscess over R’t psoas

muscle; ostemyelitis was noted.• Conservative treatment

• 6/25 : admitted to 淡水馬偕• Blood Culture : MRSA (+)• Image : abscess over R’t psoas

muscle; ostemyelitis was noted.• Conservative treatment

• 7/15 : transferred to NTUH

• 7/29 : Tarry stool (+) : coumadin suspended

• PES : duodenal ulcer• No improvement;

surgical management is indicated

• 7/15 : transferred to NTUH

• 7/29 : Tarry stool (+) : coumadin suspended

• PES : duodenal ulcer• No improvement;

surgical management is indicated

手術過程很順利 , 對於病人有

antithrombin III deficiency 這個因素 , 並沒有發現在術中有特別的影響。 • 當初進行手術的

indication, 在術後皆達到解決 , 目前病人的復原情形大致良好。

某不具名的骨科住院醫師某不具名的骨科住院醫師 負責其 primary care的住院醫師負責其 primary care的住院醫師

Why this case ?Why this case ?

• Role of coagulation• Between anesthesia and

coagulation

• What can we do ?

Preoperative Assessment of Coagulation Disorder

• Miguel Cobas, MD• Int Anesthesiol Clin (39-1), 2001: p.1-

15

A Balance

• The Vascular Compartment• Circulating blood platelets• Coagulation proteins

Thrombin : the most important coagulation

modulator

Thrombin : the most important coagulation

modulator

Antithrombin III : the major physiological inhibitor of coagulation

Antithrombin III : the major physiological inhibitor of coagulation

Bleeding or not bleeding, that is the question.Bleeding or not bleeding, that is the question.

Personal HistoryFamily HistoryMedicationPhysical

Examination

Personal HistoryFamily HistoryMedicationPhysical

Examination

The Evidence Speaking...The Evidence Speaking...

• The platelet count was abnormally low in less than 1.5% of patients, and further work-up rarely revealed any significant hematological abnormality.

• The PT and PTT were abnormal in 4.8% and 15.6% of patients, respectively.

• The PTT had no ability to predict the occurrence or absence of hemorrhage in a low-risk group, but it was a predictor of modest strength in the high-risk group.

• The platelet count was abnormally low in less than 1.5% of patients, and further work-up rarely revealed any significant hematological abnormality.

• The PT and PTT were abnormal in 4.8% and 15.6% of patients, respectively.

• The PTT had no ability to predict the occurrence or absence of hemorrhage in a low-risk group, but it was a predictor of modest strength in the high-risk group.

Munro et al. : Health Technol Assess 1997

Miguel Cobas said that...Miguel Cobas said that...

• Routine screening in an asymptomatic population yields no benefit or significantly changes the anesthetic plan or outcome.

• “...all patients receive a platelet count, PT, and PTT preoperatively if for no other purpose than to delineate baseline values.”

• Routine screening in an asymptomatic population yields no benefit or significantly changes the anesthetic plan or outcome.

• “...all patients receive a platelet count, PT, and PTT preoperatively if for no other purpose than to delineate baseline values.”

MGH : algorithm for preoperative coagulation testing

MGH : algorithm for preoperative coagulation testing

• Quantitative rather than qualitative• <20,000/mm3 : spontaneous bleeding• 20,000-100,000/mm3 : bleeding associated

with surgery/ trauma• >100,000/mm3 : adequate for any challenge

of hemostasis, assuming that function is normal.

• Qualitative test : PACT; PFA100

• Quantitative rather than qualitative• <20,000/mm3 : spontaneous bleeding• 20,000-100,000/mm3 : bleeding associated

with surgery/ trauma• >100,000/mm3 : adequate for any challenge

of hemostasis, assuming that function is normal.

• Qualitative test : PACT; PFA100

Platelet CountPlatelet Count

• Not an effective predictor of bleeding during surgery, particularly in patients with a negative bleeding history.

• Too many factors interfering with BT.• No role in preoperative evaluation of a

patient with negative history, even in those patients taking aspirin.

• Not an effective predictor of bleeding during surgery, particularly in patients with a negative bleeding history.

• Too many factors interfering with BT.• No role in preoperative evaluation of a

patient with negative history, even in those patients taking aspirin.

Bleeding TimeBleeding Time

Ferraris et al. : Surg Gynecol Obster, 1983

Prothrombin TimeProthrombin Time

An unspecific indicator of an extrinsic or common pathway

defect

An unspecific indicator of an extrinsic or common pathway

defect

• The integrity of the entire intrinsic pathway

• Sensitive to all of the factors other than VII and XIII

• To monitor heparin therapy

• The integrity of the entire intrinsic pathway

• Sensitive to all of the factors other than VII and XIII

• To monitor heparin therapy

Activated Partial Thromboplastin Time

Activated Partial Thromboplastin Time

• Whole blood

• 400-2000µl• Within 5 minutes

• ACT, aPTT, PT

Hemochron 801Hemochron 801

When do we need it?When do we need it?

To monitor high-dose heparin anticoagulation, ex. cardiopulmonary bypass surgery

When an immediate measure of heparin anticoagulation is needed at bedside, ex. ECMO, vascular surgery, hemodialysis, cardiac catheterization...

Etomidate and thiopental inhibit platelet function in patients undergoing infrainguinal vascular surgery Etomidate and thiopental inhibit platelet function in patients undergoing infrainguinal vascular surgery

A. GRIES et al.Acta Anaesthesiol Scand 2001; 45: 449–457

A. GRIES et al.Acta Anaesthesiol Scand 2001; 45: 449–457

Etomidate & thiopental offered significant platelet inhibitory properties.Higher transfusion rates & prolonged operation times may be possible

Course of Molecular Hemostatic Markers During and After Different Surgical Procedures

Course of Molecular Hemostatic Markers During and After Different Surgical Procedures

The THR and hemicolectomy : strong activation of the procoagulatory and fibrinolytic systems. Much less pronounced : endoscopic

cholecystectomy, subtotal thyroid resection. Maximum activation : 1 to 2 hours

postoperatively.Hans-Joachim G. Siemens et al.Journal of Clinical Anesthesia 11:622–629, 1999

Hans-Joachim G. Siemens et al.Journal of Clinical Anesthesia 11:622–629, 1999

A Prospective, Randomized Comparison of Thromboelastographic Coagulation Profile in Patients Receiving Lactated Ringer’s Solution, 6% Hetastarch in

a Balanced-Saline Vehicle, or 6% Hetastarch in Saline During Major Surgery

A Prospective, Randomized Comparison of Thromboelastographic Coagulation Profile in Patients Receiving Lactated Ringer’s Solution, 6% Hetastarch in

a Balanced-Saline Vehicle, or 6% Hetastarch in Saline During Major Surgery

LR Group : a hypercoagulative profile persisting into the postoperative period.HS-BS Group : a lesser change in the coagulation

profile HS-NS Group : associated with a hypocoagulative

state.G. Martin, et al. : J Cardiothorac Vasc Anesth, Vol 16, No 4 (August), 2002: pp 441-446

G. Martin, et al. : J Cardiothorac Vasc Anesth, Vol 16, No 4 (August), 2002: pp 441-446

Special Thanks toTzong-Shiun Lee

Steve JobsAll listeners, awake or asleep

Tools usedKeynote

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Special Thanks toTzong-Shiun Lee

Steve JobsAll listeners, awake or asleep

Tools usedKeynote

PhotoshopOmniGraffle

iBookMinolta X20